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THE LANCET 


A Journal of British and Foreign Medicine, Surgery, Obstetrics, Physiology, 
Chemistry, Pharmacology, Public Health, and News. 


gI IN TWO VOLUMES ANNUALLY. 
gee 


po Yat) 
` SAAG b 
Vou. CCXXX. aca MO 


VoL. I. ror 1936. 


ONE HUNDRED AND FOURTEENTH YEAR. 


EDITED BY 


Sır SQUIRE SPRIGGE, M.D. Cantar., F.R.C.P. Loxp., F.R.C.S. Ene. 


AND 7: 
EGBERT MORLAND, B.Sc., M.B. Lono., M.D. Berne, F.R.C.S, Ena. Z7 
ao _ Os = 

N 


PA 
f 


————— 


LONDON 


PUBLISHED BY THE PROPRIETORS, THE LANCET LIMITED, NO. 7, ADAM STREET, ADELPHI, W.C., [IN THE 
COUNTY OF LONDON, AND PRINTED BY HAZELL, WATSON & VINEY, LTD., 52, LONG ACRE, W.C.2 


MCMXXXYVI. 


Pages. Date of Issue. 
1- 66 .. Jan. 4th 
67—126 .. » -llth 
127-178 ..  ,, 18th 
179-238 » 29th 
239-294 .. Feb. lst 
295-348 » Sth 
349-408 » Ld5th 
409-462 » 22nd 
463-520 » 29th 
fos 
7 ie ay 


CONCORDANCE 


Tey 


To enable the reader to determine at a glance the date and serial number 
of the issue of Tre LANCET containing the required page reference. 


5570 


Pages. 
521-582 
583-642 


643—700 


823-876 
577—930 


931-986 .. 


Date of Issue. 


. Mar, 7th 


» lth 
» 2lst 
» 28th 
. Apr. 4th 
» lith 
» Sth 
» 25th 


307 4% 


~ Pages. 
987-1016 
1047-1100 
1101-1160 
1161-1222 


(1223-1278 


1279-1336 
1337-1390 
1391-1450 
1451-1508 


Date of | Issue. 


. May 2nd.. 
» Oth .. 
» 16th .. 
wee “OOP. as 
» 30th .. 

. June 6th .. 
» 13th .. 
» 20th .. i 
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THE LANCET] 


[yan. 4, 1936 


ADDRESSES AND ORIGINAL ARTICLES 


THE THERAPEUTIC ACTION OF IRON 
By L. J. Wirts, M.D. Manch., F.R.C.P. Lond. 


PROFESSOR OF MEDIOINE IN THE UNIVERSITY OF LONDON 
ST. BARTHOLOMEW’S HOSPITAL MEDICAL SCHOOL 


AT 


IRON is present in the food in the simple form of 
soluble iron salts and compounds of iron hydroxide 
with protein, and also in the complex form of hæmin 
derivatives—hemoglobin, cytochrome, and other 
respiratory ferments of a porphyrin structure. Feed- 
ing experiments on animals indicate that only about 
half the iron in the food can be assimilated. The 
available iron of the food seems to correspond closely 
with the simple forms of iron, which can be estimated 
by chemical reactions such as Hill’s dipyridil method. 
Hemin derivatives do not give these reactions, and 
they appear to escape absorption in the alimentary 
tract. Practically all of the iron of simple inorganic 
salts is available, and preparations such as ferric 
chloride, when accompanied by traces of copper, 
can be used as the sole source of iron in the diet of 
It appears that all com- 
pounds of iron must be broken down into simple 
salts before the iron can be assimilated, and that 
the hæmin compounds resist this process, so that 
their iron is not available to the organism. 

Iron is absorbed chiefly in the duodenum but the 
stomach and the whole of the small intestine may 

e part in the process. The upper part of the 


< alimentary tract is an all-important area in hemo- 


v 


~a 


sar” 


poiesis and the surgeon should avoid too ruthless 
an exploitation of this territory. The body of the 
stomach secretes pepsin and the powerful mineral 


borate hydrochloric acid, which is the solvent for the 


vailable iron of the food. So abundant is the gastric 
secretion in health that it more than suffices to 
neutralise the alkaline juices of the liver, the pancreas, 


~and the intestine, and the reaction of the whole of 


he small intestine is acid. The pyloric portion of 
the stomach and the upper duodenum secrete a 
ferment which reacts with an extrinsic factor in the 
tood to produce the liver principle. The duodenum 
is the chief site of iron absorption. The available 
iron of the food is probably reduced to the bivalent 
ferrous state in the alimentary tract, and after 


_ absorption it is either stored or transported to those 


yy 


places where it 1s required for its catalytic action 
and for the building of hemoglobin. Iron is taken 
up by the nuclei of the erythroblasts, which elaborate 
hemoglobin from it and are extruded from the ripen- 
ing cell when their task is completed. .Iron is also 
taken up by the other cells of the organism for the 
manufacture of cytochrome and other respiratory 
ferments. However administered, iron is excreted 
by the cecum and large intestine, and little appears 
in the urine even when iron is introduced paren- 
terally (Fig. 1). 

We might expect to find that in health the absorp- 
tion of iron by the stomach and small intestine 
would be equalised by the loss through the colon. 
Whether there is such an equilibrium, and, if so, 
how it is adjusted, are matters on which at present 
we have no trustworthy information. The adminis- 
tration of iron to normal animals and men does not 
affect the blood count, but much of the iron may 
be retained in the body. Absorption is proved by 
the rise in the serum iron, by the toxic effects of 


- high dosage of iron in animals, by the investigation 


5862 t1 


aN 


of patients with ileal fistulæ, and by balance experi- 
ments. The estimation of iron in animal tissues 
and excretions is so difficult and the results of analyses 
of standard biological materials such as milk and 
serum are 60 divergent, that we can place no great 
reliance on the records of balance experiments. 
Lintzel, experimenting on healthy individuals, con- 
cluded that not more than 17 mg. of iron was retained, 


ACID AND PEPTIC 
GLANDS DISSOLVE Fe. - 


PYLORIC GLANDS 
ELABORATE 
PA.FACTOR 


ABSORPTION 
OF Fe. 


ABSORPTION OF 
PA. FACTOR 


FIG. 1.—Tho hemopoietic area of the alimentary tract. 


however large a single dose was given. He assumed 
that there was an intestinal barrier to the absorption 
of iron, and stated that there was no advantage in 
prescribing more than 50 to 100 mg. of iron a “day. 
His results are at variance with experience in the 
treatment of anemia, for the hæmoglobin increment 
may correspond with a utilisation of 50 mg. or more 
of iron a day, and maximum improvement may not 
occur until large doses of iron are given. Moreover, 
Reimann and Fritsch gave patients with anæmia 
100 mg. of iron a day and found that approximately 
50 mg. a day was retained; only about 20 mg. a 
day could be attributed to the manufacture of 
hemoglobin and the remaining 30 mg. were stored 
in the body. At the 1935 meeting of the Association 
of Physicians J. F. Brock reported iron retention 
of this order occurring for many weeks in patients 
receiving large doses of iron, so that a subsequent 
speaker was constrained to say that the patients 
must be converted into pillars of iron. If these 
results are confirmed we must believe that patients 
treated with iron store the metal, in amounts as 
large or larger than those found in hemochromatosis, 
without developing siderosis of the organs; and as 
anæmic patients treated with large doses of iron 
may quickly relapse on omitting iron, we must 
believe that the iron they have sequestered (? in the 
bones) is a frozen credit which they cannot liquefy. 
Hemochromatosis, on the other hand, is probably 
the result of an inborn error of metabolism which 
affects the disposal of endogenous and not exogenous 
iron. 1° 

Two other curious facts may also be mentioned. 
The first is described by Schulten as the “threshold 
phenomenon.” We may, for example, treat a patient 
for many weeks with a daily dose of 30 grains of 
iron and ammonium citrate with no apparent effect ; 
on raising the dose to 60 grains of iron and ammonium 
citrate a day there is a reticulocyte crisis and the 
anemia is steadily repaired. Thus there is a minimal 
effective dose of iron. In other patients who are 
treated with a suboptimal dose of iron (which is 

A 


2 THE LANCET] 


far larger than any diet could supply) the anemia 
may improve for a few weeks and then become 
stationary at a higher but still subnormal level. In 
both these conditions it is difficult to explain why 
the anæmia does not slowly but steadily improve. 


Iron Requirement 


The professional fasting men, Cetti and Breithaupt, 
excreted about 10 mg. of iron a day during their 
periods of starvation, but the excretion of iron is 
abnormal during fasting owing to tissue breakdown. 
Lintzel showed that adult males can be balanced on 
a diet containing less than 1 mg. of iron a day, but 
much more iron is needed by the growing child and 
by the female during her reproductive life. The iron 
requirement in childhood has been estimated at 
0-76 mg. per 100 calories of food ingested.* In the 
female the reproductive function imposes an extra 
strain on the iron metabolism. Normally about four 
ounces of blood are lost at each period, or 50 mg. of 
iron, but in menorrhagia as much as 200 mg. may be 
lost.” During pregnancy a total of 0-9 gramme of 
iron must be supplied from the food or the body 
reserves, Or an average daily storage of 3-2 mg.® 
Under fairly ideal conditions of diet and well-being, 
it seems possible for the maternal organism to 
assimilate enough iron for this purpose, assuming that 
the diet contains 15 to 20 mg. of iron a day, that 
half of this iron is ‘‘ available,’ and that half of 
the available iron is absorbed. During lactation 
from 1 to 1-5 mg. of iron a day are secreted in the 
milk. Reproduction is a test not only of the maternal 
constitution but also of the standard of living, and 
a large section of the British community comes 
through the test badly. Davidson and co-workers 
have shown that diets averaging 11 mg. of iron a 
day, such as are taken by the poor in the Aberdeen 
area, are insufficient to maintain iron equilibrium in 
females who have begun to menstruate. 

In addition to the physiological states which 
increase the requirement of iron, there are patho- 
logical conditions which impair its absorption and 
give rise to a ‘“‘conditioned deficiency.” The most 
important is achlorhydria. Impairment of the gastric 
secretion is found in a high proportion of cases of 
nutritional anemia in infancy and childhood,} 18 
idiopathic hypochromic anemia,!? and hypochromic 
anemia of pregnancy.4* <A diet high in iron usually 
has little demonstrable effect on simple achlorhydric 
anemia, but if the food is predigested with hydro- 
chloric acid and pepsin there may be a favourable 
response.2 °26 The optimum dosage of ferrum 
redactum and of iron and ammonium citrate is 
higher in patients with achlorhydria than in those 
with normal gastric secretions. 1930353947 The 
most intractable examples of anæmia occur in patients 
in whom the gastric secretion has been reduced and 
the hemopoietic area of the stomach and duodenum 
has been side-tracked by gastrectomy or gastro- 
enterostomy. These cases seem to depend not so 
much on anacidity—in many of them the secretion 
of acid persists in spite of operation—as on a hurried 
passage through the jejunum, and they are associated 
with severe general impairment of the digestive 
powers and consequent modifications of the diet.?® 
In fatty diarrhoa also the action of iron is much 
diminished. 

Potentiation and Antagonisation of Iron 


The therapeutic action of iron can be enhanced 
by certain procedures which facilitate the absorption 
or the utilisation of iron. Bethell and co-workers 
showed that a dosage of 300 mg. a day of ferrum 


PROF. L, J. WITTS : THERAPEUTIC ACTION OF IRON 


[yan. 4, 1 936 


redactum was ineffective when given in three divided 
doses of 100 mg. but was effective when given in 
ten divided doses of 30 mg.; this seems to be a 
pure absorption phenomenon. In_ experimental 
animals iron can be absorbed and stored in the liver 
but cannot be converted into hemoglobin unless 
copper is also present 37; this is apparently a pure 
utilisation phenomenon. It is difficult to demon- 
strate the action of copper in man, in whom defi- 
ciency of copper is excessively rare. Pyrrole deriva- 
tives such as bile pigment,®4 chlorophyll, and the 
cytochrome of yeast 3233 potentiate the action of 
iron, probably by facilitating its conversion into 
hemoglobin. Other examples of potentiation are 
more complex. The beneficial effect of the simul- 
taneous ingestion of acid, in the form of hydrochloric 
acid or of buffered acid media,?’ is most simply demon- 
strated in patients with achlorhydria, in whom the 
acid acts by replacing the gastric secretion and 
facilitating absorption, but there is also evidence 
to suggest that iron is conserved in the body by 
an acid diet and that its excretion is increased by an 
alkaline dict. The potentiating action of liver is 
highly complex, as liver is an acid food and a source 
of additional iron, copper, and pyrrol derivatives.*! 
Calcium is said to have an iron-sparing action,*® 42 4° 
by which one must suppose promotion of absorption 
is meant, but the evidence is scanty, and in experi- 
ments on animals the reverse effect has been observed, 
rats becoming extremely anemic on a high calcium 
diet.44 Apart from this last observation, which is 
of doubtful human application, the only example 
of antagonism to iron I have met is Lintzel’s state- 
ment that citric, tartaric, lactic, and similar acids 
diminish the absorption of iron, on which account 
he believes that large amounts of fruit, such as apples, 
oranges, and lemons, should be forbidden in anemia. 
The potentiation of iron must always be borne in 
mind in experiments designed to estimate the effective 
dosage of preparations. It is of little immediate 
therapeutic importance, as these adjuvant actions 
can only be demonstrated when suboptimal amounts 
of iron are given, and with rare exceptions hypo- 
chromic anemia in man can always be repaired by 
massive doses of iron. On the other hand, the 
potentiation of iron is of the utmost importance to 
nutrition, because foods rich in available iron, such 
as meat and eggs, are costly, and diets should therefore 
be designed to ensure the utmost utilisation of the 
iron they contain. This is a direction in which we 
may look forward to further acquisitions of knowledge. 


Dosage of Different Preparations of Iron 


So far I have spoken of the therapeutic action of iron 
without making distinctions, but I hope to show that 
the various preparations of iron differ in therapeutic 
efficiency just as much as one star differs from another 
in brightness. One of our chief preoccupations in the 
study of anmia has been the determination of the 
most suitable preparations of iron to be prescribed 
and the optimum dosage. It will be apparent from 
what has already been said that the assessment of the 
therapeutic action of iron requires carefully controlled 
conditions. Man is the most suitable animal for 
such experiments, not merely because of his large 
size or the facility with which his blood may be 
examined and his excreta collected, nor because his 
benefit is our ultimate goal. Indeed a study of the 
literature suggests that governments are more 
interested in preventing iron deficiency in their 
domestic animals than in their human populations. 
But man is peculiarly liable to suffer from a pure 


THE LANCET] 


PROF. L. J. WITTS : THERAPEUTIC ACTION OF IRON 


[yAN. 4, 1936 3 


and uncomplicated iron deficiency which can be 
completely corrected by the administration of 
inorganic salts of iron. In this country work on 
nutritional anemia of infancy and idiopathic hypo- 
chromic anemia was considerably influenced by 
McGowan’s observations on iron deficiency in sucking- 
pigs and sheep. With this notable exception work 
on animals has rarely been capable of immediate 
transfer to man. The original denial of the value of 
inorganic salts of iron; the subsequent equalisation 
of all inorganic salts of iron; the recommendation 
of whole liver and secondary liver extract in hypo- 
chromic anæmia; the emphasis on the action of 
copper—none of these has been directly applicable 
to man. 3 

Iron is administered internally in medicine for its 
hematinic action and for its tonic or roborant action. 
My further remarks will be confined to its action in 
anzemia, though the presence of iron in every living 
cell suggests that its use in debility and in disease 
of the central nervous system is not without a 
theoretical basis. In the anemias which respond to 
iron the red cells are paler and usually smaller than 
normal. Certain anzemias of this type, when left 
untreated, may persist almost unchanged for years. 
They respond dramatically to iron and are therefore 
an ideal subject for experiment. The most important 
examples are idiopathic hypochromic anemia, with 
which I include chlorosis, and the anæmia of hook- 
worm disease. Certain chronic hemorrhagic anemias 
may also exhaust the ability to improve spontaneously 
and be suitable test-objects provided further hemor- 
rhage can be excluded. The criteria on which we 
select patients for experiment on the action of iron 
are as follows :— 

1. The anemia should be one of the torpid and hypo- 
chromic anemias which I have mentioned. 

2. Patients who have suffered from hzmorrhage or 
have recently been treated are unsuitable unless an 
adequate control period has shown no tendency to 
improve. 

3. Infection, toxemia, malignant disease, pregnancy, 
old age, and damage to vital organs such as the liver, the 
kidneys, and the thyroid, all impair the response to iron 
and render the case unsuitable. 

4. The initial hemoglobin level should not exceed 
50 per cent., or else the reticulocyte response will be too 
small to be utilised and the hemoglobin gain will not be 
comparable with that of the severer grades of anæmia. 

5. The state of the gastric secretion should be known. 
Achlorhydria should not exclude the patient and is in 
fact an advantage, as anemia is so often complicated by 
achlorhydria. Short-circuiting operations and severe 
functional disturbances of the alimentary tract such as 
steatorrhcea render the patient unsuitable. 

6. The diet and mode of life should be constant through- 
out the period of observation. 

In the pharmacopeia of the future the dosage 
of drugs will doubtless be given per kilogramme of 
body-weight and by mathematical formule or 
diagrams which express individual variations in 
therapeutic, toxic, and lethal reaction. At present 
there is neither the knowledge to compile nor the 
ability to use such a formulary, but it is well to 
remember that the customary method of stating 
doses gives little indication of the infinite variety of 
mankind in its response to medication. Some women 
with simple achlorhydric anemia improve rapidly 
on as little as 15 grains of iron and ammonium citrate 
a day, others may need 150 grains. I shall therefore 
speak only of the average effective dose. The 
‘single reticulocyte crisis”? is not very helpful in 
determining average effective doses of preparations 
of iron, as the reticulocytoses in hypochromic anzmia 
are of a lower order and less constant than those of 


pernicious anæmia.?? 30 I will refer to the use of the 
“ double reticulocyte response” later. Most use 
has been made of the “‘ rate of hæmoglobin increase.” 
The curve representing the rise of hemoglobin during 
treatment has a sigmoid shape, there being an initial 
lag, a subsequent steady rise, and a final slowing 
in the rate of hemoglobin regeneration as the normal 
level is approached. The maximum effect of treat- 
ment occurs between the second and fourth weeks, and 
the increase of hemoglobin should therefore be esti- 
mated over a period of not less than 25 and not more 
than 40 days from the initiation of treatment.5 
It has been found by experience that the rate of 
hemoglobin regeneration in man rarely exceeds 2 per 
cent. a day. The “average effective dose” of a 
preparation of iron may be defined as the dose which 
produces an average increase of over 1 per cent. 
of hemoglobin a day in a sufficiently large sample 
of patients with achlorhydria and anemia, when the 
initial hæmoglobin level does not exceed 50 per cent., 
and when the period of observation is not less than 
25 and not more than 40 days. The analyses of 
Heath and Fullerton show that about 60 per cent. 
of such a series of patients will gain more and 40 
per cent. will gain less than 1 per cent. of hemo- 
globin a day, but the mode of the series will be just 
over l percent. In the accompanying Table I have 
summarised from my own experience and from the 
literature the average effective daily dose of the 
common preparations of iron. 


TABLE showing average effective dose of common prepara- 
tions of iron, and percentage of iron administered 
utilised for hæmoglobin formation. 


Daily dose P 
Preparation. in grammes| ITOP content Utilisation 
or Ceni. in mg. (per cent.). 
Metallic— 
Ferrum redactum ? ?8! 3° | 1°5 to 6'0 | 1200 to 5000 | 0°5 to 2°0 
Ferrous— 
Ferrous chloride }° 35 0°25to0°5! 100 to 200 | 12°5 to 25 
Ferrous sulphate exsic.?> 0°6 180 14 
Ferrous lactate 78... 15 300 S 
Pil. ferri carb. 
(Blaud) °? 32 4? | 3°0 to 4°0 300 to 400 6 to 8 
Ferric— 
Liq. ferri perchlor. .. 80 400 6 


Ferric citrate °° she 

Idozan (ferric hydrox.)*® 

Soluble ferric oxide *5 
Complex ferric— 


2°0 400 | 6 
30 to 45 | 1500 to 2250 | 1°1 to 1'7 
35 1000 2'5 


Fe et ammon. cit.??* 47 | 4'0 to 8°0 | 800 to 1600 | 1°5 to 3°0 
Injection— 
Inj. Fe B.P.’ 2° 50 to 10°0| 16 to 32 100 


Organic.—As already indicated, only the non-hemoglobin-like 
part of the iron of the food is available, and hemoglobin and | 
similar compounds do not exert the therapeutic action of iron. 


It is obvious that iron is most active when given 
by injection, but in practice parenteral administra- 
tion is contra-indicated by its dangers. The thera- 
peutic dose of iron by injection (iron and ammonium 
citrate equivalent to 32 mg. iron) is so close to the 
toxic dose (48-80 mg. iron) that effective treatment 
can hardly be given by this route.*2° I have seen 
toxic symptoms from the injection of 14 mg. of iron 
a day in the form of iron and ammonium citrate, 
which is far less than the effective dose. When iron 
is given by mouth symptoms of general intoxication, 
as distinct from intestinal irritation, are most unusual, 
and in spite of the frequent prescription of enormous 
doses, only one example of severe intoxication from 
ingested iron is on record.?! The amounts of iron 
which patients have taken with impunity are very 
large—150 grains a day of reduced iron 3° ; 150 grains 
of Blaud’s pill a day for two or three months?! ; 
300 grains of iron and ammonium citrate daily 47 ; 
and while higher dosage than necessary is unwise 


4 THE LANCET] 


PROF, L. J. WITTS : THERAPEUTIC ACTION OF IRON 


(gan. 4, 1936 


there is no excuse for giving too little. The most 
important lessons from recent work on iron are the 
futility of injecting iron and the safety of large doses 
by mouth. 

The therapeutic activity of preparations of iron 
by mouth is directly proportional to their solubility 
and to the ease with which they yield free ions of 
ferrous iron. Metallic iron, colloidal ferric prepara- 
tions, and the scale preparations, in which the iron 
is In a complex form and not readily ionised, all 
require to be given in large doses to produce effects. 
The soluble ferrous salts are the most active. The 
average effective dose of ferric chloride has not yet 
been worked out with any degree of accuracy, but 
from some uncompleted experiments by N. S. 
Plummer and myself it must be higher than 400 mg. 
of iron a day, equivalent to liq. ferri perchlor. minims 
40 t.d.s. We have obtained incontrovertible evidence 
that ferric chloride is less potent than ferrous chloride 
or ferrous sulphate by the method of the double 
reticulocyte crisis. In these experiments, after a 
contro] period, we have treated the patient for a 
short time with the equivalent of 200 mg. of iron a 
day as ferric chloride, and have afterwards given 
the same amount of iron as ferrous chloride or ferrous 
sulphate. The higher potency of the ferrous salts 
is revealed by the occurrence of a second reticulocyte 
crisis and by an acceleration in the rate of hæmo- 
globin formation. Similar results have been reported 
by Reimann and Fritsch. On the other hand it is 
clear that ferric salts are effective if given in suffi- 
cient amounts. Their relative inferiority cannot be 
explained by precipitation on contact with food 
residues, as colloidal ferric preparations are less 
effective than the astringent preparations. It is 
possible that iron is not absorbed in the ferric valency, 
and that ferric salts are reduced to the ferrous state 
in the alimentary tract before absorption; on this 
account they are less potent than the preformed 
ferrous preparations (Fig. 2). 

The most active preparation of iron is not neces- 
sarily the most suitable for prescription, and the 
choice of a preparation for medicinal use is governed 
by a number of additional factors such as price, 
palatability, tolerability, durability, and ease of 
prescription. The soluble simple salts of iron are 
all irritating to the stomach. The ferrous salts tend 
to oxidise in solution, though this may be inhibited 
by avoiding over-dilution and making up the mixture 
with glucose and/or acid; if they are given in solid 
' form they may cause vomiting, whilst tablets become 


RED CELLS 


HAEMOGLOBIN 


DAYS 5 15 


CONTROL ets 194 mg SALLY FeCl2 a DALY 


FIG. 2.—Supcriority of bivalont ferrous over trivalent ferric chloride when given in doses 
containing equal amounts of the metal. 


hard and insoluble unless carefully and freshly pre- 
pared. The solution of ferric chloride is intensely 
irritating, and I found it quite impossible to use it 
in effective doses till I learnt the device of adding 
it to milk immediately before taking.14 The massive 
amounts of iron which must be ingested when reduced 
iron, colloidal ferric iron, or the scale preparations 
are ‘used, may cause indigestion, diarrhoea, cramps, 
and constipation,’® and even intestinal obstruction.‘ 
There is also evidence that large amounts of 
unabsorbed iron in the intestine may interfere with 
the absorption of other minerals 5 46 and vitamins.¢ 

The ideal preparation of iron still awaits discovery, 


but the following are some useful and cheap 
prescriptions :— 
Ferrous chloride (Howard) 3 grs. 
Syrup hs Er .. 15 minims 
Chloroform water. to 1 drachm 
e lacte, t d.s., D. C. 
Pil. ferri. carb. -. 15 grs. 
t.d.s., D.C. To be ernea. before taking. 
Iron and ammon. citrate 30 grs. 
Glycerin .. : ‘me 15 minims 
Chloroform water ei si to 1 oz. 


t.d.s., P.C. 


Among proprietary preparations, which are some- 
times more highly esteemed by patients on account 
of their elegance and costliness, one may mention 
Ferronyl (ferrous chloride), Oppenheimer’s Bipala- 
tinoids (ferrous carbonate), and Idozan (ferric 
hydroxide). 

In the Table I have estimated the percentage of the 
dose of iron administered which is utilised in the 
manufacture of hemoglobin when there is an increase 
of 1 per cent, a day, using the following calculation 15: 

Blood iron corresponding to 100 per cent. hemoglobin = 
50 mg. per 100 c.cm. 
Blood volume =5 litres. 


Thus arise of 1 per cent. hemoglobin is equivalent to a 
gain of 50/100 x50 =25 mg. of iron as hæmoglobin. 


The utilisation of an average effective dose of ferrous 
iron is approximately 20 per cent., and if minimum 
effective doses of ferrous iron are prescribed, between 
50 and 100 per cent. of the dose ingested may be 
utilised for hæmoglobin formation. Reticulocyte 
crises and repair of anæmia may be observed with a 
daily dosage as low as 22 mg. of ferrous iron by mouth. 
The massive dosage of some preparations of iron has 
led to a good deal of misunderstanding of the mode 
of action of the metal, but there now seems no doubt 
that the effective dosage of preparations of iron is 
directly proportional to the 
ease with which they yield 
free ferrous ions. The effective 
dose of soluble ferrous salts 
is small and of the same order 
as the iron contained in the 
food. The action of iron on the 
blood-forming organs can be 
simply explained as the pro- 
vision of a raw material for 
the manufacture of hæmo- 
globin. The administration of 
iron also relieves the soreness 
of the tongue and the fissuring 
at the corners of the mouth, 
the dystrophy of the nails, 
the atrophy of the skin, and 
the bruising and menorrhagia, 
which often accompany hypo- 
chromic anwmia and are prob- 
ably due to lack of iron in the 


THE LANCET] 


tissues. Excess ofiron has no influence on hemopoiesis 
in health, nor does iron provoke blood formation in 
the same way as oxygen-want, arsenic, or X rays, 
so that we are probably correct in assuming that 
iron is a nutrient and not a stimulant for the blood- 
forming organs. 

To a large extent iron is used to repair deficiencies 
which would not have occurred had the diet been 
satisfactory, and as the hygiene and nutrition of the 
world improve, we may expect conditions such as the 
“ physiological ” anæmia of pregnancy, the nutritional 
anægmia of infancy, and the anæmia of hookworm 
infestation to follow chlorosis into the limbo of 
vanished diseases. But the value of diet in anæmia 
is essentially prophylactic, and when the iron supplies 
of the organism are exhausted it is hard to replenish 
them in a reasonable time from the food. We can 
foretell no decrease in those forms of anæmia which 
cannot be prevented by diet alone, such as idiopathic 
hypochromic anemia and pernicious anæmia, in 
which the absorption of iron is impaired, and splenic 
anæmia and chronic hemorrhagic anemia, in which 
excessive amounts of iron are lost. The metal iron 
is sacred to the god of war, but even in that distant 
day when swords are beaten into ploughshares, and 
the peoples of the world are fed not with bread alone, 
but with diets adequate in biological proteins, 
vitamins, and minerals, the physician must preserve 
his skill in the therapeutic use of iron. 


Summary 


(1) The factors which affect the requirement, the 
absorption, and the utilisation of iron are discussed. 

(2) The absorption of the iron contained in food or 
drugs is proportional to the ease with which ferrous 
ions are liberated. 

(3) Iron acts as a nutrient and not as a stimulant 
for the blood-forming organs. 


REFERENCES 


References are confined to recent papers, as the older 
literature has been comprehensively reviewed by E. 
Starkenstein in his monograph on iron (Handbuch der 
experimentellen Pharmakologie, A. Hetfter and W. 
Heubner, vol. iii., Part 2, Berlin, 1934). 


1, 3 39. 

2, Beene. sai. T., and Wintrobe, M. M.: Arch. Internal Med., 
1933, lii., 464. 

3. Bethel, F. H., Goldhamer, S. M., Isaacs, R., and Sturgis, 
C. C.: Jour. Amer. Med. Assoc., 1934, ciii., 797. 

4. Blackfan, K. D.: Growth and Development of the Child, 

Part III., Nutrition. New York and London, 1932. 


5. Brock, “5 F., and Diamond, L. K.: Jour. of Pediat., 1934, 
iv., 442. 
6. Burret, G. N., and Witts, L. J.: Proc. Roy. Soc. Med., 
1934, xxvii., 447. 

T. Campbell, J. M. H.: Guy's Hosp. Rep., 1923, lxxiii., 247. 

5. Coons, C. M. Jour. Biol. ‘Chai, 1932, *xevii., 215. 

9. Dameshek, W. Jour. Amer. Med. Assoc., 1933, c., 40. 
10, Davidson, L. S. P.: Proc. Roy. Soc. Med., 1933, xxvi., 26. 
ll. Davidson, Fullerton, H. W., Howrie. J. W., Croll, J. M., 

ae: B., and Godden, W.: Brit. Med. Jour., 1933, 
12. Paridon: Fullerton, and Campbell, R. M.: Ibid., 1935, 
, 195. 


13. Elvehjem, C. A.: Jour. Amer. Med. Assoc., 
1046 ; 1933, ciii., 61. 

14. Fontes, G., and Thivolle, L.: 

15, Fullerton: Edin. Med. Jour., 1934, xli., 99. 

16. Hartfall, S. J.: Guy’s Hosp. Rep., 1934, Ixxxiv., 448. 

17. Hartfall and Witts: Ibid., 1933, INXNiii.. 


1932, xcviii., 


Le Sang, 1933, vii., 803. 


18. Hawksley, J. C., Lightwood, R., and Bailey, U.M.: Arch. 
Dis. Childhood, 1934, ix., 359. 

19. Heath, C. W. Arch. Internal Med., 1933, li., 459. 

20. Heath, Strauss, M. B., and Castle, WwW. B.: Jour. Clin. 


Invest., 1932, 
1. Hurst, A. F.: Guy’s Hosp. Rep., 1931, Ixxxi., 243. 
22. Lintzel, W.: Ergeb. d. Physiol., 1931, xxxi., S44. 
23. McGowan, J. P.: Brit. Med. Jour., 1933, i., 803. 
4. McGowan and Crichton, A.: Biochem. Jour., 1923, xvii., 
204; 1924, xvilli., 265. 
25. MeLester, J. S.: Nutrition and Diet in Health and Disease, 
Philadelphia and London, 2nd ed., 1931. 


(Continued at foot of next column) 


xi., 1293. 


PROF. F. L. APPERLY : GASTRIC ACIDITY AND ITS SIGNIFICANCE 


[san. 4, 1936 5 


GASTRIC ACIDITY AND ITS 
SIGNIFICANCE 


A CLINICAL AND EXPERIMENTAL STUDY 


By FRANK L. APPERLY, M.D. Oxon., D.Sc. Melb. 


PROFESSOR OF PATHOLOGY IN THE MEDICAL COLLEGE OF 
VIRGINIA, RICHMOND, VA., U.S.A. 


THE literature relating to variations in gastric 
acidity, and their significance, is vast and conflicting. 
Standards of normal acidity for healthy people, 
and for different sexes and ages, have been set up, 
although every degree of acidity and even achlor- 
hydria are found in perfectly healthy individuals. 
In this paper an attempt is made to bring together 
various experimental and clinical facts into a 
correlated whole, so that we may better understand 
not only how gastric acid is regulated and variations 
are produced, but the significance of these changes, 
and their bearing on general bodily conditions. 

The concentration of hydrochloric acid in pure 
gastric juice has been given different values by many 
observers. The recent and most careful work of 
Hollander and Cowgill? however shows that the 
pure parietal juice has an acid concentration of 
0-170 N (pH 0-91), a figure which is independent of 
rate of secretion or type of stimulus. Variations 
in acidity are brought about by admixture with 
mucus and solutions of sodium chloride and 
bicarbonate, secreted by the gastric mucosa and 
in some cases regurgitated from the duodenum. 

We are, however, more concerned here with varia- 
tions in acidity at various times after a standard 
meal irrespective of the mechanism by which these 
changes are brought about, 


THE RELATION OF ACIDITY TO BLOOD CO, 


In 1931 Apperly and Crabtree ? showed that varia- 
tions in the CO,-content of the fasting blood plasma 
not only governed the acidity of the gastric contents 
after a test-meal in any one individual, but were 
also responsible for the differences in gastric acidity 
between different individuals (Fig. 1). In 1932 
Browne and Vineberg? confirmed these results in 


(Continued from previous column) 


26. Mettier, S. R., Kellog, F., and Rinehart, J. F.: 
Jour. Med. Sci., 1933, CIXXXVi., 694, 

27. Mettier and Minot, G. R. Ibid., 1931, clxxxi., 25. 

28. Meulengracht, E.: Acta Med. Scandinav., 1923, lviii. ., 594; 
1932, IXxvili., 387. 

29. Minot and Castle : THE LANCET, 1935, ii., 319. 


Amer. 


30. Minot and Heath: Amer. Jour, Med. Sci., 1932, 
clxxxiii., 110. 

31. Murphy, W. P.: Arch. Internal Med., 1933, li., 656. 

32. Parsons, L. G., and Hawksley: Arch. Dis. Childhood, 
1933, viii., 117. 

33. Parsons and Hickmans, E. M.: Ibid., 1933, viii., 95. 

34. Patek, A. J., and Minot: Amer. Jour. Med. Sci., 1934, 
elxxxvili., 206. 

35. Reimann, F., and Fritsch, F.: Zeits. f. klin. Med., 1930, 
cxv., 13; 1931, cxvii., 304; 1932, CXX., ony 

36. Riecker, H. H.: Jour. Clin. Invest., 1931, , 657. 


37. Rose, M. S.: Yale Jour. Biol. and Med., 1932, iv., 499. 

38. Sargant, W.: THE LANCET, 1932, ii., 1322. 

39. Schulten, H.: Münch. med. Woch., 1930, 
1932, Ixxix., 665. 

40. Sheldon, J. H.: Brit. Med. Jour., 1934,i., 47 ;. THE LANCET, 

= 1934, ii., 1031. , 

41. Shelling, D. H., and Josepbs, H. W.: Bull. Jobns Hopkins 
Hosp., 1934, lv., 309. 

42. Sherman, H. C.: U.S. Office of Experiment Stations, 
Bull. Xo. 185, Washington, D.C., 1907. 

43. Sjoberg, H.: Acta Med. Scandinav., 1935, Ixxxv., 130. 

At. eau and Castle: Amer. Jour. Med. Sci., 1932, CISxXxiv., 


45. von W endt, G.: Skandinav. Arch. f. Physiol., 1905, xvii., 
211 
46. Waltner, K.: 


lxxvii., 355; 


Riochem. Zeits., 1927, clxxxviii., 381; and 
1929, ccv., 467. 
47. Witts: Proc. Roy. Soc. Med., 1931, xxiv., 543; 1933, 


xxvi., 607. 


6 THE LANCET] 


PROF. F. L. APPERLY : GASTRIC ACIDITY AND ITS SIGNIFICANCE 


[JAN. 4,.1936 


x X 
S2 S S 32 
S ~~ Y 
SS SS S888 
RS SUS x 
TTS Qe SE =~ 
exes = 
S 
0:10 Ss S 
0:08 
S 
N 
S 
w 0:06 
a 
= 
0:04 
0:02 


Breathing 
:} 10% 02+ 
some C02 


60 70 80 
PLASMA CO2 per 100 ccm. 


FIG. 1.—Relationship of (a) total chloride, total acidity, and 
free HCl of gastric contents one hour after the commence- 
ment of a test-meal, to (b) the CO, capacity of the fasting 
blood-plasma in one individual under various conditions of 
acidosis, alkalosis, &c. (from Jour. of Physiol.*). 


dogs and further showed that the total amount of 
acid secreted could be increased or diminished by 
artificially raising or lowering plasma CO.. 

But what are the factors responsible for variations 
in plasma CO,? Does clinical experience show that 
such variations result in similar variations in gastric 
acidity ? Obviously, of course, the respiratory 
centre is the immediate regulatory mechanism. 
But other causes underlie this. Let us therefore 
correlate what is known about gastric acidity with 
the conditions in which plasma CO, is known to be 
increased or diminished, and thus possibly obtain 
some idea as to the significance of these gastric 
variations, These conditions can be classified thus :— 

(a) Primary CO, deficit, 
with some rise of blood pH. 

(b) CO, deficit, secondary to loss of blood alkali, 
associated with fall of pH. 

(c) Primary CO, excess, associated with fall of pH. 

(d) CO, excess, secondary to rise of blood alkali, 
associated with rise of pH. 


(a) Primary CO, deficit is brought about by 
pulmonary hyperventilation from any cause (except 
that following respiration of a high CO, atmosphere), 
as for instance by heat, fevers, the earlier stages of 
oxygen shortage, altitudes, encephalitis, and certain 
cardiac diseases. The fall of plasma CO, following 
hyperventilation has been shown by Haggard and 
Henderson;* Collip and Backus,® and Grant and 
Goldman ê; that following confinement in a hot 
room by Cajori?; ina hot bath by Bazett,® Kochler,® 
and Landis 1°; and in the tropics by Sundstroem,? 
Radsma et al.,!? and others. The lowering of gastric 
acidity under each of these conditions has been 
demonstrated respectively by Delhougne?® and 
Browne and Vineberg*; by Talbert and Rosen- 
berg!4; by Apperly and Semmens!5; and by 
Nye and Sippe.?® 


commonly associated 


Apperly 17 was the first to apply the above facts as 
a possible explanation of the diminished incidence 
of peptic ulcer in warmer climates when compared 
with the incidence in people of similar habits in 
cooler climates. Ina survey of the Australian States 
he showed that peptic ulcer was commonest in 
Tasmania (latitude 43° O’ S) with an incidence of 
135 per 1000 hospital beds per year, and that the 
figures for the various States gradua'ly diminished, 
as the Equator was approached, to a minimum of 
about 28 in tropical North Queensland (latitude 
21° 10’ S). Later Nye and Sippe?® showed an 
increased incidence of achlorhydria and hypochlor- 
hydria in Queensland as compared with the cooler 
southern States, and in summer as compared with 
winter. This survey is interesting because in 
Australia we have, spread over a huge area ex- 
tending from the tropics to mild and even cold 
zones, an almost pure Anglo-Saxon race with 
almost exactly similar dietetic and other habits. 
When we compare different races with different 
diets of course this relationship to heat and cold 
no longer holds—e.g., among the cayenne pepper- 
eating “Abyssinians, “and the people of Southern 
India with their highly spiced foods, it is not surpris- 
ing to find that the incidence of gastric ulcer is 
unusually high (Bergsma,!8 Bradfield 1°). 

A further “interesting fact is the hypochlorhydria 
and achlorhydria of fevers whether of natural origin 
(Glaessner 2°) or experimentally produced by vaccines 
(Vanzant 21), but it is probable that toxic and other 
factors than the fall of plasma CO, consequent on the 
hyperventilation of pyrexia (Koehler,® Hachen and 
Isaacs 2?) are operating in these cases. 

While the effects of X radiation are still open to 
some doubt, there is considerable evidence that such 
treatment results in a fall of plasma CO, and a rise 
in pH (Iussey,?? Kast et al.,24 Myers and Booher 25), 
i.e., changes similar to those following hyperpnea ; 
but we have no direct evidence of the effects of the 
above on gastric acidity and motility. It is, however, 
of interest to note that X radiation reduces hyper- 


20 + +40 60 80 
RED CELL CONTENT % (HEMATOCRIT) 


2.—Relationship of gastric acidity after a 5 per cent, 


FIG. 


alcohol * meal ” in dogs to red cell content of blood. 


THE LANOET) 


PROF. F. L. APPERLY : GASTRIC ACIDITY AND ITS SIGNIFICANCE 


(san. 4, 1936 7 


acidity, and increases intestinal 
motility even to diarrhea 
(Pohle 2°), 

(b) Fall of plasma CO, second- 
ary to a primary alkali deficit 
usually follows loss or neutralisa- 
tion of plasma alkali by exo- 
genous or endogenous acids. 

The simplest case is that in 
which the ingestion of sufficient. 
ammonium chloride lowers both 
plasma CO, (Haldane,?? Gamble 
et al.,28 Apperly and Semmens !°) 
and gastric acidity, with a pro- 
longation of gastric emptying- 
time (Apperly and Crabtree *). 
Clinically, the same phenomena 
are exhibited in the diminished x 
gastric acidity in the later stages 
of pregnancy (Nakai,?® Davies To 
and Shelly 2°) in which there is a 
fall of plasma CO, due to alkali 
deficit ( Bock,’!? MacNider,’? Rowe 
et all.,33 and others); by the fall 
of gastric acidity after severe 
exercise (Hellebrandt and Miles 34) in which lactic acid 
causes a fall in blood CO, (Bock and Dill,?> Boje,?® 
and others); by the generally lowered acidity i in those 
of poor physical fitness (Bloomfield and Keefer 37) in 
whom there is also usually a lowered plasma CO, 
(Osman and Close 38); and by the hypochlorhydria 
and anacidity of chronic nephritis (Jones,?? Frieden- 
wald and Morrison 4°) in which plasma bicarbonate 
is so commonly diminished (Henderson, Bock et 
al.,44 and many others). 

As regards the effects of diabetic acidosis, several 
text-books state that achlorhydria and hypochlor- 
hydria are commonly found, but I am unable 
to find any statistics corrected for age and sex 
to compare with the figures for normal people. 
It is interesting, however, that insulin increases 
the secretion of gastric acid (Roholm,*? Collazo 
and Dobreff 4), the acidity after a test-meal 
(de Anciaes 44), and gastric motility (Dickson and 
Wilson 45), 

Of the effects on gastric acidity of starvation and 
the diarrhoeal disease, in both of which plasma 
bicarbonate is diminished,*® 8° there appears to be no 
definite evidence; immediately after starvation 


OQ 
© 
P 


ACIDITY AS N. 
Q 
re 


there appears to be some diminution of total acid 


Males 
E a aR 
me xX 


N 


NMN N 


Females 


BLOOD O2 CAPACITY 
© 


30 40 50 
AGE IN YEARS 


10 20 


FIG. 4.—-Variations of average normal hæmoglobin or oxygen capacity with age and sex 
*). 


(modified from Peters and Van Slyke ° 


Males 
Xe Xr 
"aai e 
è Females 2 


30 40 
AGE IN YEARS | 


20 50 60 70 


FIG. 3.—Variations of average normal gastric acidity with age and sex (after 
9); 


Alvarez, Vanzant et al. 


secretion in dogs (Kunde **) but in man Carlson 47 
could find no such changes. 

It is somewhat difficult to place the various 
anoxzmias in the classification here used. In all 
cases hyperventilation leads to diminished plasma 
CO, as in hemorrhage (Bennett,4® Buell 4%), at 
altitudes (Barcroft,®° “Wittkower, $1 Fitzgerald 52), 
and after breathing a low-oxygen atmosphere 
(Koehler, Haggard and Henderson‘). Whereas, 
however, in the early stages the loss of CO, directly 
follows hyperventilation with rise of blood pH— 
which would tempt us to classify this group under 
Class (a)—in the later stages lactic acid formation 
neutralises part of the plasma alkali, with a fall 
of pH. Most of the cases here discussed fall into 
the latter group which is therefore classed under (b). 
In each of the cases mentioned above a lowered 
gastric acidity has been demonstrated—e.g., at ` 
altitudes by Delrue in the case of dogs 71—and by 
Apperly, Crabtree, and Norris for man (unpublished) ; 
after breathing an oxygen-poor atmosphere (Crisler, 
Van Liere, and Wiles,54 Apperly and Crabtree, 
unpublished); and in some of our own observations 
following hemorrhage in both dogs and man. 
In most of the above instances the stomach 

emptying-time was retarded. 

~ Fig. 2 shows the results in 
one of our series of experiments 
on dogs, in which anemia and 
polycythemia were artificially 
produced by bleeding and trans- 
fusion.®! It will be seen that 
gastric acidity rose with red 
cell content up to a maximum 
at or slightly above the normal 
content. (Beyond this, with 
increasing polycythemia, acid- 
ity fell again, The reasons for 
this will be dealt with else- 
where.) Similar figures were 
found in normal and anmmic 
patients. Not only do we have 
acidity changes with the grosser 
forms of anoxemia, but also 
corresponding to those varia- 
tions of hemoglobin which are 
within normal limits. 

Without going into 


60 70 80 


our 


8 THE LANCET] 


experimental work here, we will merely men- 
tion the most interesting and striking similarity 
between the graph representing the average gastric 
acidities for different age- and sex-groups (as 
determined by Vanzant, Alvarez et al. from 3746 
cases,®> Fig. 3) and the graph showing the average 
hemoglobin content of the blood for similar age- 
and sex-groups (from Peters and Van Slyke,*® 
Fig. 4). Further, when the figures in these two 
graphs are plotted against each other, a straight 
line relationship is revealed (Fig. 5). We have of 
course found a considerable individual scattering 
about these average curves. These charts suggest 
two things: (1) that variations in average gastric 
acidity for different age- and sex-groups are at least 


FREE ACIDITY 


+ Males 
e Females 


35 40 45 RBCVOL.% 
I6 18-5 21 OXYGEN CAPACITY 
FIG. 5.—Relationship of average gastric acidity of different 


age and sex groups (taken from Fig. 3) to average hemo- 
globin for the same groups (taken from Fig. 4). 


partly dependent on hemoglobin differences, or 
whatever causes the latter; and (2) that, assuming 
the straight line in Fig. 5 continues as such to the 
base-line, gastric acidity disappears when the hemo- 


globin content of the blood falls to about two-thirds . 


its normal value—i.e., that anæmia can bring about 
achlorhydria. We have indeed found this in patients 
with post-hemorrhagic anemia. This observation 
is of great interest in view of the well-known work 
of Witts and others on the reverse relationship— 
i.e., that certain anæmias are preceded and caused 
by achlorhydria. It would appear that we will 
have to distinguish between Witts’s achlorhydric 
anemia and our anæmic achlorhydria. We hope 
to publish these and other observations in the near 
future. 

Dr. Alvarez has suggested to me that the changes 
in acidity and motility may explain the fact that the 
symptoms of peptic ulcer often improve after a severe 
hemorrhage. 

(e) Primary CO, excess in the plasma is brought 
about either by breathing an atmosphere containing 
an excess of CO, gas (Davies et al. 57), or by any process 
that interferes with the elimination of CO, from the 
blood—e.g., in emphysema (Scott,°& Dautrebande,®°® 
Peters et al. °°), or during an asthmatic attack (Osman 
and Close,?8 Apperly and Norris (unpublished)). 


PROF. F. L. APPERLY: GASTRIC ACIDITY AND ITS SIGNIFICANCE 


[Jan. 4, 1936 


Bakaltschuk t! and Apperly and Crabtree? showed 
the rise in acidity brought about by breathing an 
atmosphere containing 3-5 per cent. CO, or by 
rebreathing one’sownCO,. Johnston and Washeim °? 
showed the same result during sleep, when plasma 
CO, rises, possibly on account of a diminished 
sensitiveness of the respiratory centre, resulting in 
CO, retention (Endres °°), 

R. J. Main, jn this laboratory, has shown a close 
linear relationship between alveolar CO, per cent. 
and the ratio of pulmonary vital capacity to body 
surface (unpublished)}—.e., that healthy large-lunged 
individuals have a higher alveolar CO.. Full and 
Herxheimer êt have also found a decidedly higher 
average alkali reserve in athletes than in untrained 
men. This high blood alkali or CO, in normal 
people indicates an optimum oxygenation (Gesell °°), 
It is therefore not surprising that the big-chested, 
athletic type of man has, on the whole, a higher 
gastric acidity than the opposite physical type 
(Campbell and Conybeare,®® Vogeler 7). Apperly 
and Semmens?5 demonstrated a rough correlation 
between gastric acidity and the ratio of pulmonary 
vital capacity to body-weight. 

Another cause of increased plasma CO, is constric- 
tion of the bronchioles. We have found this in 
a number of asthmatics during an attack, but of the 
effect on gastric acidity of bronchiolar constriction 
brought about, for example, by asthma, noxious 
gases, and possibly by smoking with inhalation, we 
know nothing. The hyperchlorhydria of many 
smokers is generally attributed to the direct effect 
of swallowed irritants on the gastric mucosa. Possibly 
an increased bronchiolar constriction, reflex or 
direct irritation, might be a factor. 

(d) Increased plasma CO, secondary to primary 
alkali excess has been demonstrated experimentally 
after the ingestion of large doses of sodium acetate 
and other alkaline salts by Davies and Haldane,** 
Palmer et al.,68 Gesell and Hertzman,®® and others, 
and clinically during a course of Sippy’s diet (Kast,?? 
Myers and Booher ?5). That gastric acidity is raised 
under the same conditions has also been shown by 
Apperly and Crabtree? and by Ifardt and Rivers *° 
respectively. The former also observed an increased 
gastric motility. 

The accompanying Table is a summary of the above 
observations. 


RELATION OF GASTRIC ACIDITY TO BLOOD pH 


In the Table Groups (a) and (b) are associated with 
diminished plasma CO, and (c) and (d) with increased 
plasma CO,. On the other hand, those conditions 
in which pH is increased are found in Groups (a) 
and (d), while (b) and (c) contain those associated 
with a fall of pH. It will be seen that gastric acidity 
follows variations in CO., but has no relationship 
to blood pH. 


RELATION OF GASTRIC MOTILITY TO BLOOD pH 


Although few observations have been made on the 
relation of gastric motility to blood chemistry, 
the evidence presented above and summarised 
in the Table shows that experimental and clinical 
variations of the plasma CO, associated with increased 
gastric motility fall in Groups (a) and (d), while those 
associated with a retarded emptying rate fall in 
Groups (b) and (c). This seems to indicate that blood 
pH is a factor in determining gastric motility, these 
two varying in the same direction. 


THE LANCET] 


PROF. F. L. APPERLY : GASTRIC ACIDITY AND ITS SIGNIFICANCE . $, 


Table showing Relation of Gastric Acidity and Emptying- 
time to Blood Bicarbonate and pH 


Figures denote references 


(a) PRIMARY CO, DEFICIT 


Plasma Blood Gastric | Gastric 
=. CO, pH acidity. |motility 
Dim. Inc. Dim Inc. 
Hyperpnea.. 4, 5,6 4, 5, 6 3,13 
Hot room 7 7 14 
Hot baths Es 8, 9, 10 10 15 15 
Tropics a a 11, 12 12 16 
Fevers oe a 9, 22 9 20, 21 
Altitudes 50, 51, 52 50 71, 72 
Encephalitis 73, 74 73 ne aA 
X radiation .. 23, 24, 25 123, 24, 25 E 26 
Some cardiac failures 
withoutpulm. comp. 75, 76, 
(6) PRIMARY ALKALI DEFICIT 
— Dim. Dim Dim. Dim 
Ingestion of amm. 
chloride or HCl] .. |27;28, 77,2) 28, 77 2,3 2 
Chronic nephritis 41 etal. 41 39, 40 
Diabetes 78,25 78, 25 Tk. acs 
Severe exercise š 35, 36, 74 | 35, 74 34 34 
Menstruation a 38 on 83 
- Pregnancy .. 31, 32, 33 | No pH 29, 30 
changes 
reported. 
Anoxemia chronic .. 53, 4 53, 4, 81 54, 72 54, 72 
Hemorrhage severe 48, 49 48, 82 Fig. 2. 9i 
Poor physical Arness 38, 64, 15 a 37 15 
Starvation . 79 79 46 De 
Infantile diarrhæa . 80 80 a | 
Some cardiac failures 
near death ae 75 75 ie | 
Tk. =Text-book statement. 
(C) PRIMARY CO, EXCESS * 

— Inc. Dim. Inc. Dim 
Breathing Goi ss 57 84, 85 2, 3. 61 2 
Sleep. 63 za 62 62 
Large VC: t or so 86 87 15,66 | 67,15 
Emphysema ~. | 58, 59, 60 59 
Ast bmatió attacks .. 38, 72 
Certain cardiac fail- 

ures with CO, 
retention .. ene 75, 88 75, 88 


* This group is often complicated by anoxremia, hence may 
overlap Group (b). tSee text. ł Alveolar CO». 


(d) PRIMARY ALKALI EXCESS 


— Inc. Ine Ine Inc 
Ingestion pinanne 
salts .. 157,68, 69,2) 57,69 |2, 3, 89, 90 2 
Sippy diet . 24, 25 24,25 2, 70 Dt 
Insulin following dia- 
betic acidosis | 42, 43, 44 45 
Dim, =diminishbed. Inc. =increased. 


Pulm. comp. =pulmonary complications. 


PRACTICAL CONSIDERATIONS 


The preceding suggest some possible practical 
applications :— 

1. Hyperchlorhydria and the symptoms associated 
with it might be diminished by, among other things, 
(i) removal to a warm climate, (ii) araea fever, 
(iii) heat treatment, (iv) bleeding, and (v) the substitu. 
tion of oxides and non-absorbable bicarbonates for 
the usual sodium bicarbonate treatment, since the 
latter salt in large amount, by increasing plasma 
CO,, may actually raise gastric acidity, 


[san. 4, 1936 9 


2. Certain of the hypo-acid dyspepsias are more 
likely to be influenced by attention to the underlying 
anoxemia or acidosis than by direct local treatment. 
A search for the causes of a low plasma CO, may be 
fruitful, since it may give a clue to the underlying 
pathological conditions. 

3. In dealing with cases in which achlorhydria or 
hypochlorhydria is associated with anæmia, it might 
be well to investigate which of these conditions is 
primary—i.e., whether we are dealing with an anemic 
achlorhydria or an achlorhydric anemia (Witts). 


SUMMARY 


Gastric acidity after a meal is chiefly a function 
of the blood CO,. In normal people this is regulated 
by the hemoglobin content of the blood, by the 
ratio of the pulmonary vital capacity to body-weight 
(or surface), and by temperature. Under abnormal 
conditions anoxzemia, anemia, altitudes, pregnancy, 
nephritis, fevers, diabetes, severe exercise, and lowered 
physical fitness may diminish plasma CO, and there- 
fore gastric acidity. Asthma, emphysema, &c., 
which raise plasma CO., would be expected to raise 
gastric acidity, while encephalitis, X radiation, and 
certain cardiac conditions, which lower plasma CQ,, 
would be expected to lower gastric acidity; but 
these effects have not been investigated. The acidity 
of the gastric juice is a rough measure of the alkali 
reserve of the blood (except in marked anæmia), 
while the rate of gastric evacuation would seem to 
be influenced partly, at least, by blood pH. A 


consideration of the possible causes of such variations 


of plasma CO, and pH may give valuable hints as 
to the pathological conditions underlying certain 
dyspepsias. 

There is also a direct relationship between the red 
cell content of the blood and gastric acidity. When 
the former falls to about half or two-thirds normal 
(on the average) free acid disappears from the stomach. 
A distinction is therefore made between the achlor- 
hydric anemia of Witts and anzemic achlorhydria. 


Part of the expenses connected with this work 
was generously borne by Parke, Davis and Co. 


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10 


THE LANCET] 


PROF. B. ZONDEK : FOLLICULAR HORMONES AND THE PITUITARY GLAND 


[san. 4, 1936 


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47. Carlson, A. J.: Ibid., 1918, xiv., 120. 

48. Bennett, M. A.: Jour. Biol. Chem., 1926, lxix., 675. 

49. Buell, M. V.: Ibid., 1919, xl., 29. 

50. Barcroft, J., Binger, C. A., Bock, A. V., et al. : Phil. Trans. 
Roy. Soc. B., 1922, cexi., 351. 

51. Wittkower, E.: Pfliigers Arch. f. d. ges. Physiol., 1933, 
cexxxiii., 607. 

52. Bivecrald, M. P.: Phil. Trans. Roy. Soc. B., 1914, Ixxxviii., 


48. 

53. Koehler, A. E.: Amer. Jour. Physiol., 1923, Ixiii., 404. 

54. Crisler, G., Van Liere, E. J., and Wiles, I. A.: Amer. Jour. 
Digst. Dis. and Nutrit., 1935, ii., 221. 

55. Vanzant, F. R., Alvarez, W. C., Enstermann, G. B., Dunn, 
i hae Berkson, J.: Arch. Internal Med., 1932, 
xlix., 345. 

56. Peters, J. P., and Van Slyke, D. D.: Quantitative Clinical 
Biochemistry: Interpretations, Baltimore and London, 
1932, p. 545. 

57. Davies, H. W., Haldane, J. B. S., and Kennaway, E. L.: 
Jour. of Physiol., 1920, liv., 32. N 

58. Scott, R. W.: Arch. Internal Med., 1920, xxvi., 544. 

59. Dautrebande, L.: Compt. rend. Soc. de Biol., 1925, xciii., 


Jour. 


Jour. Pharm. and 


° 


60. Peters, J. P., Bulger, H. A., and Eisenman, A. J.: 
Clin. Investig., 1925, iii., 497. 

Bakaltschuk, M.: Klin. Woch., 1928, vii., 1551. 

62. Johnston, R. L., and Washcim, H.: Amer. Jour. Physiol., 
1924, Ixx., 247. : 

63. Endres, G.: Biochem. Zeits., 1923, exlii., 53. 

64. Full, F., and Herxheimer, K.: Klin. Woch., 1926, v., 228. 

65. Gesell, R.: Physiol. Rev., 1925, v., 551. 

66. Campbell, J. M. H., and Conybeare, J. J.: 
Rep., 1924, Ixxiv., 354. 

67. Vogeler, K.: Arch. f. Verdauungskr., 1919, xxv., 480. 

68. Palmer, W. W., Salvesen, H., and Jackson, H.: Jour. 
Biol. Chem., 1920, xlv., 101. 

69. Gesell, R., and Hertzman, A. B.: 
and Med., 1925, xx., 298. 

70. Hardt, L. C., and Rivers, A. B.: 
1923, xxxi., 171. P 

71. Delrue, G.: Arch. internat. de physiol., 1934, xxxviii., 126. 
Delrue, G., and Lacquet, L.: Compt. rend. Soc. de biol., 
1933, cxiv., 570. f 

72. Apperly, F. L., Crabtree, M. G., and Norris, J. H.: 
(unpublished). . 

73. Harrop, G. A., and Loeb, R. F.: Jour. Amer. Med. Assoc., 
1923, Ixxxi., 452. 

74. Peters, J. P., Bulger, H. A., ct al.: Jour. Biol. Chem., 1926, 
lxvii., 176. 

75. Fraser, F. R.: THE LANCET, 1927, i., 529 ct seq. , 
76. Meakins, J. C., and Davies, H. W.: Respiratory Function 
in Disease, Edinburgh and London, 1925. : 
Gamble, J. L., and Ross, S. G.: Amer. Jour. Dis. Child., 

1923, xxv., 470. 
78. Bock, A. V., Ficld, H., and Adair, G. S.: Jour. Metab. Res., 
1923, iv., 27. 
79. Gamble, J. L., Ross, S. G., and Tisdall, F. F.: 
Chem., 1923, lvii., 633. : 
80. Howland, J., and Marriott, W. McK.: 
Child., 1916, xi., 309. 
Gesell, R., and Hertzman, A. B.: 
1927, Ixxxii., 591 and 608. 
82. Johnston, C. G., and Wilson, D. W.: 
1930, Ixxxv., 727. © 
83. Vanzant, Il’. R., and Alvarez, W. C.: 
Mayo Clinic, 1931, vi., 419. : f 
84 Ege, R. and Henriques, V.: Biochem. Zeits., 1926, clxxvi., 


Jour. 


Guy’s Hosp. 


Proc. Soc. Exp. Biol. 
Arch. Internal Med., 


-J 
=J 
e 


Jour. Biol. 
Amer. Jour. Dis. 


Amer. Jour. Physiol., 


a 
m 


Jour. Biol. Chem., 


Proc. Stait Meet. 


441. , 
85. Gesell, R., and Hertzman, A. B.: Amer. Jour. Physiol., 
1926, lxxviii., 610. 
86. Main, R. J.: (unpublished). 
87. Peters, J. P., and Van Slyke, D. D.: 
i p. 940, fig. 103. 
88. Peters, J.P., and Barr, D. P.: Jour. Biol. Chem., 1920, xlv., 
53 i 


7. 
89. Szilard, Z.: Deut. Arch. f. klin. Med., 1930, clxviii., 360. 
90, Crohn, B. B.: Amer., Jour. Med. Sci., 1918, clv., 801. 
91. Apperly, F. L., and Cary, M. K.: (unpublished). 


Op cit. (ref. 56), 


THE INHIBITORY EFFECT OF 
FOLLICULAR HORMONE 


ON THE ANTERIOR LOBE OF THE 
PITUITARY GLAND 


By BERNHARD ZONDEK, M.D. 
PROFESSOR IN THE HEBREW UNIVERSITY OF JERUSALEM 


(From the Gynecological and Obstetrical Department 
of the Hadassah-Rothschild Hospital, Jerusalem) 


IN previous papers I have been able to determine 
the following facts. The anterior pituitary is the 
motor of sexual function. The gonadotropic hor- 
mones of the anterior pituitary represent the superior 
sexual hormones. The anterior lobe stimulates the 
secretion of (a) folliculin (cestrin) in the theca cells by 
means of prolan A (follicle-stimulating hormone), 
and (b) progestin, in the granulosa cells by means of 
prolan B (luteinising hormone). Without the 
anterior lobe there is no folliculin. The follicular 
hormone, produced in the ovary through the action 
of the follicle-stimulating hormone (prolan A), 
reacts in its turn upon the anterior lobe. 

The present paper is a preliminary report of experi- 
ments in which I have studied the inhibitory effect 
of the follicular hormone given over long periods in 
amounts much larger than those ordinarily produced 
in the body— given, that is to say, as a drug. Else- 
where I shall report the effect of these large doses of 
follicular hormone on its effector organ, the uterus, 
and I now propose to describe their effect on the 
controlling gland, the anterior pituitary. 

My first finding is that the hormonic function of 
the anterior pituitary can be inhibited. 


INHIBITION OF THE GROWTH HORMONE 


The experiments were performed on rats. Infantile 
rats, 3-4 weeks old, weighing 25 g., received sub- 
cutancous injections of follicular hormone twice a 
week. These injections consisted of either «-hormone 
in aqueous or oily solution, or the benzoic ester of 
the dihydrofolicular hormone (Dimenformon).* The 
control animals received injections of normal saline 
or olive oil. In doses of 100 M.U. (mouse units) 
twice a week folliculin had no effect on body growth. 
After four months’ treatment, with a total amount 
of 2900 M.U., the treated animals were of the same 
sizo and weight as the controls. On tho other hand, 
when 1000 M.U. was applied twice a week, definite 
inhibition of growth was seen in 4} wecks (after a 
total of 9000 M.U.). The larger the amount of hormone, 
the greater the inhibition of growth. The effect is 
very obvious if 5000 or 10,000 M.U. dimenformon 
is applied twice a week. A slackening of growth is 
apparent within a short time, though it only becomes 
realy definite when the animals have reached the 
juvenile stago and weigh 70 g. While the weight 
curve steadily rises in the control animals, the curve 
of those which have been treated remains constant 
or rises very little. After 3-4 months’ treatanent— 
e.g., after the application of 100,000-200,000 M.U.— 
a difference in weight amounting to as much as 
43 per cent. may be shown. For instance, the 
control animals weigh 164 g., and the treated animals 
96°5 g. l 

lf the experiments are performed on juvenile 
animals with a weight of 70 g., their growth may 


*I am indebted to tho Organon (Oss) for kindly supplying 
largo amounts of Folliculin Menformon and Dimenformon. 


THE LANCET] 


similarly be inhibited. The application of 5000 M.U. 
folliculin twice a week produces inhibition after 
three weeks (total 30,000 M.U.), and if continued 
for 3—4 months (120,000-160,000 M.U.) leads to a 
difference in weight amounting to 20 per cent. The 
earlier the experiments are begun—i.e., the younger 
the animals—the more striking is the inhibition of 
growth. Itis seen equally in male and female animals. 

The relation between growth inhibition and the 
dose of hormone is shown in the accompanying 
Table. The inhibition affects the skeleton as well 
as the organs. The treated animals are shorter, and 


Table’ showing Growth Inhibition resulting from 
Follicular Hormone 


(A) INFANTILE ANIMALS 


t 4+3 
"h A 
2a 
Dura : oS 
dom otl total, Ega 
Sex.| Preparation. Dose. real Foll.- |a33 > 
mn | Ment. po Ba 
weeks,| U2 m.u. 59 a3 
Or p 
F Foll.-Menf 100 m.u. twice a 16 2900 0 
aqu. sol. week. 
(a-hormone). 
M. | Foll.-Menf. 1000 m.u. twice 54 | 12,000 9:6 
aqu. sol. a week. 
F. ey 500 m.u. twice a 124 | 13,500 11°1 
week. 
M Dimen- 5000 m.u. twice 54 | 60,000 32°7 
formon. a week. 
M s 10,000 m.u. twice 54 | 120,000 31°7 
a week. 
F. 5 5000 m.u. twice 15 |130,000 30 
a week. 
F. n 124 | 145,000 23 
Initial injection 
of 15,000 m.u., 
then 5000 m.u. 
twice a week. 
M. 53 12% | 145,000 43°3 
F. a Initial injection 1239| 225,000 30:7 
of 15,000 m.u., 
then 10,000 m.u. 
F. i 2. twice a week. 124 275,000 39 
(B) JUVENILE ANIMALS : 
F. | Foll.-Menf. | 5000 m.u. twice 15% ' 155,000 26.3 
oily sol. ` a week. l 
F. | Foll.-Ment. TE 174 | 190,000 | 23°5 
aqu. sol. l 


* No treatment from 8/8 to 21/8. 
Foll.-Menf.=Foliculin-Menformon. 
aqu. sol.= aqueous solution, 
oily sol.= oily solution. 


the bones are more delicate. As an example I report 
the differences in weight of one of the experiments. 


Control animal.—The femur weighs 0°35 g., tibia and 
fibula 0°31 g. 

Folliculin animal (R 117) (five months’ treatment with 
a total of 205,000 M.U.).—The femur weighs 0°29g., 
tibia and fibula 0°24 g.—i.e., a difference in weight of 
17 and 22 per cent. respectively. 


The anatomical changes in the epiphyseal lines 
will be reported in a separate communication. 

Mention may further be made of changes in the 
fur of animals under treatment. The hair is rough 
and shaggy, and shows a tendency to fall out, parti- 
cularly in the gluteal region. 

The experiments demonstrate the possibility of 
inhibiting growth by prolonged application of large 


PROF, B. ZONDEK: FOLLICULAR HORMONES AND THE PITUITARY GLAND [JAN. 4, 1936 11 


amounts of follicular hormone. The younger the 
animal, the more intense the inhibition. The retarda- 
tion is particularly conspicuous during the puberty 
of the rats—i.e., ata weightofabout 70g. H.M. Evans 
and Long were able to demonstrate that the growth of 
rats can be increased by injection of anterior pituitary 
extracts. My experiments show, conversely, that 
large doses of follicular hormone may destroy the 
effect of the growth hormone of the anterior pituitary. 
Evans and Long produced giant animals by means of 
growth hormone, while I produce dwarf animals by 
means of follicular hormone. The fact that the inhibi- 
tion of growth results from the paralysis of the growth 
hormone caused by the follicular hormone becomes 
evident when we find that the gonadotropic hormones 
which are produced in the anterior lobe may equally 
be inhibited. 


INHIBITION OF THE GONADOTROPIC HORMONES 


The sexual organs of the animals whose growth 
has been inhibited by follicular hormone show definite 
changes. Prolonged application of the hormone 
induces a continuous oestrus, with the result that 
vaginal smears regularly show cornified cells. The 
vagina is thickened and hyperplastic, and the mucous 
membrane proliferates. The uterus also shows much 
enlargement, and the myometrium is in the stage of 
pronounced proliferation. These enlarged genital 
organs contrast remarkably with pale and small 
ovaries, which may undergo so great an involution 
that they are no longer recognisable as such. While 
abundant corpora lutea are to be found in the control 
animals, they are absent in the ovaries of the treated 
animals. In serial sections small follicles are usually 
to be found, also some follicles of average size, but 
rarely large follicles, and never corpora lutea. This 
difference clearly manifests itself in reduction in 
the weight of the ovaries. When the application of 
follicular hormone was started in the juvenile stage 
(the animals weighing 70 g.), administration of 
165,000 M.U. during 16 weeks caused a reduction of, 
e.g., 20 per cent. in body-weight and 58 per cent. in 
the weight of the ovaries. The ovaries of the control 
animals weighed 37 mg., those of the treated animals 
15 mg. 

The development of the ovaries is retarded by the 
prolonged application of follicular hormone; the 
follicles do not rupture, and corpora lutea are not 
formed. This effect undoubtedly originates in the 
following fashion: follicular hormone paralyses the 
gonadotropic hormones of the anterior pituitary— 
and, as it appears, the luteinising hormone, prolan B, 
in particular—thus hindering them from exerting 
their normal influence on the ovaries. 

The same reaction is to be observed in the male. 
It has long been known that folliculin has an anti- 
masculine effect, and that the testes diminish in 
size when it is administered. The way in which 
this happens has not hitherto been explained, but my 
experiments demonstrate that it is due to inhibition 
of those hormones of the anterior pituitary which 
stimulate testicular development. In the experi- 
ments previously described by other workers and 
by myself, relatively small doses of folliculin were 
used; but I am now able to show that if male rats 
are given doses sufficient to arrest their body growth 
tremendous changes in the testes are produced. 
This may be illustrated by the following example. 


. Male rat, 4 weeks old, and weighing 30 g., received one 
injection of 15,000 M.U. dimenformon, followed by regular 
application of 5000 M.U. twice a week. After three months’ 
treatment, with the total dose of 155,000 M.U., the animal 


12 THE LANCET] 


weighs 94 g., while the control animal weighs 160 g.t 
—a difference of 41 per cent. In the control animal the 
weight of the mature testis was 1000mg., but in the 
treated animal only 50 mg.—a difference of 95 per cent. 
The testes of the treated animal remained at the infantile 
stage seen in animals two weeks old. 


The development of the genital apparatus (testis, 
spermatogenesis, prostate, and seminal vesicles) is 
completely arrested by prolonged application of 
folliculin. 

In a further report I hope to describe the effects 
of large doses of folliculin on the thyrotropic hormone 
and other hormonotropic active principles, as well 
as the changes in the anterior lobe of the hypophysis 
of the treated animals. The importance of these 
results in clinical work will be discussed later. 


INTRAVENOUS CURARINE IN THE 
TREATMENT OF TETANUS 


By RANYARD WEsT, M.D., M.R.C.P. Lond. 


BEIT MEMORIAL RESEARCH FELLOW ; DEMONSTRATOR OF PHARMA- 
COLOGY IN THE UNIVERSITY OF OXFORD ; ASSISTANT PHYSICIAN 
TO THE SEAMEN’S HOSPITAL, GREENWICH 


CURARINE is the commonest active principle of 
curare. It is responsible for the characteristic 
action of the curares of British Guiana and its 
presence in these is constantly due to the bark of 
a ligneous vine, Strychnos toxifera, which is a chief 
ingredient of the native mixture. 

Curarine is a quaternary alkaloid which can be 
prepared in crystalline form either from suitable 
curare or direct from S. toxifera. It is the latter 
source which has enabled the alkaloid to be prepared 
in quantity recently (King, 1935). 

The action of curarine is the classical one of curare— 
a paralysis of muscle from a failure of the effective 
transmission of the impulses travelling to it along 
the motor nerve. Death from curarine is due to 
asphyxia following failure of the respiratory muscles. 
But the paralysing action of curarine is not necessarily 
sudden, complete, and universal; it is graded 
quantitatively and has a selective anatomical distribu- 
tion. Experimentally, in animals, small doses cause 
a failure of maintenance of contraction (response to 
electrical tetanus) while the response to single stimuli 
remains good. Recently curarine has been found to 
act selectively on certain rates and strengths of 
electrical stimuli (Briscoe, 1935). Further, the 
pathological conditions of decerebrate rigidity in the 
cat and of experimental local tetanus have been found 
by Bremer (1927) to respond selectively to curare, 
and, in the case of decerebrate rigidity, to curarine 
(1935). Anatomically, the order of sensitivity of 
muscles is strikingly constant, viz.: (1) muscles 
receiving a cranial nerve-supply; (2) the skeletal 
muscles generally, including the intercostal muscles ; 
and (3) the diaphragm, 

Curare has been introduced into therapeutics and 
abandoned on many occasions since the middle of 
last century. The irregular strengths and composi- 
tions of curares would make their standardisation 
very difficult. Curarine was isolated from curare 
by Preyer (1864) and tried therapeutically by 
Hoffmann (1879). It was prepared from 8S, toxifera 
by Boehm and given to a case of tetanus by Hoche 
(1894), (Hale-White, 1901). Recent partial successes 


t The control animals received olive oi] subeutancously twice 
a week in the same amounts as were used for the oily solution 
of dimenformon in the treated animals. 


DR. R. WEST: INTRAVENOUS CURARINE IN TETANUS 


[san. 4, 1936 


in treating chronic pathological rigidities with some 
crude curares (Hartridge and West, 1931; West, 
1932) has led to a collection of plant material ind a 
resurvey of the pharmacology of curarine (West, 
1935). Meanwhile Cole (1934) and Mitchell (1935) 
have reported cases of acute tetanus treated with 
curare and with curarine respectively. Florey, 
Harding, and Fildes (1934) gave curarine to animals 
in experimental tetanus. 

In our animal experimentation it was noticed that, 
in the cat, a clear removal of decerebrate rigidity 
without failure of respiration could be maintained 
only by giving the drug very slowly. The intravenous 
route was found much safer than the subcutaneous in 
that by it partial recovery will occur within a few 
minutes of stopping the inflow of the drug. A 
tendency to bronchial spasm and hypersecretion 
was met by atropine or adrenaline, for rapid action 
the latter being preferable. This intravenous tech- 
nique was transferred to man and tried in a volunteer 
suffering from advanced parkinsonism. The method 
finally adopted, and here described, formsa provisional 
suggestion for the treatment of severe cases of tetanus. 


Method of Treatment 


The apparatus used is the following :— 


l. An intravenous drip outfit, with duplication of 
reservoir and dripper. The dripper must be calibrated. 
The Canny-Ryall or Farquharson dripper commonly 
delivers from 500 to 700 drops per ounce of fluid. The 
vein may be entered either by needle or cannula. 

2. A malleable gutter splint to fix the arm in a comfort- 
able position. 

3. Artificial respiration equipment: endotracheal 
catheter—e.g., St. Bartholomew’s type (grey), small, 
medium, or large. Two oxygen cylinders, with good 
fine adjustments on the taps; glass junctions for tubing. 

4. Direct-vision laryngoscope. 

5. Mason’s gag, tongue forceps, mounted swabs (as 
anvsthetist’s tray). 

6. Adrenaline solution 1 : 1000. 

7. Curarine chloride in solution, 100mg. of the solid 
to a pint of saline or glucose saline. 


Dose.—The standard rate of curarine inflow may 
be taken as 0:25 mg. per kg. of body-weight per hour. 
The rate of drip required to deliver this may be 
calculated as follows :— 


Drops per minute = 
ing. curarine per pint saline x 60. 


If the curarine is made up at a strength of 100 mg. 
to the pint, the patient’s weight is 70 kg., and the 
dripper is found to deliver 600mg. per oz., this 
becomes— 


Drops per minute =275 x 70 x 600 x 20 _ 35 


100 x 60 


A pint of solution lasts about six hours. 
Technique.—An initial dose of atropine (gr. 1/50) 
is given subcutaneously, and ten minutes later an- 
intravenous needle is strapped in position in a suitable 
vein on an arm which is splnted so as to flex the 
elbow at some 30°. (The fully extended arm was 
found a very painful posture.) A can of warmed 
glucose saline with a visible drip attachment is 
connected, and curarine added to the solution so 
as to deliver 0:25 mg. per kg. per hour to the patient. 
It is convenient if it is arranged so that this is 
equivalent to about 30 drops per minute in the dripper. 
A second can of warmed normal glucose saline 
connected to the intravenous system near the patient’s 
arm is a valuable means of securing fluid and food 
to the patient and of preventing clotting in the 


THE LANCET] 


needle or vein whenever the curarine-saline has to 
be turned off. 

At first the curarine-saline is run in at six times its 
“maintenance rate’’—e.g., 3 drops per second—so 
that 0-25 mg. per kg. is delivered in about ten minutes. 
This should be sufficient for curarisation, and during 
the administration the patient is closely watched, and, 
if well enough, interrogated about his sensations. 


Curarisation.—A muscular weakness in the distribu- 
tion of the cranial nerves is to be expected as the sign 
of partial curarisation. The patient may complain 
that his head is heavy, that his tongue will not move, 
or of diplopia. Ptosis is usually the first objective 
sign-of curarisation, but weakness of other motor 
cranial nerves may be noted early. At the first 
sien of curarisation it is wise to halve the rate of 
inflow. But, speaking from my present limited 
experience, I would designate as the best sign of 
effective curarisation a change in the breathing. 
A nurse will record the breathing as “shallow.” 
Actually intercostal respiration almost or quite 
ceases, abdominal (diaphragmatic) respiration con- 
tinuing steadily and without effort. The change is 
often sudden and indicates that curarisation has 
gone as far as it can be taken unless respiratory failure 
is to be courted deliberately. 

On completion of the induction of curarisation, 
the inflow is stopped for about five minutes and then 
restarted at the maintenance level of 0-25 mg. 
per kg. per hour. For the first hour its effects should 
be watched closely, as the rate may be too high and 
lead to an actual shallowness or a visible effort 
in abdominal breathing, or too low, with resultant 
return of intercostal breathing or an increase of the 
pathological rigidity. 

In a case of tetanus with persistent tonic rigidity 
of jaw, neck, and abdomen, there should be marked, 
if not complete, relaxation of these muscles when 
curarisation has occurred to the level indicated. 
With an ordinary sized dripper (e.g., the Canny- 
Ryall) a pint of curarine-saline, dripping at a rate of 
30 drops per minute, may be expected to last about 
six and a half hours. Animal experiments suggest 
that atropine (gr. 1/100 to 1/50) should be given 
subcutaneously every four hours, if bronchial spasm 
and hypersecretion are to be avoided. Should they 
occur, adrenaline is probably a better immediate 
remedy. 

It is not yet possible to say how long treatment 
by curarine, drip can be maintained in tetanus. 
In Case 2 (below) it was continued for 20 hours without 
difficulty, other than from (avoidable) clotting in 
the needle. 

Sleep remains an important desideratum. I think 
a small nightly dose of morphine may be given safely, 
and the treatment is not incompatible with light 
Avertin anesthesia (0-05 c.cm. per kg.). The patient 
to whom this was given slept well and yet lghtly 
for three hours. Weakness of the muscles of degluti- 
tion may cause difficulties and accidents in swallow- 
ing, and if these occur a feeding-tube should be 
passed early and kept in position as along as is 
necessary. 

If dangerous spasms occur they are likely to be 
respiratory in type, and particularly bronchial. 
These may be due to the tetanus. But pure curarine 
is itself capable of causing bronchial and laryngeal 
spasm in animals, and the history of one patient 
(Case 13) shows this to be a real danger of curarine 
in man. So sudden may the onset of the spasm 
be, that, even when it is watched for and the requisite 
apparatus is immediately to hand, it may be difficult 


DR. R. WEST: INTRAVENOUS CURARINE IN TETANUS 


[yan. 4, 1936 13 


to deal with. An intermittent closure of the glottis 
occurs, and an endotracheal catheter has to be 
passed during the first possible moment of relaxation 
if the patient’s airway is to be secured. I have used 
the St. Bartholomew’s type (grey) intratracheal 
catheter in one emergency of this kind, and found 
it satisfactory. A rapid stream of oxygen should 
be delivered through the catheter. Consciousness 
is lost very early; the catheter should be retained 
until there are signs of its return, and only removed 
then if spontaneous breathing is active. 

In critical cases of tetanus adequate relaxation 
may be incompatible with the retention of spontaneous 
respiration. Curarisation may then be deliberately 
deepened, and a means of artificial respiration provided. 
The Bragg-Paul Pulsator (Messrs. Siebe Gorman 
and Co.) can be used. But in view of the risk of. 
bronchial spasm it is essential to be able, in addition, 
to deliver oxygen directly to the lungs by the endo- 
tracheal catheter. For, in animals under severe 
curarine spasm, it is impossible to perform effective 
artificial respiration by a compression method. 


Ten Cases of Tetanus 


The accompanying Table summarises 10 cases of 
tetanus treated during 1935. They illustrate the 
observation that when the incubation period is under 
Seven days or the period of development of symptoms 
to the point of generalised convulsions less than 
three days, death must be expected whatever the 
treatment adopted. Cases 1, 2, 3, 4, 8, 9, and 10 
fall into this category, and though their treatments 
were various, all the patients died. Of these 7 cases 
it will be noted that, in 5, death occurred not later 
than the day after the onset of general convulsions. 
The exceptions are Cases 2 and 10. The former was 


‘given intravenous curarine, the latter avertin in 


repeated doses. Case 10 was exceptional in the very 
long incubation period of 19 days being followed a 
day later by generalised convulsions. On the twenty- 
second day of his illness the patient, a man of 63, 
appeared to be improving. Acute hyperpyrexia 
occurred, with cardiac failure, on the twenty-third 
day. The case treated with curarine (No. 2) is 
described below. 

Of the three cases in which the outcome was 
reasonably in doubt (Nos. 5, 6, 7) two had an incuba- 
tion period of seven days, and one of these recovered. 
Cole (1934) recorded the treatment of such a patient 
with curare and his subsequent recovery. This 
patient (No. 5) was a boy of 13. He received no 
curare and no special treatment beyond repeated anti- 
tetanic serum and a chloral and bromide mixture. 


CASES TREATED WITH CURARINE 


CasE 2 was extremely severe. The incubation period 
was five days and the generalised convulsions occurred 
on the following day. On admission, 60,000 units of 
antitetanic serum had been given. Paraldehyde grs. 60 
and bromide grs. 40 had been given repeatedly. I saw 
the patient early on the seventh day. There was a high 
degree of tonic spasm of the jaw, neck, and abdominal 
muscles. 

Treatment.—After atropine gr. 1/50, curarine 12 mg. 
was given intravenously, taking seven minutes over the 
injection. Complete ocular ptosis resulted, with partial 
relaxation of the muscles of the jaw, neck, and abdomen. 
Curarine is rapidly excreted, and much of the rigidity 
returned within 30 minutes. When full rigidity had 
returned, 10mg. of curarine in 10c.cm. of solution was 
injected intravenously during four minutes. Full relaxa- 
tion of the trismus occurred, the patient supporting his 
fallen jaw in his hand. Relaxation of the neck and 
abdominal muscles followed. Fifteen minutes later, and 


ee ek Ee ED ot A ee Pee een ee EN at tgs a ee ee ge en ee 


14 THE LANCET] 


DR, R. WEST: INTRAVENOUS CURARINE IN TETANUS 


[yan. 4, 1936 


Table of Oases of Tetanus, 1935 


Incubation and 


development. Treatment. 
Case (a) 
and | Onset. Outcome 
Probable (b) Serum 
ABC.) site of co a. and Gen Ta 
Jed sions. | period. special. 
Day. | Units 
1 | Splinter| (a) 5th | 490,000! Sedatives. | Fatal spasm on 
(9) | in foot. | (b) 6th 2nd day of sym- 
ptoms, 7th day. 
2 Nail in | (a) 5th | 200,000) Curarine in- | 8th day. Resp. 
(27)| foot. | (0) 6th |3days.| travenously | spasin and as- 
20 hours. phyxia. 
| Avertin 0°05 
l c.cm. per 
kg. once. 
3 "3 (a) 5th | 120,000) Avertin 0°05] 8th day convul- 
(c. (b) 7th | 2 days. jc.cm. per kg.| sions ceased: 
50) 2-hourly. hypostatic 
pneumonia. 
4 | Splinter] (a) (b) — — Death under light 
(9) | in leg. qth chloroform 
ether anæs- 
thesia, for djag- 
nostic lumbar 
| puncture. 
5 — (a) 7th | 24,000 Chlora]l 3 convulsions on 
(13) (b) 10th] 2 days, grs. 10, 10th day. llth 
365,000} bromide day improving. 
8 days. ers. 15, 34th day re- 
4-bourly. covered. 
6 Nailin (a) 7th | 192,000) Curarine in- | 12th day. Resp. 
(32)| foot. (b) 11th] 2 days.| travenously.| spasm, cardiac 
failure. 
7 Cut |(a) 10th| 150,000 Curarine sub-| 15th day. Fatal 
(24)| hand. (b) 14th cutaneously.| resp. spasm fol- 
lowing feeding. 
8 | Infected!(a)?11th) 200,000} Avertin 0°1 | 13th day. Gen- 
(51)| finger. [(0)?12th) at c.cm.perkg.| eralised fatal 
once. 6-hourly spasm. 
(reduced). 
9 Nailin i(a) 13th 120,000} Chloral and | 16th day. Fatal 
(38)! foot. (b) 15th) 2 days.| bromides. spasm (the 
second). 
10 Com- i(a) 19th| 200,000) Avertin 0°05 | 23rd day. Hyper- 


(63)| pound (b) 20th/ 3 days. | c.cm. per kg. 
Ma aue 4-hourly. 
tibia. 


pyrexia and 
sudden cardiac 
failure. 


during full relaxation, 10 mg. curarine was given sub- 
cutaneously. Curarine takes 20-30 minutes to be absorbed 
from the subcutaneous tissues. Good relaxation was 
obtained for 2 hours. After 44 hours full tonic rigidity 
had returned and small added spasms had commenced at 
5-minute intervals. After atropine gr. 1:50, curarine 9 mg. 
in 9 e.cm. in 4} minutes was given intravenously. 
Rigidity was removed but began to return in 35 minutes, 
Thereupon the curarine intravenous drip was started. 

Induction of relaxation was obtained by giving 7-5 mg. 
in 7 minutes. A lower rate of inflow was thon adopted, 
and 66 mg. was given in each 6-hourly period for 18 hours. 
During this period the patient remained almost flaccid, 
slept and was fed. He received two injections of morphine 
gr. 4, and during the treatment sleep was assisted by 
one-half dose (0°05 c.cm. per kg.) of avertin rectally. 
After 18 hours of treatment, difficulty from clotting in 
the needle caused the return of rigidity, a rapid deteriora- 
tion in the patient’s condition, and the onset of attacks 
of respiratory spasm. Curarine was restarted as a 
continuous subcutaneous injection, but it was found 
impossible to maintain a constant rate of inflow. Further 
respiratory spasms were difficult to control owing to 
the difficulty of introducing endotracheal catheters. The 
patient’s own respiration was probably weakened by the 
curarine, and the strain of right-sided cardiac congestion 
and anoxemia caused a comparatively suddon cardiac 
failure. 


The outcome of this case was a disappointment. 
For it was felt that a patient who had been success- 


fully treated for two days after the onset of violent 
tetanic spasms might have survived if further time 
could have been given for the progressive removal 
of his toxemia. 


Case 6.—The onset of symptoms was on the seventh 
day, and although generalised spasms did not occur 
until the eleventh, the case then became critical. A 
generalised convulsion had occurred during the early 
morning. During the day the patient was free of spasms, 
but in the evening they returned and by midnight they 
were prolonged and severe. The technique described was 
followed and an intravenous drip established at a rate of 
0-27 mg. per kg. per hour. Considerable relaxation was 
obtained and the patient continued to breathe spon- 
taneously without difficulty. After 3 hours of curarisa- 
tion spasms involving the bronchial muscles occurred. 
Four such spasms occurred within an hour and necessitated 
the passage of the endotracheal catheter. The patient 
was considerably cyanosed before the catheter could be 
introduced, and his general condition had deteriorated. 
After the institution of endotracheal oxygenation tbere 
was no further cyanosis, but larger concentrations of 
curarine (0'4 mg. per kg. per hour) had to be given to 
maintain flacecidity. Six hours after the commencement 
of curarisation, and 2 hours after the passage of the 
catheter, the pulse-rate had risen and there were already 
signs of pulmonary congestion. The jaw remained 
relaxed, the neck muscles largely relaxed, the abdominal 
muscles partly so. The limbs were flaccid, the patellar 
reflexes which are abolished only in deep curarisation 
were generally but not always obtainable. It was 
decided not to stop the curarine inflow, in view of the 
inevitable return of muscular spasm. But from the time 
of the last respiratory spasm the patient’s condition 
became worse until death from cardiac failure 2} hours 
later. 


CasE 7.—In this case the incubation period was ten 
days, and a further four days elapsed before the onset 
of generalised spasm. The patient was first seen after 
these had become very severe. Rapid respiration, 
tachycardia, and high fever were present. Each spasm 
arrested respiration for about a minute, and each was 
expected to end fatally. Curarine 2°5 mg. was given 
subcutaneously when the case was seen. An hour later 
the patient was fed through a tube and immediately 
suffered a long respiratory spasm. Curarine 7-5 mg, was then 
given subcutaneously and oxygen continuously by a 
short nasal tube. Relaxation occurred 30 minutes 
subsequently, but the patient never recovered conscious- 
ness after the previous respiratory spasm and died an 
hour later. 


Death from generalised spasm involving respira- 
tion is one of the common ends in cases of tetanus. 
But in animals curarine had itself shown a tendency 
to cause respiratory spasms (West, 1935). In 
decerebrate cats these spasms can be prevented by 
atropine and removed by adrenaline. The means 
of their production is not clear, for though an isolated 
strip of the tracheal muscle of the cat will contract 
under the influence of curarine, it does so uncertainly 
and only with the drug in high concentration (1 : 1700). 
Such contractions of the isolated tracheal muscle are 
relaxed by adrenaline (1: 125,000), but not by 
atropine. 

Control Observations 


In order to ascertain the therapeutic effect of 
curarine on the rigidity of post-encephalitic 
parkinsonism, three advanced cases were treated 
with the drug by the intravenous route. 


Cask 1]1.—After the effects of ascending doses had been 
tried, the first patient received 0-25 mg. per kg. in 10¢c.cm, 
of solution during 1] minutes by intravenous injection. 
Blurred vision and slight headache occurred, but there 
was no loss of rigidity or of tremor, both of which were 
marked features of the case. The result confirmed 
previous observations with curarine given subcutaneously 
(West, 1935). No respiratory symptoms developed. 


THE LANCET] 


CasE 12.—The second patient received intravenous 
curarine by the drip method; an induction with 0-1 mg. 
per kg. in 5 minutes (1:2 mg. per kg. per hour) resulting 
in a temporary reduction of rigidity. The rate of inflow 
was halved after 5 minutes and continued at about 
0-6 mg. per kg. per hour for 10 minutes. Severe ptosis 
developed, the pathological rigidity relaxed, probably 
with some loss of power, and respiration became purely 
abdominal. The curarine inflow was then stopped, but 
restarted 10 minutes later. Rigidity returned very 
quickly after cessation of the curarine inflow. No 
laryngeal spasm occurred. The case shows that, even with 
the best conditions—a dripping inflow giving a gradual and 
controlled rise of concentration in the blood stream— 
the power of removing rigidity is transitory and the 
margin between the effective and the asphyxial 
concentrations small. 


CasE 13.—The third patient was very rigid, with a 
good deal of added tremor. A preliminary injéction 
of atropine gr. 1/50 was given ; the patient having already 
considerable tolerance to drugs of this series. Curarine 
induction occupied 20 minutes and was continued until 
the arms were relaxed, the tremor being somewhat 
diminished. The flow was then interrupted for 5 minutes, 
after which stiffness was again increasing. Curarisation 
was continued at about 0-8 mg. per hour until ptosis 
developed (3 minutes), the patient felt unable to raise the 
arm (5 minutes), and breathing became “light ”—i.e., 
abdominal (10 minutes). Parkinsonian rigidity was 
virtually abolished, and tremor remained nowhere- but 
in the lips. This level of curarisation was maintained 
for 15 minutes at a rate of 0-2 mg. per kg. per hour, when 
the inflow was stopped. An hour later the patient had 
had a meal and the rigidity had largely returned. Curarisa- 
tion was now induced more rapidly, at over 3 mg. per kg. 
per hour. Relaxation and “light” breathing occurred 
after 8 minutes and the inflow was stopped. Immediately 
subsequently the patient pointed to her throat, choked, 
and was apparently unable to breathe further. The 
condition closely resembled what has been described 
in animals under curarine (loc. cit.). An electric laryngo- 
scope was instantly inserted into the mouth, and the 
endotracheal catheter passed, with some difficulty, owing 
to a spasm of the false vocal cords. A stream of oxygen 
was blown through the catheter, which was not removed for 
nearly half an hour, when its presence appeared to embarrass 
the patient. After the catheter had been passed, adrenaline 
and later strychnine were given hypodermically. The 
patient was able to talk 59 minutes after the onset of the 
spasm. She recollected no events between its commence- 
ment and the manipulation of an airway after the removal 
of the oxygen catheter. Sore-throat and some bronchial 
catarrh developed on the following day, but the patient 
was able to get up on the third day. She declared her 
rigidity to be less then than previously, but if this were 
so it did not remain so. 


The alarming experience of this “control” 
case demonstrates the reality of the danger of curarine 
respiratory spasm. 


Conclusions 


(1) Curarine treatment of tetanus should still 
be reserved for cases which are already very severe 
or in which by the accepted criteria (Cole, 1935) 
the prognosis is very grave. I have not yet had 
experience of a case of tetanus which showed its 
first symptom less than seven days after infection, 
and which subsequently recovered. Cole (1935) 
records one such case, with recovery under antitoxin 
and general treatment only. But cases occurring 
on the seventh day have recovered with and without 
curare. 

(2) If curarine be given in severe tetanus, the 
intravenous drip is probably the most effective 
method of its administration. 

(3) A real danger of curarine treatment—bronchial 
spasm—is shown by the experience with a “ control” 
ease of advanced parkinsonism (Case 13). The 


DR. R. WEST: INTRAVENOUS CURARINE IN TETANUS 


(san. 4, 1936 15 


spasm can be effectively treated by prompt endo- 
tracheal intubation only. Probably the risk of it 
is increased if the induction of curarisation is hastened 
beyond the rate of 1-5 mg. per kg. per hour (or 0-25 mg. 
per kg. in ten minutes). Animal experiments justify 
the administration of atropine gr. 1/100-1/50 hypo- 
dermically before and at four-hour intervals during 
the period of curarisation, and of a full dose of 
adrenaline (1 c.cm. liquor adrenalini hydrochlor.)* 
if the spasm occurs. 

(4) Curarine in its present available form is 
unsuitable for the treatment of cases of chronic 
rigidity. 

(5) Curarine is given to cases of tetanus only as 
a means of removing muscular spasm. It may be 
combined with other methods of treatment, 
particularly with light avertin narcosis. Needless 
to say antitoxin is required as urgently as with any 
other treatment. At present I would give 200,000 
units when the diagnosis is made. This is the 
recommendation of Cole in his recent full review of the 
treatment of tetanus (1935). In the early and ‘acute 
cases, if the patient can be kept alive for two days, 
the giving of more serum should be considered. I 
should like to endorse Cole’s plea for early diagnosis : 
“ Stiffness. of the jaw, especially if accompanied 
by pain in the back or abdomen, probably means 
tetanus.” 

Summary 


(1) The administration of curarine by continuous 
intravenous drip is described. 

(2) Ten cases of tetanus are recorded, nine of which 
proved fatal. Treatment varied (see Table). 

(3) In two fatal cases curarine was given intra- 
venously, and in one of them death was delayed 
beyond the expected point. Respiratory spasm 
followed an inability to maintain an even curarisation 
after 18 hours of successful treatment.. 

(4) The treatment of three cases of advanced 
parkinsonism by the administration of curarine 
intravenously is recorded. The absence of an 
adequate margin between the rigidity-removing 
(‘‘lissive’’?) dose and that affecting respiration, 
together with the transitory action of curarine, 
renders it, in its present available form, unsuitable 
for the treatment of these chronic conditions. 

(5) Experience with one case of parkinsonism under 
curarine treatment establishes bronchial spasm as a 
serious danger of curarine therapy in man. 

(6) It is suggested that the best method of giving 
curarine which is at present available is by intra- 
venous drip. This method can be controlled from 
minute to minute, if necessary, and enables the narrow 
margin between the beneficial ‘‘lissive’’ action and 
the asphyxial action on respiration to be increased. 
It is further suggested that the only present place for 
intravenous curarine in therapeutics is its contimued 
experimental use in cases of tetanus in which, by the 
accepted standards (Cole, 1935), recovery cannot be 
expected by other means. 


I am indebted to the following for permitting me to 
see cases of tetanus under their charge: Mr. P. H. 
Mitchiner, Dr. R. Harvey-Williams, Dr. W. M. Robson, 
Dr. Maurice Shaw, Dr. Leslie Cole, Dr. R. Grainger, 
and the medical superintendents. of Kingston Municipal 
Hospital, Croydon Municipal Hospital, and West Park 
Mental Hospital, Epsom. I received both help with cases 
and suggestions for improving technique from: Dr. Maurice 


* Recent animal experiments showing a spasmodic action of 
curarine on isolated tracheal and bronchial muscle to be 
immediately antagonised by adrenaline suggest that this drug 
should be given very slowly by the intravenous route until 
relaxation occurs. 


A2 


16 THE LANCET] DRS. PARKINSON & THOMSON : MERCURIAL SUPPOSITORY IN CARDIAC ŒDEMA ([JAN. 4, 1936 


Shaw (who suggested the intravenous route), Mr, J. 
Lindahl Dr. R. Woolmer, and A. Kennedy. 


The research embodied in this paper was undertaken 
with the assistance of an expenses grant from the Medical 
Research Council. 

REFERENCES 


Briscoe, G.: Jour. of Physiol., 1935, Ixxxiv., 43 P. 

Cole, L. B.: THE LANCET, 1934, ii., 475; Quart. Jour. Med., 
1935, iv., 295. 

Florey, H. W., Harding, H. E., and Fildes, P.: 
1934, ii., 1036. 

Hale White’s Text-book of Pharmacology, London, 1901, p. 199. 

Hartridge, H., and West, R.: Brain, 1931, xliv., 312. 


THE LANCET, 


King, H.: Nature, 1935, cxxxv., 469. 
Mitchell, J. S.: THE LANCET, 1935, i., 262. 
West, R.: Proc, Roy. Soc. Med., 1932, xxv. (Sect. Neurol.), 39. 


t e 
West, R.: Ibid., 1935, xxviii. (Sect. Therap.), 41 ; THE LANCET, 
1935, i., 88. 


A MERCURIAL (NOVURIT) 
SUPPOSITORY AS A DIURETIC FOR 
CARDIAC CDEMA 


By JOHN Parkinson, M.D., F.R.C.P. Lond. 


PHYSICIAN IN CHARGE OF THE CARDIAC DEPARTMENT 
OF THE LONDON HOSPITAL; AND 


Wittram A. R. THomson, M.D. Edin. 


PATERSON RESEARCH SCHOLAR AND CHIEF ASSISTANT IN 
THE DEPARTMENT 


ORIGINALLY introduced by Zieler 1ł as a remedy 
for syphilis in 1917, Novasurol was first used as a 
mercurial diuretic for dropsy by Saxl and Heilig 3% 
in 1920. Satisfactory as a diuretic, it proved to have 
the disadvantage in some patients of causing a 
severe diarrhea and other toxic effects. By means 
of chemical modifications, Salyrgan was synthesised 
in 1923, and it is now clear that as a diuretic it is 
as potent as novasurol, and that its toxicity is negli- 
gible. A similar though not identical product known 
as Neptal was subsequently produced in France, and 
it also proved efficacious in the treatment of dropsy. 


These preparations have the disadvantage of 
having to be administered intravenously or intra- 
muscularly, preferably by the former route. Slough- 
ing may result from leakage into the subcutaneous 
tissues, and the patient have to submit to an exceed- 
ingly painful arm for the subsequent 24-48 hours. 
This should seldom occur, and it can be obviated 
with fair certainty and with little additional trouble 
by diluting the contents of the phial to 10 c.cm. with 
sterile water or saline as recommended by Bedford.! 
Attempts have been made to administer salvrgan 
by mouth, but with little success. Thus Fleckseder ê 
gave it in daily doses with ammonium chloride over 
a period of several weeks with a meagre result. 
Engel and Epstein ë refer to rectal administration 
of salyrgan in 100 c.cm. water, with moderately 
good results. 

Herrmann and his colleagues? suggested that a 
combination of the organic mercurial diuretics and 
the purine bases produced a larger diuresis than 
either separately. Such a combination is found in 
a preparation with the trade name of Novurit which 
has been. tested and found satisfactory by many 
workers including Popper, Crawford and McDaniel,’ 
and DeGraff, Nadler, and Batterman.4 Novurit is 
a sodium salt of trimethyleyclopentandicarboxylic acid 
allylamidmethoxymercurichydroxide combined with 
theophyllin. It may be given intravenously or intra- 
muscularly in doses of 1-2 c.cm., each ¢.cm. con- 
taining 0-10 g. of the mercurial salt and 0-05 g. of 
theophyllin. 


Recently the same drug has been prepared in the 
form of a suppository which contains 0-5 g. of novurit 
in cocoa butter. Though rectal administration of a 
drug often has clear disadvantages compared with 
oral administration, an effective suppository would 
be a simpler method in private practice than an 
intravenous injection. It would be an advance in 
the therapeutics of congestive heart failure to be 
able to administer a mercurial diuretic simply and 
safely by this route. This paper records our short 
experience of the clinical action of novurit sup- 
positories. We have been assisted throughout by 
Dr. Basil S. Grant to whom we are indebted. 


METI{ODS 


The problem of controls in a clinical investigation 
is always dificult. To take alternate patients and 
give to one the suppository, and to the next an 
intravenous mercurial diuretic the action of which 
is already known, has the disadvantage that no two 
cases of cardiac dropsy are alike. The alternative, 
and the method used by us, is to administer different 
drugs to the same patient. Of course, one disad- 
vantage of this method is that the drug first adminis- 
tered is more likely to produce a diuresis than one 
given later when the edema is already diminishing ; 
but on the whole we feel that it is the better method. 

Twelve consecutive cases have been so treated, 
all being cases of congestive heart failure with oedema, 
although in some the œdema was slight. Two of 
them are excluded from this report: one died with 
hemiplegia and coma a few days after admission for 
heart failure; the other was excluded because he 
had received regular doses of digitalis, and we wished 
to test only those free from all medication other 
than the diuretics under discussion. Brief sum- 
maries of the ten consecutive cases utilised for this 
study are as follows :— 

Case 1.—Female, aged 23. Mitral stenosis. Aortic 
incompetence. Normal rhythm. Failure. Two years, 
dyspnea. Eight weeks, palpitation and swelling of 
abdomen. Three days, swelling of ankles. 

On admission : Cyanosis, dyspneea, cedema of feet and 
lumbar region, ascites, enlarged liver, right hydrothorax. 
Pulse-rate 100. Ilectrocardiogram, sinus tachycardia. 
Urine, trace of albumin. Weight 7 st. 3} lb. (46-1 kg.). 

On discharge: No evidence of cedema or hydrothorax, 
liver not palpable. Weight 5 st. 84 lb. (35-7 kg.). 


Case 2.—Male, aged 60. Angina pectoris. Normal 


rhythm. Failure. Light years, angina of effort. Two 
months, dyspnea. Two weeks, swelling of ankles. 
On admission: Dyspnea, liver slightly enlarged. 


Pulse-rate 100. Blood pressure 120/95.  Radioscopy, 
small right hydrothorax. Urine, trace of albumin. 

On discharge: No evidence of oedema or hydrothorax, 
liver not palpable. 


CasE 3.—Male, aged 59. Auricular fibrillation. Failure. 
One year, increasing dyspnea, palpitation. Two weeks, 
swelling of ankles. Three days, jaundice. 

On admission : Orthopneea, cyanosis, Jaundice. Marked 
oedema of ankles and lumbar region. Pulse-rate 104. 
Electrocardiogram, auricular fibrillation. Radioscopy, no 
hydrothorax. Urine, trace of albumin. Weight 9 st. 5} Ib. 
(59-8 kg.). 


On discharge: No evidence of œdema. Weight 
8 st. 4$ lb. (53-0 kg.). 
Case 4.—Female, aged 66. Hypertension. Auricular 


fibrillation. Failure. Several years, increasing dyspnea. 
Two weeks, persistent dyspna@a and œdema of feet. 

On admission: Orthopnea, cyanosis, oedema of feet, 
legs, and lumbar region. Liver enlarged. Pulse-rate 90. 
Electrocardiogram, auricular fibrillation. |Radioscopy, 
right hydrothorax. Urine, trace of albumin. Weight 
11 st. 103 Ib. (74-8 kg.). 


Response to diuretics was slow. Died in hospital three 


+ . 


THE LANCET] 


weeks after admission. 
10 st. 4 Ib. (65-5 kg.). 


CasE 5.—Male, aged 68. Hypertension. Normal 
rhythm. Bronchitis and emphysema. Failure. One year, 
dyspnea and cdema. Six months ago, in-patient with 
heart failure. 

On admission: Orthopnoea, gross anasarca, ascites, 
bilateral hydrothorax. Pulse-rate 104. Electrocardiogram, 
normal rhythm. Blood pressure 170/110. Urine, cloud 
of albumin. 

On discharge: No evidence of cdema or enlargement 
of liver. Loss of weight, 3 st. 8 lb. (22-7 kg.) (see Chart). 


CasE 6.—Male, aged 25. Mitral stenosis. Aortic 
incompetence. Auricular fibrillation. Failure. In-patient 
on three occasions during preceding year on account of 
failure. Three weeks, swelling of abdomen. One week, 
increasing dyspnea. 

On admission: Afebrile, dyspnea, anasarca, ascites, 
liver enlarged. Pulse-rate 90. Electrocardiogram, 
auricular fibrillation. Blood pressure 140/90 approxi- 
mately. Radioscopy, no hydrothorax. Urine, trace of 
albumin. Weight 10 st. 104 lb. (68-4 kg.). 

On discharge: No cdema. Liver not palpable. Weight 
8 st. 8} Ib. (54:8 kg.). 

CasE 7.—Male, aged 58. Chronic bronchitis. Angina 
pectoris. Normal rhythm. Failure. Ten years, “ winter 
cough.” Two months, angina pectoris, palpitation, and 
dyspnea, 

On admission : No orthopnea, slight cedema of ankles. 
Pulse-rate 96. Electrocardiogram, normal rhythm. 
Blood pressure 170/80. Radioscopy, small left hydro- 
thorax. Urine,no albumin. Weight 12 st. 11 lb. (81-4 ie ). 


Weight (4 days before death) 


On discharge: No œdema or hydrothorax. Weight 
11 st. 4 lb. (71:8 kg.). 
CasE 8.—Female, aged 53. Chronic bronchitis. Normal 


rhythm. Failure. 
pnoea and cedema of ankles. 
cough ” for many years. 

On admission: Dyspnea, slight 
oedema of legs. Pulse-rate 76, normal 
rhythm. Blood . pressure 162/70. 
Radioscopy, no hydrothorax. Urine, 
no albumin. Weight 10 st. 104 lb. 
(68-4 kg.). . 

On discharge: No cedema. Weight 
10 st. 5$ lb. (66 kg.). 


CasE 9.—Male, aged 65. Aortic 
stenosis (arterio-sclerotic). | Normal 
rhythm. Failure. One year, dyspnea 
on exertion. Four months, nocturnal 
dyspnea. Two months ago, im- 
patient with heart failure. 

On admission: Orthopnea, cdema 
of legs, moderate ascites, liver en- 
larged to umbilicus. FPulse-rate 80. 
Electrocardiogram, normal rhythm, 
low voltage all leads. Blood pressure 
110/70. Radioscopy, no hydrothorax. 
Urine, trace of albumin. Weight 
9 st. 6 lb. (60 kg.) 

On discharge: No oedema. Liver 
not palpable. Weight 8 st. 2} lb. 
(52 kg.). 

Case 10.—Male, aged 64. Chronic 
bronchitis and emphysema. Normal 
rhythm. Failure.’ Several years, 
“winter cough.” One year ago in- 
patient with heart failure. 

On admission: Orthopnea. Slight 
cedema of ankles. Liver just palpable. 
Pulse-rate 78. Electrocardiogram, 
normal rhythm. Blood pressure 
130/70. Radioscopy, no hydrothorax. 
Urine, no albumin. Weight 9 st. 5 lb. 
(60 kg.). 

Progress: Œdema disappeared and 
liver no longer palpable, but very little 
relief of cough. Weight 8 st. 10 lb. 
(55-4 kg.). 


The two drugs used as controls 


N 


Four years, dys- 
“ Winter 


200 


180 


URINARY OUTPUT AND FLUID INTAKE -OUNCES 
yer) œ o N rs ron 
© O © © S © 


A 
oO 


i 


| 
J 


NS.-NOVURIT SUPPOSITORY 
N — NOVURIT INTRAVENOUSLY 
S — SALYRGAN 


Chart showing comparative effects of various mercurial diuretics in an 


DRS! PARKINSON & THOMSON : MERCURIAL SUPPOSITORY IN CARDIAC @DEMA [JaN. 4,1936 17 


were salyrgan and novurit, the former because its value 
has now been well established, the latter in order to 
compare the effect of the same drug intravenously and 
by rectum. Both were given intravenously and never 
intramuscularly, salyrgan in the dose recommended 
by the makers, i.e., 2 c.cm. which contains 0-2 g. of 
the salt, and novurit also in the dose recommended, 
i.e., 2 c.cm. which contains 0-2 g. of the mercurial 
salt and 0-1 g. of the theophyllin. 

No other drugs were administered if it could be 
avoided, excepting ammonium chloride as an adju- 
vant as described below. In only two cases was 
digitalis given during the period of observation, 
though naturally it was often used later. In one 
of these (Case 3) only 45 minims (3 c.cm.) of the 
tincture were given on the day of admission, three 
days before observations were begun. The other 
patient (Case 4) had severe congestive failure and 
auricular fibrillation, and digitalis had to be adminis- 
tered in view of a rising ventricular rate and increasing 
symptoms. Observations on the mercurial diuretics 
were therefore made only before digitalis was given 
and again in combination with digitalis when the 
effect of the latter on the urinary output had become 
stabilised. 

Ammonium chloride as an adjuvant in the treat- 
ment of edema with organic mercurial preparations 
has been widely adopted during the last ten years 
following upon the work of Rowntree, Keith, and 
Barrier,!? and Keith and Whelan.® There is still no 
agreement as to the optimum dose, and in this 
investigation we have given it only for the 24 or 


| 
| 

gi 
| 4 
pi 


E 
WEIGHT IN LBS. 


k pe XA yA PAARA Ga 


Kyn i54 


| 
| piii 
| | i 
14 16 18 20 i | 26 i 30 l 7 36 | 40 42 
DAYS IN HOSPITAL 


0 12 


C—-AMMONIUM CHLORIDE 
O- URINARY OUTPUT 


INTRAVENOUSLY M-FLUID INTAKE 


illustrative case. (Case 


18 THE LANCET] 


48 hours preceding the exhibition of the mercurial 
preparation. In most cases it was given for 48 hours— 
grs. 120 (8 g.) during the first 24 hours and grs. 90 
(6 g.) during the second. In the few cases where 
it was given for 24 hours only, the dose was grs. 120 
(8 g.). There is difficulty in disguising its salty 
taste; in this series it was prescribed with liquid 
extract of liquorice, as recommended by the British 
Pharmaceutical Codex,? but the disguise is thin. 
The sucking of a lemon helped to remove the 
unpleasant taste from the mouth in some patients. 


The method of investigation was as follows. The 
patient was kept in bed and a low-salt diet was 
ordered from the outset with a daily fluid intake 
restricted to 20-30 ounces (2000-2500 c.cm.). For 
the first three days, or until it was evident that the 
urinary output was steady, no treatment beyond 
rest was given. Thereafter the three preparations— 
noyurit suppositories and novurit and salyrgan intra- 
venously—were administered as follows. 


SCHEMA 


(1) Novurit suppository preceded by enema a few hours 
before. 

(2) Novurit suppository. Aperient two nights before. 

(3) Novurit suppository preceded by enema a few hours 
before. Ammonium chloride administered during previous 
48 or 24 hours. 

(4) Novurit suppository. ,Aperient two nights before. 
Ammonium chloride administered during previous 24 or 
48 hours. 

(5) Novurit intravenously with or without previous 
administration of ammonium chloride as in (3) and (4). 


(6) Salyrgan intravenously with or without previous 


administration of ammonium chloride as in (3) and (4). 


As a general rule one of these preparations was 
administered every third day. 


RESULTS 


In no case did we fail to obtain a diuresis with 
each of the drugs used. The accompanying Chart 
has been chosen as a typical example of the results 
achieved. The oedema began to diminish immediately 
and all clinical evidence of it had disappeared as a 
rule within a fortnight; the exact time varying with 
the initial degree of edema. Thus in Case 6 there 
were no clinical signs of œdema a fortnight after 
treatment had been begun. 


An equally satisfactory result was obtained in 
those cases with hepatic enlargement—in every 
case the liver returned to normal size. In Case 9, 
for example, where the hepatic enlargement was 
much more striking than the degree of cdema, the 
liver was not palpable at the end of a fortnight. 
The table summarises the results obtained in all the 
cases, and there are several points to which we 
would draw attention. Taking, in the case of each 
drug, the average 24 hours urinary secretion per dose, 
it is scen that for the novurit suppository this is 
87:2 oz. (2470 c.cm.), for novurit given intravenously 
121-1 oz. (3435 c.cm.), for salyrgan 91-8 oz. (2600 
c.cm.). 

The onset of diuresis was more rapid and tended 
to be less prolonged with salyrgan than with the 
other two drugs. Thus with salyrgan, taking the 
average percentage excretion per dose, 81-7 per cent. 
of the diuresis occurred during the fir st twelve hours, 
while with novurit and novurit suppositories ihe 
corresponding figures were 67-1 and 68-7 per cent. 
respectively. Further analysis shows that in the 
first four hours the average percentage excretion 
per dose was 44-9 per cent. for salyrgan, 25-9 per cent. 


for novurit, and 23-2 per cent. for novurit sUppoOsi- | 


. t. 


DRS. PARKINSON & THOMSON : MERCURIAL SUPPOSITORY IN CARDIAC ŒDEMA [JAN. 4, 1936 


Table showing the Twenty-four Hours Urinary 
Excretion following the Administration of Mercurial 
Diuretics 


NOVURIT INTRAVENOUS INTRAVENOUS 
SUPPOSITORIES. NOVURIT. SALYRGAN. 
‘ Š voeo 
Case. = =2 = | £21 
> » © z- > © 
Z |” Total 7 | 7 Total 
Ammon Ammon. . 
chlor chlor. | 
| OZS OZS. OZS. OZS. ozs. 
I. ‘ls 138 | 138 se a 
137 137 
338 83 | 
its s ste 98 98 
s4 64 6i | 
89 z 89 
55 55 | 
II. .. see 56 56 127 | 
a 114 | 114 s | 
.. | GL 61 bas 
ey eee ee ee 
140 140 = | 
Ifo os ss 43 43 sii 60 
sa 69) 69> .. | .. | 
51 51 i Oe 
15 15 ie | 
y se 40 40 189 ' 1 
if 137 | 137 7 181 ate 1 
gu 70 70 
191 p 191 
158 158 | 
70 70 | 
134 S 134 
VI. . 184 | 184 | 154 
206 a 206 es 
128 128 
110 110 
VII .. ica 21 21 .. | 64 
51 ae 51 150 oe 
76 ee 76 ee 
82 ae 82 
Vil. ee ee 43 43 ee ae 
“se 74 wile sa 
47 47 
66 66 
ING ‘ws np 92 92 82 
68 3 68 aE 
aye 66 66 ie ae 
57 as 57 ans a 
X s S 638 68 83 
90 Ei 91) 
84 zi S4 
Average ' 
diuresis | 96-7 | 78:5 | 87-2 f 130 110 |12111109: dai 78 
In c.cm. | 2760 | 2230 | 2470 | 3690 | 3120 | 3435 3110 | 2230 
i 
tories. The corresponding figures for the third four- 


nour y period were salyrgan 12-1 per cent., novurit 
9-5 per cent., and novurit suppositories 14:9 per cent. 
Diuresis was never maintained beyond twenty-four 
hours. 

The question as to whether it is desirable to secure 
evacuation of the bowels by means of an enema or 
an aperient was also investigated. It was found 
that with a preceding enema the average 24 hours 
urinary secretion was 98:4 oz. (2790 ¢.cm.), with an 
apericnt two nights before it was 79-9 oz. (2266 c.cm.), 
while with neither it was 73:4 oz. (2082 ¢.em.). As 
the numbers are so small, there is probably no statis- 
tical significance in these differences, and it may 
be concluded that the premedication treatment 
makes little difference provided there has been a 
satisfactory evacuation of the bowels. lt was noted 
that several patients experienced more difliculty in 
retaining the suppository after an enema than after 
an aperient ; on this account the aperient should be 
given two nights before the suppository, as, given 


THE LANCET] DRS. PARKINSON & THOMSON : 
the night before, it would be more likely to leave 
the rectum in an irritable condition. The aperient 
used was liquid extract of cascara sagrada in doses 
of 1 fluid drachm (4 c.cm.). 

With intravenous administration of the mercurial 
diuretics it is the general experience that the pre- 
liminary administration of the acid-forming salts 
results in a greater diuresis. Our figures, though 
small, support this belief, as in the case of novurit 
the diuresis with and without preliminary ammonium 
chloride was respectively 130 oz. (3690 c.cm.) and 
110 oz. (3120 c.cm.), while for salyrgan the corre- 
sponding figures were 109-7 oz. (3110 c.cm.) and 
78-5 oz. (2230 c.cm.). The results with the supposi- 
tories were similar, as with ammonium chloride the 
result was 96:7 oz. (2760 c.cm.), while without it 
the average 24 hours urinary secretion per dose was 
78-5 oz. (2230 c.cm.). 


No toxic or local irritative effects were observed 
except that in Case 1 after one suppository there 
was a small motion with each passage of urine, but 
without other upset. Further suppositories pro- 
duced no such effects; nor did such effects arise in 
any other patient. All our patients received at 
least three suppositories in as many weeks (apart 
from successive intravenous injections), and one 
(Case 5) received seven within six weeks. The pre- 
sence of a fissure or inflamed hemorrhoids should 
doubtless be a contra-indication to their use. Occa- 
sionally the patient had difficulty in retaining the 
suppository, but even when it was retained for only 
two hours, the subsequent diuresis was satisfactory— 
e.g., Case 2 only retained the first suppository for 
two hours, yet the diuresis was 96 oz., while the 
second suppository, which was well retained, was 
only followed by a diuresis of 64 oz. In one case (5) 
the antecubital veins became so sclerosed that intra- 
venous medication became difficult. This resulted 
in a slight leakage with the final dose of intravenous 
novurit. By the evening the forearm had become 
swollen and very tender and it did not return to 
its normal size until several days had elapsed. This 
is one of the disadvantages of intravenous adminis- 
tration, and is just as likely to occur with salyrgan. 


DISCUSSION 


Digitalis is of primary importance in the treatment 
of congestive heart failure. Often this is all that is 
required, but in a large proportion of cases some 
further therapy is necessary. Tor persistent dropsy, 
and even for a persistent hepatic enlargement, the 
organic mercurial diuretics are now the best means 
available. 

From the results of this preliminary investigation 
we are not prepared to discriminate between novurit 
and salyrgan both given intravenously, though the 
Table suggests that novurit is rather more eflicient. 
The studies of Limova,® Crawford and McDaniel, 
and DeGraif, Nadler, and Batterman ‘ are in favour 
of novurit. 

In order to obtain information concerning the 
unaided action of these drugs, digitalis was not given 
either before or with the mercurial diuretics. In 
practice digitalis would nearly always be given 
before and with these drugs, and as a result a larger 
diuresis would be expected. 

The main reasons for preferring rectal adminis- 
tration by means of a suppository to intravenous 
medication have already been stated. Rectal admini- 
stration will prove particularly useful to a practi- 
tioner who does not happen to have regular oppor- 
tunities for using drugs intravenously. In addition, 


MERCURIAL SUPPOSITORY IN CARDIAC G@DEMA [JAN. 4, 1936 19 


there are cases where cedema of the upper extremities 
renders intravenous medication almost impossible. 
A further advantage is that the intelligent patient, 
under full medical supervision, should be able, if 
necessary, to insert the suppository himself. | 


The results reported here seem to indicate that 
as a diuretic the suppository is satisfactory, particu- 
larly in view of the fact that the degree of edema 
in several members of the series was slight. The 
diuresis is not as great as with intravenous medi- 
cation, although a larger amount of the drug is 
contained in the suppository than in the recommended 
intravenous dose, but such a finding is only to be 
expected in view of the smaller absorption there 
must be in rectal as compared with intravenous 
administration. Still a diuretic agent so simple to 
administer and which can produce a flow of 206 oz. 
(5840 c.cm.) in twenty-four hours and which on an 
average produces 87-2 oz. (2470 c.cm.) is an addition 
of value in the treatment of dropsy. 


SUMMARY 


(1) The therapeutic value of an organic mercurial 
diuretic which can be given as a suppository, the 
novurit suppository, has been investigated. This 
suppository, according to the manufacturers, con- 
tains 0:5 g. of novurit, a complex organic mercurial 
compound akin to salyrgan, but combined with 
5 per cent. of theophyllin, in cocoa butter. 

(2) Ten cases of congestive heart failure with 
edema have been treated with this suppository 
and also with novurit intravenously and with salyrgan 
intravenously. 

(3) The average twenty- four hours excretion of 
urine per dose was for the suppository 2470 c.cm. 
(87-2 oz.), for novurit intravenously 3435 c.cm. 
(121-1 oz.), for salyrgan aneravepously 2600 c.cm. 
(91-8 oz.). 

(4) The previous administration of ammonium 
chloride results in an increased diuresis with the 
suppository, as it also does with novurit and salyrgan 
intravenously. 

(5) With the suppositories 68:7 per cent. of the 
diuresis occurred within the first twelve hours, while 
the corresponding figure for salyrgan intravenously 
was 81-7 per cent. The diuresis does not extend 
beyond twenty-four hours. 

(6) No toxic or irritative effects of the suppository 
have so far been detected. Free evacuation of the 
bowels is desirable though not essential, and if an 
aperient is necessary, it should be given forty-eight 
hours before the suppository. 

(7) It is concluded that novurit suppository is an 
effective and safe diuretic. 


é 


REFERENCES 


. Bedford, D. E.: Proc. Roy. Soc. Med. (Sect. Ther. and 
Pharmacol.), 1931, xxiv., 1. 

. British Pharmaceutical Codex, London, 1934, p. 110. 

. Crawford, J. H., and McDaniel, W.S.: "Ann. Internal Med., 
1935, viii. 1266 

. DeGraff, A. C., Nadler, J. E.,and Batterman, R. C.: Amer. 
Heart. Jour., 1935, X. , 832, 

. Engel, K., and Epstein, i Ergebn. d. inn. Med. u. 
Ixinderh., 1931, x1., Aa 

. Flecksedez, R.: Zeit. . Urol., 1934, ae 32. 

. Herrmann, G., ca. E. H., Ston C” T., 
W. L.: Jour. Lab. and em, "Ned. "1933, XViii., 

g Keith, N. M., and Whelan, M. Jour. Clin. Invest., 


iii., 149. 
< Limova, M.: Casop. lék. césk., 1934, ails . 1317. 
- Popper, Los Med. Klin., 1929, xxv., 91: 

x Re » : Ibid., 1930, RET 1229. 
. Rowntree, L. G., Keith, N. M., and Barrier, C. W.: 
Amer. Med. Assoc., 1923, ISXXFV., 1187 
. Saxl, P., and Heilig, R.: W ien. klin. W och., 


943. 
. Zieler, K.: Münch. med. Woch., 1917, lxiv., 1257. 


and Marr, 
902. 
1926, 


Oo N NO a A UON m 


Pot pand pel 
w= = 


Jour. 


1920, xxxıii., 


(i 
ka W 


ae 


-A> 


20 THE LANCET] DR. LEWIS THATCHER : 


HYPERVITAMINOSIS D 
By LEWIS THATCHER, M.D., F.R.C.P. Edin. 


PHYSICIAN TO THE ROYAL HOSPITAL FOR SICK CHILDREN, 
EDINBURGH ; LECTURER IN CHILD LIFE AND HEALTH 
IN THE UNIVERSITY OF EDINBURGH 


THE case is that of a baby aged 11} months whose 
health had been failing steadily for about four months 
without any obvious reason; he died four days 
after admission to hospital, when lesions characteristic 
of hypervitaminosis D were found in the kidneys. 


CASE RECORD 


Preliminary history——In April, 1934, at the age of 
44 months, he was admitted to the Royal Edinburgh 
Hospital for Sick Children suffering from mild seborrheic 
dermatitis. He was a well-nourished child, the body 
length being 26in. and the weight 141b. 10 0z.; he had 
thriven well on artificial feeding, and was taking a reason- 
able ration of undiluted raw certified milk ; he had been 
perfectly well except for the dermatitis that had been 
present for about three weeks. He was discharged cured 
in a fortnight, and brought up for inspection a month later, 
in June; he was very well, the skin was clear, and he had 
gained 1} 1b. to 15 lb. 14 oz.; the diet was left as it was— 
raw milk without any additions. He was not seen again 
for nearly five months, until he was readmitted to hospital 
on Nov. 7th, 1934. 

History.—His general health had been failing since the 
beginning of July ; he lost his good colour and was always 
fretful, without actual pain or fever; there was persistent 
anorexia, with constipation, and he had become steadily 
worse during the last month. He had not gained weight 
satisfactorily, and there had been many fluctuations 


‘between July and mid-October, when he weighed 


16 lb. 10 oz. ; then there was a steady loss, and on Nov. 7th 
he weighed only 15 lb. 13} 0z.—the same as five months 
‘before, although he had grown 2?in. in that time. He 
had been well cared for, and was out of doors constantly 
throughout the summer; the home conditions were good, 
in a pleasant open part of the city ; he had been given two 
treatments with the ultra-violet lamp in October. 

The daily dict had been as follows. Late June and 
July : 35-40 oz. of raw Grade A (T.T.) milk with about 
loz. of sugar added; ten drops of cod-liver oil thrice 
daily; six teaspoonfuls of orange juice; Virol, for one 


week only. August: as before, but the milk was cut 


down to about 300z. and one feed of oatflour porridge 
or some other cereal was given; strained soup and gravy 
and potato were given occasionally, and the yolk of an 
egg twice a week; feeding gradually became difficult 
because of loss of appetite; cod-liver oil was given 
regularly, and the mother sought to combat the increasing 
weakness and flagging weight curve by giving as much 
as half to one teaspoonful (1 to 2 grammes) three times 
on many days. During September and October the dict 
was very much rostricted because of tho persistent anorexia ; 


Jess than one pint of milk was taken, with a little mixed 


feeding; cod-liver oil and fruit juico were given as in 
August, and pressed upon the unwilling child. 

Extract from case notes.—He is a pale, thin, and very 
feeble infant, collapsed but not severely dehydrated ; rectal 
temperature subnormal; no cdema; muscles small and 
very soft; cranial bones well calcified, the anterior 
fontanelle being of normal size; eight good tecth. The 


urine is scanty in amount and strongly acid; there is a 


trace of albumin, and no sugar or acetone; on micro- 


‘seopical examination of a fresh uncentrifuged specimen 


a few pus cells are seen—about four to tho high-power 
field ; no red blood corpuscles, and no casts after centrifug- 
ing. Staphylococcus aureus was cultured from the urine, 
but this was assumed to be a contamination because a 
specimen taken two days later was sterile; (post mortem, 
the genito-urinary tract was found to be free of pyogenic 
infection). 

End of illness.—A diagnosis of terminal pyelonephritis 


‘was made, but no explanation could be given for the 


persistent failure to thrive, and for the fact that the urine 


HYPERVITAMINOSIS D [JAN. 4, 1936 | 
was sterile. The urine was alkalinised within 24 hours 
without improvement in the baby’s general condition ; 
there was irregular and increasing pyrexia, and several 
convulsions with a normal cerebro-spinal fluid; death 
took place four days after admission to hospital. 


POST-MORTEM YINDINGS 


A post-mortem examination was performed by Dr. Agnes 
Macgregor, pathologist to the hospital, who reported as 
follows. 

The body was that of a small, thin male infant. The 
bones were well calcified and their ossifying junctions 
appeared to be normal. Apart from slight hypostatic 
congestion and cedema of the lungs, and mild fatty 
degeneration of the liver, the only significant pathological 
changes were in the kidneys. These were swollen, pale, 
and rather severely congested in a patchy fashion. On 
section there were found peculiar deposits of a grey 
granular material, very slightly gritty, which formed a 
narrow line along the bases of the medullary pyramids. 
This material could not be expressed or removed by 
scraping. It was present in every pyramid of both 
kidneys, but could not be detected elsewhere with the 
unaided eye. There were no foci of suppuration. The 
pelves and ureters were healthy. 


Microscopical examination.—In certain tubules of the 
kidney there were deposits of a material which, both with 
hematoxylin and with von Kossa’s silver nitrate method, 
gave staining reactions characteristic of calcium (see 
Figures), These were most numerous and largest in the 
medulla, especially at the bases of the pyramids, but they 
were present also in the cortex, where they were very small. 
The calcium-containing material occupied the lumen 
of the tubules, sometimes completely filling it; in some 
instances cells attached to the wall of the tubule, or lying 
free in the lumen, were calcified. Around all the larger 
and some of the smaller deposits there was some prolifera- 
tion of cellular fibrous tissue. In the cortex a few glomeruli 
contained calcium deposits, the affected tufts being 
swollen and the capillaries obliterated. There were 
some small foci of mononuclear-cell infiltration, unrelated 
to calcium deposits ; some dilatation of groups of tubules 
which contained ‘colloid’? casts; parenchymatous 
degeneration of the epithelium of tubules in the cortex ; 
and slight cdema of the stroma. The arteries were 
healthy. No evidence of pyogenic inflammation was 
found. The liver showed slight fatty degoneration. 
Microscopical examination of lung, myocardium, stomach, 
spleen, lymph gland, thymus, thyroid, parathyroid, 
aorta, and various arteries revealed no pathological 
changes. 

Pathological diagnosis.—The lesions in the kidneys 
were similar to those described in previously reported 
fatal cases of hypervitaminosis D in the human subject, 
and closely resembled those produced in animals by 
experimental administration of excessive quantities of 
vitamin D. 


DISCUSSION 


A clinical diagnosis of hypervitaminosis D should 
have been considered, for the illness resembled 
very closely that known to be caused by excessive 
doses of vitamin D and by minute amounts given to 
infants who are abnormally sensitive to the action 
of the drug. It was not realised that the baby might 
have been affected by the vitamin D `n the cod-liver 
oil that had been administered daily in considerable 
doses throughout four summer months, augmented 
as it was by that contained in a full ration of fresh 
cow’s milk and by that formed in his tissues under 
the influence of sunshine—to which he had been 
exposed a great deal throughout the summer. In 
addition, he had been given two treatments with the 
ultra-violet lamp about three weeks before he died ; 
these were not persevered with because irradiation 
did not seem to suit him. No other cause for his 
illness was found either before or after death, for the 
condition of the urine did not indicate a severe 
infection of the urinary tract. It is known that 


THE LANCET] 


DR. LEWIS THATCHER: HYPERVITAMINOSIS D 


[JaN. 4, 1936 21 


he was perfectly well and thriving satisfactorily 
without any signs of rickets just before the institution 
of the intensive antirachitic régime that was carried 
out without remission from June to the end of 
October. 


In 1924 A. F. Hess! and also Steenbock and Nelson ? 
discovered that ergosterol was endowed with anti- 
rachitic properties by exposure to the rays of an 
ultra-violet lamp, and it was proved that this was 
due to the formation of vitamin D. More recently 
the pure vitamin was isolated in crystalline form from 
this preparation,’ and given the name of calciferol ; 
its potency is about 40,000 international units of 
vitamin D in a milligramme, whereas a good sample 
of cod-liver oil contains only about 100 per gramme. 


Very soon after the introduction into the practice 
of medicine of preparations containing irradiated 
ergosterol reports of its toxicity in certain cir- 
cumstances began to appear. Experimentally 
Pfannenstiel* found that a dose 100 times greater, 
than the minimum antirachitic one did not produce 
any recognisable effect on rats; one 1000 greater 
was definitely harmful when taken over long: periods 
of time; and one 10,000 greater was strongly toxic. 
Moreover, it was recognised that these ill-effects 
are exaggerated when the diet is modified in certain 
ways (especially when it is insufficient or badly 
balanced), that young and non-rachitic animals 
have less tolerance than those that are mature or 
rickety, and that there is a conspicuous difference 
in the susceptibility of different species as well as a 
possibility of individual idiosyncrasy. It is important 
to note that animals may recover very quickly if 
the drug is withheld in reasonable time. There is 
abundant evidence that infants also may react badly 


72 š ex : 
a 3 
Les 
Tchr wa 
3 Ņ -y 
FIG. 1.—Section through base of pyramid 
showing calcium deposits. von Kossa’s 


stain. (X 35.) cosin. 
to “safe” doses 5°; there may be a true idiosyncrasy. 
It has been found that undue susceptibility is most 
common in premature or feeble infants, and in those 
that are not rickety ; in addition, tolerance may be 
lowered by febrile illness and by exposure to the 
rays of the sun and of the ultra-violet lamp.77?° 

The indications that vitamin D is exerting a toxic 
influence may be summarised as follows. There is 
failure of general health without obvious cause, and 
progressive asthenia is associated with marked 
atony of the muscles ; persistent anorexia is a striking 
feature ; there may be vomiting and slight diarrhcea 
at first, followed by constipation ; the mental state 


Tere, 
posed E gy, € wy 


FIG. 2.—Calcium deposits in tubules at base 
of medullary pyramid. 
(x 75.) 


PFCS, 


a TEN : 

d Ja ‘ 
Rowe . Pd) 
s . 

r ; 4 3 Cen. #2) 
Foes -i 
¢ 

“ f Ca 
> A 
f EAA “3 
> i . a 

gia 

a) 


FIG. 3.—Calcified masses of one of the larger deposits showing 
calcified masses in tubules and slight fibrosis. Hoematoxylin 
and eosin. (xX 160.) 


is abnormal (fretfulness with a strange apathy) ; 
there is neither pain nor fever; the weight is likely 
to be stationary for some time, followed by a steady 
decline ; albuminuria and pyuria seem to be found 
constantly in the later stages; there may be a rise 
in the amount of inorganic blood phosphate without 
a corresponding hypercalcemia. 

The post-mortem findings are conclusive, for they 
are pathognomonic of hypervitaminosis D. We 
do not know of any other agent, or any disease, that 
will cause the characteristic deposition of calcium 
salts in the tissues ; it is found always in animals that 
have been poisoned 
with vitamin D, and 
is most abundant in 
the kidneys and 
urinary passages— 
where there may be 
calculi—and in the 
walls of the great 
arteries. The state 
of the kidneys in the 
case reported in this 
paper is similar to 
that described in the 
two other cases of 
hypervitaminosis D 


GA ee ee we ae affecting babies in 
Ta) MR © Rta ee oe which the diagnosis 


was established by 
careful post-mortem 
examination! ??; 
calcification of other 
tissues has not been 
seen in the human 
subject. 

I can find the record of one case only in which 
fatal illness may have been caused by the vitamin D 
contained in cod-liver oil. 


Hematoxylin and 


Malmberg, following the work of Agduhr and other 
Scandinavian workers, reported the case of an infant one 
week old who was given half a teaspoonful of the oil daily. 
It disagreed, causing vomiting that ceased immediately 
the oil was withheld ; it was given again about a fortnight 
later in half a teaspoonful dose twice a day; this was 
increased soon to a teaspoonful at the same times, and 
was continued in this amount until the baby died when 
she was 4 months old. The diet was human milk, fruit 
juice, and a little butter gruel occasionally. There had 
been inexplicable failure of health for several weeks before 


22 THE LANCET] 


DR. E. R. JONES & PROF. H, D. WRIGHT: B. AERTRYCKE FOOD POISONING 


[yan. 4, 1936 


death ; the weight was stationary, but loss was obscured 
by the presence of subcutaneous cedema; there was 
neither vomiting nor diarrhea; the state of the urine 
was not described. Post mortem, the only significant 
findings were degenerative changes in the myocardium 
and elsewhere similar to those found in experimental 
animals that had been given excessive amount of cod- 
liver oil for a long time; but the deposition of calcium 
in the urinary tract was not noted and, therefore, the 
case cannot be accepted as one of hypervitaminosis D. 


It is common experience that a reasonable dose 
of cod-liver oil is extremely well tolerated by infants, 
and that digestive disturbance may be brought about 
by injudicious use of it. The signs, as a rule, are those 
of gastro-intestinal irritation with diarrhea, and they 
clear up quickly when the oil is withheld, or a smaller 
dose given. It is conceivable that ill-effects might 
be brought about if intestinal peristalsis was 
unhurried, permitting more complete absorption, 

‘and especially in the presence of constipation that 
seems often to accompany vitamin-D poisoning. 

It is important to know that the vitamin-D content 
of cod-liver oil has been definitely increased during 
the last few years; the monopoly that it enjoyed as 
an antirachitic agent was broken by the introduction 
of numerous well-advertised preparations containing 
calciferol—the potency of which is made much of— 
and this intensive competition had to be met. Not 
long ago many samples contained little or no 
vitamin D; now most of the oil that is sold is 
standardised to contain a certain number of inter- 
national units per gramme. I have ascertained the 
certified potency of eight samples that are available 
on the British market ; five popular brands contain 
about 100 international units, one has 140, one 160 
(both of these are fortified by the addition of halibut 
oil), and one 200; the latter is a natural Norwegian 
oil, and was used in the case reported here. 


SUMMARY 


The case is that of a baby aged 114 months known 
to be thriving and free of rickets just before the addi- 
tion to the daily diet—at the beginning of June— 
of a considerable dose of cod-liver oil with an 
exceptionally high vitamin-D content. He had been 
brought up on raw cow’s milk, fruit juice, and the 
customary amount of mixed feeding; he was out 
in the open air and sunshine a great deal, and had 
been given abundant opportunities for muscular 
exercise. He died early in November after an 
illness similar to that described as being caused by 
hypervitaminosis D. Post mortem, changes pathog- 
nomonic of that condition were found in the kidneys. 


CONCLUSIONS 
Young infants may have idiosyncrasy to the 
vitamin D contained in cod-liver oil as well as 
to artificially prepared calciferol. The present-day 
tendency to increase the vitamin-D potency of cod- 
liver oil is undesirable and unnecessary ; that to which 
the public is accustomed, and upon which popular 
dosage is based—viz., about 100 international units 
per gramme—is sufficient for all purposes, There 
ig no reason whatever to administer cod-liver oil to 
infants during the summer months when diet and 
hygienic conditions are satisfactory and there is 
no evidence of rickets. 
REFERENCES 


1. Hess, A. F.: Amer. Jour. Dis. Child., 1924, xxviii., 517. 

2. Steenbock, H., and Nelson, M. T.: Jour. Liol. Chem., 
1924, Ixii., 209. 

3. Vitamins: a Survey of Present Knowledge. Med. Research 
Counc., Spec. Rep. Ser. No. 167, London, 1932. 

4. Pfannenstiel, T.: Klin. Woch., 1927, vi., 2310. 


(Continued at foot of next column) 


B. AERTRYCKE FOOD POISONING 


DUE TO CONTAMINATION OF FOOD WITH EXCRETA 
OF MICE 


By E. R. Jones, M.D. Liverp., D.P.H. 


ASSISTANT CITY BACTERIOLOGIST; AND 


H. D. Wricut, M.D., D.Sc. Edin. 


PROFESSOR OF BACTERIOLOGY IN THE UNIVERSITY 
OF LIVERPOOL 


THE details of this small outbreak of food poisoning 
caused by B. aertrycke (Salmonella typhi murium) 
have appeared worth recording because the source 
of infection seems to have been definitely proved 
to be food contaminated with mouse fæces and also 
because of the impression we have formed that the 
completeness of the chain of evidence was due to 
the use of tetrathionate broth and brilliant green- 
eosin agar, 

The outbreak involved five members of one family, 
living in conditions of poverty and squalor in a poor 
quarter of Liverpool. 

The first case was a child of eight months who was 
admitted to Fazakerley hospital for infectious diseases 
on Oct. 22nd, 1935, with a large abscess in the left buttock 
and smaller ones in the right groin and on the dorsal 
surface of the left wrist. He was in a somewhat collapsed 
condition and suffered from diarrhoea which, the mother 
stated, had lasted for some days. The condition gradually 
became worse and the patient died on Oct. 27th. A speci- 
men of feces examined on Oct. 23rd yielded a heavy 
growth of B. aertrycke, largely in the group phase. At a 
post-mortem examination on Oct. 28th the abscess was 
found to bo due to Staphylococcus aureus and was peculiar 
in that it contained a large mass of necrotic fat and sub- 
cutaneous tissue, about 3 in. by 1 in., lying free in the 
cavity. Changes in the bowel were those of shght 
inflammatory congestion and in the other organs those 
associated with toxemia. B. aertrycke was isolated from 
the contents of the stomach, jejunum, ileum, ascending 
colon, and rectum, and from the spleen and heart blood. 
Serum collected at autopsy agglutinated salmonella 
group suspension in a dilution of 1 in 640 and B. aertrycke 
(type) suspension at 1 in 320. 

On further inquiry it was ascertamed that the 
father, mother, and two sisters of the dead child had 
all begun to suffer from diarrhea on Oct. 24th, 
two days after the child had been removed to hospital. 
The attacks were mild and lasted in one case for one, 
and in the others for three days. Specimens of 
fæces from all four cases collected on Oct. 30th 
yielded cultures of B. aertrycke. Sera collected from 
three of the patients on Nov. 8th agglutinated 
standard suspensions as follows :— 


Se an ea Aertrycke O. 
Patient A zs lin 20 lin 40 Nil 
ps B Ji lin 80 Ss lin 40 ae lin 80 
» C cs Nil lin 40 lin 80 


In view of the ave of the first patient (8 months) 
and the nature of the infection it was suspected that 


(Continued from previous column) 


. HMottinger, A.: Zeits. f. Kinderbeilk., 1927, xliv., 61. 

. Mess, A. F., and Lewis, J. M.: Jour. Amer. Med. Assoc., 
1928, xci.. 733. . 

Schlutz, F. W.: Ibid., 1932, xcix., 384. 

Gordon, M. B., and Lieberman, H.: Amer. Jour. Med. Sci., 
1932, clxxxiii., 784. 

. Warkany, J.: Wien. klin. Woch., 1932, xlv., 206. 

. Smitb, M. I. and Elvove, E.: Pub. Health Rep., Washing- 
ton, 1929, xliv., 1245. 

Putschar, W.: Zeits. f. Kinderheilk., 1929, xlvii., 269. 

. Thatcher, L.: Edin. Med. Jour., 1931, xxxviii., 457. 

3 Maln perg, N.: Acta Pædiat., 1928-29, vol. viii., Suppl., 

pD. i r 


p= 
QW NS = © e aon fort S| 


pond pmi bad 


THE LANCET] 


milk might be the vehicle of infection and mice the 
source. Through the courtesy of the medical officer 
of health for Liverpool (Prof. W. M. Frazer) it was 
possible to examine six mice trapped in the house 
between Nov. 5th and 7th. From the intestinal 
contents of one of these B. aertrycke was isolated. 
The intestinal contents and spleen of the other five 
failed to provide cultures of this organism, as also 
did the spleen of the mouse whose feces contained 
B. aertrycke. 

A partly used tin of a dried milk preparation with 
which the child had been fed was fortunately available 
for examination. This was found to contain several 
pellets of mouse fæces of which four were examined, 
and from one B. aertrycke was isolated. 


It seems reasonable to suppose that the infant was 
infected via the milk and that this had become 
infected by contamination with mouse fæces. So 
far as could be ascertained no other member of the 
family had consumed any milk and it is possible 
that they may have been infected from the first case. 
At the coroner’s inquiry it was made clear that the 
conditions in the house and the habits of the inmates 
were such as to render this highly probable. 


The possibility that rats or mice might be the 
source of infection in some outbreaks of food poisoning 
has been suggested by several workers, notably 
Bainbridge (1912) and Jordan (1931), in view of the 
fact that rodents are not infrequently found infected 
with organisms of the salmonella group under natural 
conditions. Most workers have found B. enteritidis 
(Gaertner) the infecting agent in rats, while in guinea- 
pigs and mice it is more often B. aertrycke. But 
although outbreaks have been traced by various 
authors (Shibayama 1907, Willfuhr and Wendtlandt 
1921, Spray 1926) to the contamination of food with 
“rat virus” this has usually been due to direct 
contamination of utensils without the intervention 
of the mouse or rat. The only instance of association 
with naturally infected mice which we have been able 
to trace occurred in the outbreak described by Salthe 
and Krumwiede (1924) which appears to, have been 
well established. Another possible case is the out- 
break No. 51 in the series recorded by Savage and 
Bruce White (1925), though the mice in this instance 
were not examined until some weeks after the 
outbreak occurred. 

We have been unable to obtain any evidence that 
“rat virus’? was employed for rodent destruction 
in the neighbourhood where these cases occurred. As 
most of these viruses contain B. enteritidis (Gaertner) 
the infection is unlikely to have come from such a 
source. The house was found to be badly infested 
with mice and little or no effort had been made to 
protect food from them. 

We have been interested to find that Willams, 
Murray, and Rundle (1910) recorded a group of seven 
cases of “ summer diarrhea ” in Liverpool from which 
they isolated organisms of the salmonella group. 
The first of our series might easily have been so 
diagnosed. 

The ease with which the chain of evidence has 
been established in this outbreak is in no small part 
due to the use of specially satisfactory media. These 
have consisted of an enrichment broth containing 
sodium tetrathionate prepared as described by 
Schafer (1935) following Müller (1923) and an agar 
medium containing brilliant green and, eosin described 
by Teague and Clurman (1916) and recommended 
by Meyer and Stickel (1918). We have found this 
combination extremely valuable in the isolation 
of all members of the typhoid-paratyphoid group 


CLINICAL AND LABORATORY NOTES 


[yan. 4, 1936 23 


but apparently of no value for dysentery bacilli. 
Kauffmann (1930, 1935) has also reported very 
favourably on the employment of a modified 
tetrathionate broth for the investigation of intestinal 
infections. As these media appear to be so satisfactory 
we think our experience may be of interest to those 
engaged in the investigation of these conditions. 


We wish to express out indebtedness to Prof. Frazer 
and his staff, especially to Dr. B. T. J. Glover, for assistance 
in obtaining material for examination and for data 
regarding the onset of the attacks, and to Dr. A. E. 
Hodgson for the opportunity of investigating the first 
case and for clinical information. 


REFERENCES 


Bainbridge, F. A.: THE LANCET, 1912, i., 705, 771, and 848. 
Jordan, E. O.: Food Poisoning and Food-borne Infection, 


Savage, W. G., and White, P. B.: Medical Research Council, 
Spec. Rep. Series No. 92, 1925. 
Schafer, W.: Zentr. f. Bakt., 1935, Abth. i. Orig. cxxxiii., 458. 
Shibayama, G.: Minch. med. Woch., 1907, liv., 979. i 
Spray, R. S.: Jour. Amer. Med. Assoc., 1920, Ixxxvi., 109. 
Teague, O., and Clurman, A. W.: Jour. Inf. Dis., 1916, xviii., 647. 
Wilführ and Westlandt: Zeits. f. Hyg., 1921, xciv., 192. 
AET R: map URAN: H. L., and Rundle, C.: THE LANCET, 
, l., . 


Clini cal and Laboratory Notes 


s MORBUS BRITANNICUS ” 
A FORM OF FIREMAN’S CRAMP 


By Sv. E. Kororp, M.D. 


MoRBUS BRITANNICUS is the name we have given a 
special sort of fireman’s cramp, seen very often 
among the sailors of British trawlers coming to the 
Faroe Islands. It is never seen among Scandinavian 
sailors. In the ‘‘Ship Captain’s Medical Guide” 
(London, 1929), by D. D. F. Macintyre, the disease is 
described as follows :— 

“Firemen are peculiarly liable to a severe form of 
cramp, which affects the muscles of the belly, arms, and 
legs. The patient is usually discovered groaning and 
writhing on the deck, with his extremities curved, in 
excruciating pain, and his muscles drawn into hard rigid 
knots. ... There may be frequent watery stools and 
signs of collapse. ... The complaint is specially pre- 
valent after leaving home ports, and decreases when 
well in blue water. . . . It attacks men who drink large 
quantities of cold water when the body is overheated... . 
Treatment: As the condition is due to deficiency of salt 
in the system, the treatment should be directed towards 
rectifying this deficiency. A pinch of salt should be put 
in every drink the men take in the stokehold. A hot 
salt-water bath will afford speedy relief. In bad cases 
an enema of warm salt solution—a teaspoonful of salt 
to the pint of water—may be given... . Other treat- 
ment is to rub the affected parts with turpentine liniment 
and to give a dose of cramp mixture, which may be 
repeated in half an hour if necessary.” 

The picture of the illness we have seen in tho 
Faroe Islands, and which we have given the name of 
morbus Britannicus, is not quite identical with the 
one given by Macintyre, but there are so many 
points of similarity that we conclude that it must be 
fireman’s cramp. Of the 30 patients in whom we 
have made this diagnosis, 10 were firemen, 6 trimmers, 
3 engineers, and 5 cooks, and 6 had other occupations. 
Eleven were less than thirty years old, 11 between 
thirty and forty, and 8 more than forty. 

The symptoms include headache, abdominal pain, 
and constipation—sometimes diarrhea, but more 


94 THE LANCET] 


. frequently constipation, which must be emphasised 


as a feature differing from the above description. 
Further were observed nausea, vomiting, and pain in 
the muscles of the belly, arms, and legs. The pain 
is often very alarming and spasmodic; only seldom 
have we seen generalised tonic and clonic spasms — 
namely, in cases when the disease has lasted a very 
long time, or where there was complicating organic 
stenosis of the pylorus. There have been only 
5 cases with generalised spasm. 

We have not seen fever. The pulse is ordinarily 
normal, in some cases a little more rapid than usual. 
The patients are pale, shocked, and apathetic. The 
spasm of the belly can be so intense that it looks like 
a regular pseudo-defence. This we have seen in 
10 cases. It is therefore easy to understand that the 
diagnosis may be difficult, because the question of 
ulcer, cholelithiasis, or appendicitis arises. The 
patients may be suffering from terrible pain and 
‘the muscles iron-hard. The abdomen is boat-like, 
retracted, and diffusely painful. The spasm takes all 
the muscles of the abdomen more specially the recti 
abdominis. Therefore one considers first of all the 
‘possibility of a perforation with consequent peri- 
tonitis ; but the picture is usually less violent, there 
is less shock, and pulse and temperature are not 
affected. Also flatus is usually free. Nevertheless 
we have in 3 cases very nearly diagnosed appendicitis, 
in 1 case cholelithiasis, and in 2 cases gastric ulcer. 

In such doubtful cases it generally suffices to 
observe the patient carefully for some hours and give 
a small glycerin enema. Then we see opening of the 
bowels, and the patient will pick up. If one thinks 
of the possibility of fireman’s cramp one is almost 
sure to get information about pain in the muscles of 
the arms and legs and find tetanic and rigid muscles. 

We have the impression that the abdominal spasm 
comes first, perhaps because there is constipation. 
Another question is connexion with sea-sickness. 
We have no doubt that this is often present and 
partly causes the headache, nausea, and vomiting. 
Fireman’s cramp is due to loss of salt by sweat, and 
naturally this is aggravated by sea-sickness, where 
there is loss of chlorine ions by vomiting, which in 
itself can lead to gastric spasm. 

We have also seen cases of ulcus ventriculi com- 
plicated with morbus Britannicus. In one of these 
-there was a violent spasm of pylorus accompanied by 
universal tonic spasm. The very ill patient was most 
strikingly relieved by two intravenous injections of 
‘5 c.cm. 10 per cent. of calcium chloride. Later a 
radiogram showed great dilatation of the stomach 
due to a duodenal ulcer. The other patient had a 
less violent attack of spasm. After the attack we 
discovered distinct symptoms of a stenosing ulcera- 
-tion of the stomach, and he was operated upon by 


_ a retrocolic posterior gastro-enterostomy. Since then - 


he has been well and he is now cook in a trawler. 

' Remembering Prof. J. S. Haldane’s researches into 
« miner’s cramp,” we have looked for chlorides in 
‘the urine. These were never completely absent, but 
the reaction was very weak in spite of the small 
diuresis. We have not yet been able to make 
quantitative researches on the chlorides in urine and 
blood, but we intend to do so in future. In our cases 
it seems that the amount of chlorine is more important 
‘than the amount of sodium chloride, and we have 
seen good results from calcium chloride per os, per 
rectum, or intravenously. Experienced captains 
believe that starvation and excesses are predisposing 
‘causes ; also previous diseases. We have seen a case 
of morbus Britannicus occurring just after a bad 


CLINICAL AND LABORATORY NOTES 


[san. 4, 1936 


attack of malaria, and this was in a trimmer forty 


years of age who had been at sea for many years all 


over the world. As a direct cause bad weather is 
almost always observed. 

We have never seen this disease among the fisher- 
men of the Faroe Islands, and I think this is due to 
the salt food of these men. Sea-sickness is the same 
for British and other sailors, and so cannot be the 
cause of the prevalence among British sailors. 

Morbus Britannicus is rather an important disease 
on British ships, which is proved by the fact that we 
in Klaksvig (in the northern part of the Faroe 
Islands) in the last three years have treated 180 
British sailors, of whom 30 were suffering from this 
disease. We shall therefore conclude by suggesting 
that salt meat should be introduced as a part of the 
food on British ships, because this has proved to be 
preventive against the illness on Scandinavian ships. 
The treatment recommended in the “Ship Captain’s 
Medical Guide’? has not been effective, because the 
‘men are sea-sick at the same time and vomit the salt 
drink recommended, and usually do not trust them- 
selves to give enemas. Prevention is most certainly 
in these cases best. 


SEVERE SYPHILITIC ANAEMIA OF THE 
PERNICIOUS TYPE 


By Cuartes R. Box, M.D., F.R.C.P. Lond., 
F.R.C.S. Eng. 


CONSULTING PHYSICIAN TO ST. THOMAS’S HOSPITAL, 
LONDON ; AND 


A. Morton GILL, M.D. Lond. 


SYPHILIS is a common disease and pernicious 
anemia by no means rare, and yet the combination 
of the two diseases in the same patient is not often 
seen. In cases of severe anemia with.a positive 
Wassermann reaction it is usual to follow Stokes’s 
classification ! which is as follows :— 

(1) True pernicious anemia with 
Wassermann reaction. 

(2) True pernicious anzmia in association with syphilis. 

(3) Severe anemia due to syphilis. 


a false positive 


We believe that the following case belongs to the 
third group, and we have therefore endeavoured to 
trace any previous case, clinically and hzmato- 
logically resembling pernicious anæmia, with a positive 
Wassermann reaction showing no response to stomach 
extract, but restored to normal by antispecific 
measures only. We have been unable to find any 
record of such a case. 

In the days before liver and stomach extract therapy, 
Labbé? in 1906 reported a case of severe anæmia 
in a syphilitic which failed to respond to iron but was 
cured by mercury ; Nathan? in 1914 reported a case 
of pernicious anxmia and syphilis cured by anti- 
specific measures only ; while Naegeli 4 had a case of 
pernicious anemia and tertiary syphilis which 
responded to arsenic and mercury, in 1893, and was 
well when seen in 1918. Since the introduction of 
liver by Minot and Murphy, de Lillo > has reported a 
case of pernicious anemia and syphilis, cured by 


antispecific measures only, but the effect of liver or | 


stomach extract was not tried. The following case, 
therefore, appeared to us to be of interest :— 


History.—The patient, a man aged 48, was admitted 
to the Royal Masonic Hospital on Oct. 14th, 1934, 


THE LANCET] 


CLINICAL AND LABORATORY NOTES 


[yan. 4, 1936 25 


1934. 1935. 

Oct. | Oct. | Nov. | Nov. | Dec. | Dec. | Dec. Jan. | Jan. | Jan. | Jan. | May 

16th. | 30th. | 17th. 30th, 6th. | 13th. | 20th. 3rd. | 14th. | 22nd. | 31st | 31st. 
Red cells (millions) | 1°480 | 1°530 | 3°090 | 3°150 | 3°610 | 3°510 | 3°460 Red cells (millions) | 3°740 | 4°280 | 3° ag 4°930 | 5'460 
Hb. per cent. ie 36 40 64 65 66 74 71 Hb. per cent. gig 79 79 94 104 
Colour-index bi 1:2 1:29 1:03 | 1°03 | 0°92 1:06 1°03 Colour-index ; 1:05 | 0°93 | 0° 186 0°96 | 0°95 
Anisocytosis ee + + sis ar es hen. <x Anisocytosis =s + is + ss es 
Poikilocytosis is + + Poikilocytosis zS + oa Jc a s 
Punct. basophilia.. |. .. + z Nucleated red ens we ex a Par 
Polychromasia .. + + A << re i Fl White cells 7000 | 7000 1810 5440 | 8400 
Normo blasts si + be ing Ba a5 a -Polymorphs e. |64°3%] .. 2'2 %| 53°0 %| 49% 
White cells 50890 | 5000 | 6000 | 7000 | 5000 | 8000 | 8000 Small mononuc. .. |267% 36-3 wj 170%! 21% 
Polymorphs e. | 320%] 38°93 % .. Sie ety sa a Large mononwe. .. 4°0 % 8°6%| 80 %l 16% 
Small mononuc. .. | CE7 %|517% Hyalines .. . 4 6% 10°5%| 10% 
Large Mononuc. .. 2°7%| 40% Eosinophils 50% 6:3%| 11:5 3 4% 
Eosinophils 16%] 6'0% 
Mast cells .. 00% 00% ; 
complaining of nasal catarrh of some ten months’ duration. with a steady improvement in the blood picture. The 


On admission his pallor was such a striking feature that 
it was apparent that there was something more seriously 
amiss than nasal catarrh, and, on being questioned, he 
admitted that he also suffered from dyspnoea on slight 
exertion, palpitations, giddiness, and feelings of pins and 
needles in both arms and legs. His occupation was that 
of an accountant, and he had a wife and family, all in good 
health. 

Examination.—The mucous membranes were pale 
and the patient had a bilateral malar flush. He was some- 
what thin, his weight being 8st. 9lb. 70z. His tongue 
was smooth with atrophy of the papille, his teeth false. 
The heart was clinically slightly enlarged to the left, 
and a loud blowing systolic murmur was audible in all 
areas ; the blood pressure was 140/70 mm. Hg; examina- 
tion of the optic fundi revealed much pulsation in the 
retinal veins, together with the presence of opaque nerve- 
fibres on both sides. The liver and spleen were both 
palpable. No abnormal physical signs were detected in 
the respiratory or central nervous systems, and examina- 
tion of the urine was negative. The patient also presented 
a rash, and this was seen by Dr. A. C. Roxburgh who 
reported as follows: ‘“‘ Psoriasiform shiny scaly papules 
elbows and backs of hands. Peeling areas both palms.” 

Response to treatment.—Clinically the case was one of 
pernicious anzemia and the patient was placed on adequate 
doses of stomach extract by mouth. He was also given a 
mercurial ointment to be applied to the areas affected by 
the rash. A blood count and fractional test-meal appeared 
to confirm the diagnosis, as the laboratory reports show. 

On Oct. 25th he complained for the first time of nausea 
with abdominal discomfort, and in view of the absenceof free 
hydrochloric acid as shown in the test-meal, he was given 
a mixture containing pepsin and dilute hydrochloric 
acid at meal-times. There was no clinical improvement 
in his condition, so that we were not unduly surprised when 
a blood count on Oct. 30th also failed to reveal any 
progress. On this date he was again seen by Dr. Roxburgh, 
who made a note that the psoriasiform patches had almost 
disappeared. The fact that a rash, affecting both palms, 
had rapidly improved on an ointment containing mercury 
seemed suspicious, and on the same day a blood Wasser- 
mann reaction was done and found to be strongly positive. 
We thereupon decided to try the effect of antispecific 
measures alone. All previous therapeutic measures 
were abandoned and the patient was placed on a mixture 
containing pot. iod., grs. 10, and liq. hydrarg. perchlor., 
M 30 t.d.s., p.c. The next blood count, a fortnight later, 
showed a 100 per cent. improvement, and the dose of 
potassium iodide was increased to grs.15 and of liq. 
hydrarg. perchlor. to M 45. The next count, on Nov. 30th, 
showed no improvement, and the dosage of potassium 
iodide was increased to grs.20 and the liq. hydrarg. 
perchlor. to M60. On Dec. 6th the blood count had 
again improved, the red cells having increased by nearly 
half a million, and on Dec. 13th, although the red cells 
were approximately the same, thie hamoglobin had risen by 
8 per cent. 

The next blood count was disappointing, and so intra- 
venous N.A.B.: (neoarsphenamine) was begun, the first 
dose of 0-6 g. being given on Dec. 21st. This was given at 
weekly intervals while the patient remained in hospital, 


patient’s general condition also improved enormously ; 
all his symptoms disappeared, including profuse night 
sweats, concerning which he had complained bitterly, 
and he was discharged on Feb. llth, 1935, having gained 
over a stone in weight since admission. 

On May 30th he was readmitted to hospital for estima- 
tion of progress. Since his discharge from hospital he 
had returned to business and had been taking Hutchinson’s 
pill, 2 t.d.s., p.c. Apart from this, he had had no treat- 
ment since leaving hospital. He looked and felt a new man, 
and a blood count on May 3lst was normal with the 
exception of a rather high colour-index. After a further 
test-meal, and a blood Wassermann reaction which 
proved to be still positive, he returned home on June 2nd. 
Five more N.A.B. injections were given in June and 
July, and in a letter written in December he states that 
his health is excellent. He continues to take Hutchinson’s 
pills. 

Laboratory winvestigations.—Fractional test-meals on 
Oct. 18th, 1934, Jan. 24th, Feb. 8th, and June Ist, 1935, 
all showed a complete absence of free hydrochloric acid 
and a very Jow total acid curve. Blood Wassermann 
tests on Oct. 29th, 1934, Jan. 23rd and May 3lst, 1935, 
were all strongly positive. The blood counts are set out 
in the accompanying Table. 


DISCUSSION 


A case is described presenting symptoms, signs, 
and blood picture closely resembling Addisonian 
pernicious anæmia with, in addition, syphilis; the 
disease failed to respond to adequate doses of stomach 
extract, but showed a gratifying improvement under 
antisyphilitic measures only. We cannot believe 
that this was a natural remission, unconnected with the 
therapeutic measures adopted; the improvement 
both in the general condition and in the blood 
picture was so steadily progressive, particularly after 
the administration of N.A.B. was begun, that we 
feel no doubt that the one was intimately connected 
with the other. 

There remains the problem as to the site of the 
lesion. Had this been a syphilitic gastritis, causing 

atrophy of the pyloric and fundus glands (as was 
suggested by the fractional test-meals), then one would 
have expected a response to stomach extract, which 
supplies both hemopoietin and the anti-anemic 
principle. Whether a syphilitic lesion elsewhere 
in the gastro-intestinal tract could interfere with the 
absorption of the anti-anemic principle seems to us 
problematical. There remain two other possibilities : 
either that a syphilitic lesion in the liver prevented 
storage of the anti-anemic principle (cf. pernicious 
anemia in hepatic cirrhosis) or that the bone-marrow 
was affected in some way by the spirochete, so that 
normal formation of the red cells was prevented. 


Our thanks are due to Dr. Roxburgh for his reports 
on the skin condition, to Dr. J. Bamforth for the last 


26 THE LANCET] 


three blood counts, and to Dr. Eastes’s laboratory for 
all the other pathological investigations. 


REFERENCES 
: SEE J. H.: Modern Clinical Syphilology, Philadelphia, 
. Labbé, M.: Presse méd., 1906, xiv., 472. ‘ 


. Nathan : Ann. de mal. vénér., 1914, ix., 359. 
A Sacro, O.: Blutkrankheiten und Blutdiagnostik, Berlin, 


. de Lillo, G.: 1933, 
xiv., 951. 


ao BUON m 


Rassegna internaz. di clin. e terap., 


THE SYNDROME OF CROCODILE TEARS 


By I. A: TUMARKIN, M.B. Liverp., F.R.C.S. Edin. 


HON. AURIST TO THE BOOTLE HOSPITAL 


INCOMPLETE recovery after Bells palsy occurs 
in about a fifth of the cases observed, and these may 
be afflicted in a variety of ways. One of the most 
interesting, and incidentally most distressing, is the 
syndrome of crocodile tears. 

Briefly, this consists of a troublesome epiphora 
which occurs during mastication. This is to be 
distinguished from the epiphora which occurs in the 
early stage of most facial palsies, and which is, of 
course, due to the paralysis of the orbicularis 
palpebrarum. The crocodile tears appear late, even 
in the presence of an active orbicularis, and although 
some epiphora may or may not be produced by 
exposure to wind and so on, yet the really copious 
flow is only excited by the act of mastication. In 
a severe case the patient is constantly mopping 
his eye during a meal, and may indeed develop a 
secondary blepharitis. 

Considering the comparative frequency of this 
syndrome, it is surprising that it should have received 
such scant attention. In a recent investigation,} I 
found, in confirmation of A. B. Duel’s figures, that fully 
20 per cent. of Bell’s palsy do not recover completely. 
Out of these incomplete recoveries, no less than 
80 per cent. (15 out of 18) showed crocodile tears to a 
greater or less extent. Three certainly complained 
bitterly of it. 

Theory of causation.—This syndrome is interesting 
in connexion with the associated movement often 
seen even in patients who regard themselves as 
cured. Such a patient is unable to contract one 
set of muscles without throwing other sets into 
action. When told to close the eye, he also 
unconsciously contracts the mouth or nose muscles. 
This is not to be attributed to spasm or hyper- 
sensitivity of the muscles, or to some overflow of 
energy in the facial nucleus. A much simpler explana- 
tion is available as follows: the nerve having under- 
gone degeneration, new axons are pushing their 
way out seeking their various destinations. Unfor- 
tunately some are diverted, and find their way to 
the wrong muscle or gland. Thus, when, for instance, 
the nerve centre for the orbicularis palpebrarum 
goes into action, some of its energy output is carried 
via aberrant axons to other muscles. An explanation 
suflices for crocodile tears—i.e., that fibres intended 
for the parotid gland are diverted to the lacrymal 
so that during mastication the salivatory nucleus 
is also bombarding the lacrymal gland with secreto- 
motor stimuli. 

Sundry anatomical points are raised by this theory. 
It seems clear that the lacrymal gland is supplied 
by the facial nerve, and the actual path postulated 
is as follows: great superficial petrosal—vidian— 
spheno-palatine gang. Spheno-palatine nerve—sup. 


i 1 Brit. Med. Jour., 1934, ii., 1027. 


CLINICAL AND LABORATORY NOTES 


[Jax. 4, 1936 


maxillary division of the fifth. The latter com- 
municates via its orbital branch with the lacrymal 
nerve, and so reaches the gland. I am not aware 
of any explanation for this fantastic course, but there 
seems no doubt that the petrosal nerve really carries- 
lacrymatory fibres. Dandy has shown that in the 
anterior approach to the Gasserian ganglion, the 
petrosal is liable to be damaged, and that this results 
in diminished flow of tears. 

The parotid is also supplied by the facial, via the 
chorda tympani, which sends a branch to the otic 
ganglion. This disposes of the theory that the glosso- 
pharyngeal is responsible via /Jacobson’s nerve, 
the tympanic plexus, and the small superficial 
petrosal nerve. In point of fact, Jacobson’s nerve 
has recently been shown to be sensory, and indeed 
to be the source of that particular subdivision of 
glossopharyngeal neuralgia known as tympanic 
neuralgia. 

The pathological and surgical implications of this 
theory are of considerable importance. To begin 
with, it is clear that the strangulation (or whatever 
the lesion is in Bell’s palsy) must, in these particular 
cases have affected the nerve where the petrosal is 
given off—i.e., in the region of the geniculate ganglion. 
Such a case would not presumably benefit from a 
decompression limited to the vertical portion of the 
Fallopian canal. It would be necessary to uncap 
the nerve in its paratympanic course—an operation 
of the utmost finesse. Again, it is possible that we 
may find in a lacrymatory test some quite valuable 
information as to the location and severity of the 
lesion. Whilst absence of epiphora in the early 
stages of a Bell’s palsy might be due to a mild lesion, 
it is more likely to be due to a severe lesion high up 
enough to involve the petrosal. It should be possible 
to differentiate these two types. In the former case, 
lacrymation would still be present, but not in the 
latter. Such a test would however be complicated 
by the lacrymatory effect of the sympathetic, and 
possibly by the action of accessory lacrymal glands. 
Nevertheless a careful investigation of the tear flow 
in the various stages of facial palsy would seem to be 
a promising line of research. 

The prognosis in crocodile tears is still doubtful. 
The syndrome can certainly persist for years, but 
I have reason to believe that it tends to diminish 
with the passage of time. 

Treatment, if called for, is likely to prove difficult. 
The most likely line which occurs to me would be 
excision of the lacrymal gland. Apparently there 
are enough accessory lacrymals to prevent the 
development of xerosis. Alternative operations such 
as ligation of the lacrymal artery, or avulsion of the 
orbital nerve are likely to be more difficult and 
probably less satisfactory. 


I am happy to tender thanks to the various 
colleagues who allowed me access to their files for the . 
purpose of abstracting the cases on which this paper 
is founded. 


Kine Ipwarp VII. HOSPITAL, WINDSOR. — Sir 
tomer Berry, chairman of the hospital, and Lord Camrose 
have each given another £1000 towards the cost 
of the nurses’ hostel. Their contributions, which now 
amount to £21,741, cover the whole cost of the hostel. 


EDENBRIDGE WAR MEMORIAL J]OSPITAL.—A new 
block for consultation clinics and additional nurses’ 
bedrooms is to be erected at this hospital and an 
appeal for funds is being made. The increased accommoda- 
tion is much needed and the cost of building and equipment 
will be about £2700. 


THE LANCET] 


{[san. 4, 1936 27 


MEDICAL 


SOCIETIES 


LIVERPOOL MEDICAL INSTITUTION 


AT the December meeting of this institution, the 
vice-president, Mr. T. P. McMurray, being in the 
chair, Dr. R. E. ROBERTS read a paper entitled 


Radiology in Obstetrics 


with special reference to its dependability. 

Dr. Roberts considered the various questions 
which might bë- put to the radiologist by practising 
obstetricians, showed with lantern illustrations the 
ways in which the radiologist would endeavour to 
answer them, and discussed briefly the reliance which 
might be placed on the answers. His conclusions 
were: (1) Radiology in obstetrics has proved to be 
teliable in the diagnosis of pregnancy after the 
sixteenth week—sometimes earlier. (2) It gives 
information on the position and presentation, and 
on multiple pregnancy or fotal abnormalities, 
which is more complete and reliable than that obtain- 
able by any other diagnostic means. (3) In assessing 
the period of gestation where this is in doubt, radio- 
logy often gives information considerably more exact 
than that obtainable by clinical means. (4) Radio- 
logy, in skilful hands, gives precise help in assessing 
disproportion by demonstrating the size of the fetal 
skull and the measurements of the maternal pelvis: 
the application of these cephalometric and pelvi- 
metric data is, however, outside the province of 
the radiologist. (5) In the diagnosis of intra-uterine 
death, the radiological evidence is reliable if positive ; 
if this condition be suspected a firm negative opinion 
can only be given if repeated examinations are made. 
(6) The X ray diagnosis of extra-uterine pregnancy 
is reliable if direct .radiology be followed where 
necessary by the use of contrast media. (7) In the 
diagnosis of placenta previa, two methods of employ- 
ing contrast media are described: (a) Radiography 
after the injection of uroselectan into the amniotic 
sac. This method is open to the objection that the 
injection is almost certain to induce labour, and 
that in the radiograms the exact site of the filling 
defect due to the placenta is not always readily 
detected. (b) Radiography after the injection of 
an opaque solution into the bladder and demon- 
stration of an inercased gap between the fœtus and 
bladder in placenta praevia. This method is only 
reliable in the later months of pregnancy in cases 
of central placenta previa where a central clot is 
excluded. Both these methods are in their infancy ; 
insutlicient data are available for a firm opinion as 
to their reliability. 

In the discussion which followed, Dr. C. H. WALSH 
said he was pleased to note that Dr. Roberts only 
went so far as to claim that he could measure the 
pelvic brim by his special method, and thereafter 
leave the obstetrician to decide the mode of delivery. 
Dr. Walsh maintained that a radiogram of a moderate- 
-sized hydrocephalus is extremely difficult to interpret, 
and that the final diagnosis rests on clinical findings. 
With regard to amniography, Dr. Walsh stated that 
after considerable experience of this method, which 
he instituted at Mill-road Infirmary, Liverpool, 
about three years ago, he had come to the conclusion 
that the introduction of uroselectan into the amniotic 
-sac had a useful but limited place in obstetric diag- 
nosis. It would outline the placental site and would 
-demonstrate beyond doubt an abnormal fetus. The 
disadvantages of the method were that from the 
xadiological standpoint only an expert radiologist 


could interpret the findings, and that sooner or later 
labour would be induced by its application. 
Dr. A. WINFIELD praised the pioneer work done 


‘by Dr. Roberts in X ray pelvimetry. Amniography, 


however, entailing insertion of a needle and risk of 
abortion, did not appear to be of much practical 
value, and might well shake the confidence of a 
patient who had only expected to have a picture 
taken. 

Dr. F. J. BURKE said that in a series of cases he 
had found amniography safe and, as a diagnostic 
measure, accurate and helpful in the diagnosis of 
doubtful cases of placenta previa. An advantage 
of the method was to make it possible to demonstrate 
abnormalities of the fetus which might not be 
shown by direct radiography—e.g., meningocele. 
This was possible because foetal soft parts as well 
as the bony skeleton were outlined. The method by 
which radio-opaque substance was injected into the 
bladder was not, in Dr. Burke’s view, sufficiently 
accurate to be of real value. The diagnosis depended 
on a study of the distance between the posterior 
aspect of the bladder and the anterior aspect of 
the foetal skull. To obtain a view in the correct. 
plane demanded the most careful radiographic 
technique. It was difficult to see how it was pos- 
sible to diagnose placenta previa in this way unless 
the placenta occupied the anterior part of the lower 
uterine segment, and was actually interposed between 
the maternal bladder and the feetal skull. 

Mr. St. GEORGE WILSON said that obstetricians 
did not need exact measurements of the bony pelvis 
and of the fetal head. What they needed was the 


foetus presenting by the head in utero at or about 


thirty-seven weeks, in order to decide whether the 
fœtus would pass through. It was important to 
remember the factor of uterine action. With regard 
to the evidence of placenta previa, he had had a 
little experience of sodium iodide in the bladder, 
and he considered it was better than the amnio- 
graphy method in that it did not tend to start labour. 
However, he recognised that it was only of use in 
the central and marginal types of placenta previa. 
In cases where the uterus was so tense that palpation 
was of very little use, diagnosis by means of X rays 
was very valuable. 
Mr. R. KENNON read a paper entitled 


The Kidney from the Surgeon’s Point of View 


He drew attention to the large number of urinary 
cases so indefinite as to require the attention both 
of surgeon and physician; some had frequency, 
others hematuria or renal colic, which could only 
be explained as renal congestion or mild nephritis. 
That normal urine (without casts) could be excreted 
in the presence of advanced nephritis was evident 
from occasional reports upon cases of ‘“‘ essential 
hæmaturia ” which had been explored. Normal 
urine was common in the presence of multiple renal 
abscesses and perinephritic abscess. Infective neph- 
ritis had been overshadowed by the milder term 
pyelitis on slender pathological evidence. The 
possibility of acute nephritis of the abdominal type 
required continued emphasis to avoid a dangerous 
laparotomy. Subnormal gall-bladder function or a 
normal hypertonic stomach in ill-health at 60 might 
be the first indication of oncoming uremia. Mr. 
Kennon commented on the swing from alkalinisation 
to the ketogenic diet and mandelic acid. Results 
were best when stasis was avoided. Delay to recog- 
nise when relief of tension by nephrotomy, &c., was 


` 


28 THE LANCET] 


required produced disaster. Nephrectomy performed 
for essential hæmaturia, often in fear of early tuber- 
culosis, was a serious matter. Renal carbuncle 
rarely called for nephrectomy. This operation 
carried a mortality of 7 per cent. for all types of 
case, and must frequently be preceded by drainage. 
In the discussion which followed, Mr. CosBIE Ross 
commented on the relative frequency with which 
cases of uremia presented themselves as abdominal 
conditions, and quoted three such examples seen 
within a period of two years. One was admitted 
as a case of hematemesis, another as acute intestinal 
obstruction, and a third as pyloric obstruction. An 
interesting feature of the case of hematemesis was 
that the house surgeon stopped all fluids by mouth, 
with the result that the patient’s condition became 
steadily worse; when the diagnosis was established, 
and forced diuresis instituted, rapid recovery ensured. 
All three cases were subsequently proved to be 


REVIEWS AND NOTICES OF BOOKS 


[san. 4, 1936 


uremic. Mr. Ross expressed his firm belief that as 
a means of estimating renal efficiency, the indigo- 
carmine test was superior to the estimation of urea 
in the urine collected by means of a ureteric catheter. 

Dr. R. W. BROOKFIELD said that the classification 
of kidney disease was continually undergoing modi- 
fication. The precise etiology of many renal condi- 
tions was still obscure, and none were more baffling 
than those cases of undoubted renal pain which were 
unaccompanied by any demonstrable abnormality 
in kidney or ureter, and were rvlieved by renal 
sympathectomy. He thought it fmportant that 
surgeons performing operations for calculus should 
give more than a passing thought to the possible 
existence of a generalised bone condition still in an 
early stage of development. In this connexion he 
referred to a patient with well-marked Paget’s 
disease, recently seen, who had had a renal calculus 
removed some years earlier. 


REVIEWS AND NOTICES OF BOOKS 


The Parathyroids in Health and Disease 


By Davin H. SHELLING, B.Sc., M.D., The Johns 
Hopkins University and Hospital, Baltimore. 
London: Henry Kimpton. 1935. Pp. 335. 25s. 


THIS is an up-to-date and accurate critical review 
of the anatomy, pathology, physiology, chemistry, 
and clinical medicine of the parathyroids. Dr. 
Shelling refers to the rapid progress which has been 
made in the past decade, especially in the chemical 
and clinical phases of the subject. He hopes that 
the monograph will appeal to the investigator as 
well as to the clinician, and disarms criticism by 
expressing his fears that the radiologist or surgeon 
may find the discussion on calcium and phosphorus 
metabolism somewhat lengthy and involved, that 
the chemist may find it too brief and sketchy, and 
that the pathologist may consider his subject neglected 
at the expense of chemistry or radiology. In order 
to compensate in part for these shortcomings a biblio- 
graphy has been appended to each chapter, so that 
those who wish to pursue further any particular 
phase of the subject may know at once where to 
turn for the original source of information. 

Under the heading Pathology of the Parathyroids 
variations are described in number, position, size, 
and weight. Quotations from six authors show 
that a good deal of confusion still exists on these 
simple matters. Dr. Shelling’s descriptions and 
illustrations of the histology of parathyroid tumours 
are excellent. On this point he quotes in detail the 
writings of H. M. Turnbull who showed the varia- 
bility of the histo-pathology of parathyroid tumours 
in hyperparathyroidism. Thus dark oxyphil cells, 
ballooned chief cells, or pale oxyphil cells may con- 
stitute the bulk of the tumour. In the discussion 
on the physiology of the parathyroids the effects of 
total parathyroidectomy and the pathogenesis of 
parathyroid tetany are discussed in detail. Making the 
most of the few recorded cases of idiopathic lypopara- 
thyroidism Dr. Shelling quotes at length the work 
of W. Bauer, A. Marble, and D. Claflin on the meta- 
bolism of calcium and phosphorus in this rare con- 
dition. The biochemical effects of repeated frequent 
injections of the parathyroid hormone naturally 
receive much attention, and details are given of 
the effects on blood calcium, phosphorus, non- 
protein nitrogen, sodium chloride, and CO.. 

An illustration of the thorough method adopted 
throughout the work is the short section on psychosis 


in tetany, in which the observations of five authors 
are recorded. Tetany is discussed under three head- 
ings: (1) tetany dependent upon a reduction in the 
total concentration or an inactivation of part of 
the calcium in the serum ; (2) tetany due to intoxica- 
tions; (3) tetany due to magnesium deprivation. 
Table III. gives a useful summary of the differential 
diagnosis of the various forms of tetany. The long 
section entitled Hyperparathyroidism and Osteitis 
Fibrosa exemplifies the good judgment of the author. 
He gives due consideration not only to skeletal 
signs and symptoms but also to the four other symp- 
tom groups which he calls general, urinary, meta- 
static, and metabolic. Priority is properly allocated 
to F. Mandl in Europe and J. C. Aub in America 
for appreciation of the true significance of hyper- 
function of the parathyroids. The differential 
diagnosis of hyperparathyroidism is discussed under 
the headings osteomalacia, Paget’s disease, rena] 
rickets, osteoporosis, localised lesions in the bones, 
generalised xanthomatosis of bones, secondary carci- 
nomatosis, leukemia, Hodgkin's disease, erythroblastic 
anemia, and osteogenesis imperfecta. In the critical 
review of the effects of parathyroidectomy the work 
of E. D. Churchill and O. Cope forms the basis for 
discussion, It is disappointing in this section to 
find such a sketchy description of the bones in 
generalised osteitis fibrosa; a footnote refers the 
reader to the work of F. von Recklinghausen and 
H. M. Turnbull on this subject. A whole chapter 
is devoted to the relation of the parathyroids to 
vitamin D, and the last chapter deals justly with 
those who misuse the parathyroid hormone in thera- 
peutics. Useful appendices supply details as to 
meals of low calcium and low phosphorus content. 
The book is attractively printed, and the illustrations, 
especially those of radiograms and histological 
sections, are exccllent. 

We heartily commend this book and wish it the 
success it deserves, 


A Textbook of Bacteriology 
By Tnurman B. Ricr, A.M., M.D., Professor of 
Bacteriology and Public Health at the Indiana 
University School of Medicine. London: W. B. 
Saunders Co., Ltd. 1935. Pp. 551. 2ls. 
Tus text-book covers the ground required by the 
average student of medicine. The author has 
obviously tried to present the subject in the simplest 


THE LANCET] 


possible fashion, and at times his search for simplicity 
has led him into jejune and popular methods of 
expression which are undesirable in a text-book. 
For example, such a statement as “‘by all means, 
hands should be kept out of the mouth and should 
be washed several times a day” may represent 
laudable doctrine but is best omitted from a 500- 
page work on bacteriology. On the whole the informa- 
tion given in the book is accurate, though the definition 
given of a unit of diphtheria antitoxin as “‘ the amount 
of antitoxin ‘hat will neutralise 100 M.L.D. of freshly 
made diphtheria toxin” is almost enough to dis- 
qualify an author from being regarded as a serious 
exponent of immunology. Chapters on immunity, 
filtrable viruses, and protozoa give completeness 
to a book which, if in no way inspired, provides a 
serviceable enough introduction to bacteriology, 


Antenatal and Postnatal Care — 
By Franois J. BRownE, M.D. Aberd., D.Sc., 
F.R.C.S. Edin., F.C.0.G., Professor of Obstetrics 
and Gynecology, University of London; Director 
of the Obstetric Unit and Obstetric Surgeon, 
University College Hospital, London. London : 
J. and A. Churchill Ltd. 1935. Pp. 480. 15s. 
His sense of the growing importance of ante- 
natal and postnatal care and the inadequacy 
of its representation in obstetric literature has 
spurred Prof. Browne to write a book which 
really meets a need. He starts with a welcome 
account of development of antenatal care, tracing 
its history back for four hundred years, and then 
proceeds logically to consider the management 


of the patient from her first visit to ascertain whether 


or not she is pregnant. We observe that he advises 
a Wassermann test in every case. Prof. Browne 
explains what importance is attached to an accurate 
history of past pregnancies and labours and goes on 
to say that this history “is usually obtained by a 
senior nurse.” This may be all very well in hospitals 
and clinics, but since the book is presumably designed 
for practitioners and students we suggest that in a 
future edition this section might with advantage be 
enlarged to include a note on the special points in 
the past history that may or may not be of significance. 
The paragraphs upon diet in pregnancy are suggestive, 
but again not sufficiently detailed. Dr. Grantley 
Dick Read is responsible for Chapter VI. entitled 
The Influence of the Emotions upon Pregnancy and 
Parturition. It is mainly concerned with parturition, 
and an expansion of the subject matter to fit the 
title would be welcome; the section on the mental 
outlook of the midwife is excellent. 

The difficulties and pitfalls of pelvic and fetal 
mensuration are fully discussed and a vivid picture 
is drawn of the problems associated with minor 
degrees of disproportion. The treatment of abnormal 
presentations and positions is clearly set out; more 
attention might have been directed to the breech 
presentation as a possible warning of other and more 
dangerous complications, The chapters on ante- 
partum hemorrhage, the toxemias, and the inter- 
relationship of pregnancy with various diseases and 
ailments are on sound orthodox lines. 

Only 9 of the 480 pages are allotted to postnatal 
care; there must be a good deal more that could 
usefully be said on this subject by such an authority 
as Prof. Browne. Such subjects as the medicinal 
induction of labour, specialised diets, and the conduct 
and scope of antenatal clinics are helpfully discussed 
in appendices, and a large bibliography completes 
the work, 


REVIEWS AND NOTICES OF BOOKS 


[syan. 4, 1936 29 


If occasionally emphasis seems to be laid on the 
detection of the abnormal, rather than on the preserva- 
tion of the normal, it is because the latter aspect of 
antenatal work is an attitude to be cultivated rather 
than a discipline to be taught. Prof. Browne 
certainly conveys this attitude better than do most 
writers on antenatal care and his book should be 
of the greatest interest and assistance to all engaged 
in the practice of obstetrics. 


1. Demonstrations of Physical Signs in 
Clinical Surgery 
Fifth edition, revised. By Hamitton Barley, 
F.R.C.S., Surgeon, Royal Northern Hospital, 
London. Bristol: John Wright and Sons, Ltd. ; 
London: Simpkin Marshall. 1935. Pp. 287. 21s. 


2. An Introduction to Surgery 
Third edition. By RUTHERFORD Morison, M.D., 
F.R.C.S., Emeritus Professor of Surgery, Durham 
University ; and CHARLES F. M. Saint, C.B.E., 
M.D., F.R.C.S., Professor of Surgery, Cape Town 
University, S.A. Same publishers. 1935. Pp. 367. 
15s. 


3. The Early Diagnosis of Malignant Disease 


By GEOFFREY KEYNES, M.D. Cantab., F.R.C.S. 
Eng., Assistant Surgeon to St. Bartholomew’s 
Hospital; Surgeon to Mount Vernon Hospital. 
London: John Bale, Sons and Danielszon, Ltd. 
1935. Pp. 70. 2s. 6d. 


1. This admirable book has been still further 
improved in its new and revised edition. It is a 
book which every student should read and keep by 
him. The steps of physical examination are clearly and 
simply set out and the work is beautifully illustrated. 

2, A new edition of this book, originally written 
many years ago, will be welcomed by student and 
teacher alike. It fulfils well its purpose, for it 
supplies an introduction to surgery which can be 
understood by the novice to clinical work: The 
method of presentation is simple and effective— 
altogether a most satisfying work. 

3. In this small book the main facts which enter 
into the diagnosis of malignant disease in different 
parts of the body are set out clearly and readably, 
but not in very great detail. When the reader 
gets over a feeling of slight surprise that its gifted 
author should have devoted his energies to the 
compilation of a collection of diagnostic paragraphs 
interspersed with a few illustrative clinical records 
he will perceive that these are presented more vividly 
and with greater precision than the corresponding 
paragraphs scattered through surgical text-books. 

—— ——"7/_\) 
Praktische Anatomie pe ON ene we 

By Dr. T. von LANZ, Professor of Anatomy 

in the University of Munich; ;and Dr. W. 

WaclisMUTH, Privatdozent for- Surgery in the 

University of Bonn, Vol. I., Part III, The Arm. 

Berlin: Julius Springer. 1935, Pp. 276. R.M.26.- - 

THE title of this book is somewhat misleading to 
the English reader, to whom a “‘ practical anatomy ”’ 
book is a dissection manual. The work is actually 
concerned with the practical application of anatomy 
in clinical matters. The authors start with the sound 
precept that anatomical knowledge is the basis of 
all correct physical procedure in clinical work ; 
they have produced an interesting and fairly full 
account of the anatomy of the arm. We would like 
to see more stress laid on the function of the muscles 
immediately surrounding the shoulder-joint when 


30 ‘THE LANCET] 
dislocations at this articulation are under considera- 
tion. The fact that the head of the radius is always 
in contact with the humerus constitutes an obstacle 
to the blind acceptance of the statement here made 
that shocks passed from the hand to the radius 
are transmitted by the interosseous membrane 
to the ulna. The illustrations are semi-schematic 
and clear; numerous figures representing persons 
turning their limbs about within hollow spheres 
marked longitudinally and latitudinally in degrees 
are of the nature of an acquired taste, but will not 
prevent—even if they do not encourage—an apprecia- 
tive reception of this effort to serve the surgical 
practitioner in his work. 


The Stomach and Duodenum 


By GrorcE B. Evusterman, M.D., F.A.C.P., and 
DonaLtp ©. Batrour, M.D. Tor., F.A.C.S., 
F.R.A.C.S., and Members of the Staff, The Mayo 
Clinic and the Mayo Foundation for Medical Educa- 
tion and Research. London: W. B. Saunders Co., 
Ltd. 1935. Pp. 958. 45s. 


THE authors of this book after surveying the 
etiology and physiology of the stomach proceed 
to describe the useful methods of examination, and 
discuss the significance of symptoms and the various 
diseases of the stomach and duodenum. Special 
chapters are devoted to such subjects as anxsthesia 
for gastric operations and the medical treatment 
of inoperable cancer of the stomach, anæmia following 
operations on the stomach, and other complications 
which occur after operations on that organ or the 
duodenum. Chapters of great interest are devoted 
to such rarities as diaphragmatic hernia, hypertrophic 
pyloric stenosis in adults, non-malignant tumours 
of the duodenum, sarcoma of the stomach, and 
paraduodenal hernia. 

The Mayo Clinic stands in the eyes of the medical 
world as a great surgical institution and it is 
perhaps scarcely just to criticise this work on 
the grounds that it seems to show a strong 
surgical bias. But as the name of Dr. Eusterman 
is placed first amongst the authors, and medical 
education and research are mentioned prominently i in 
the early pages of the volume, the prominence 
throughout the book of surgery at the expense 
of medicine is a little disappointing. The faint 
enthusiasm towards medical treatment must leave 
the average reader with the impression that the 
therapeutics of every gastric disease consists in the 
successful application of surgery in order to terminate 
an illness in which medical treatment has been 
laudably but Auefflectively applied for a considerable 
period, This sutgical bias is to be found also in 
the suggestion which is made again and again 
‘that the risk of malignant change is a strong reason 
against the medical treatment of gastric ulcer. Thus 
in Chapter IV. Dr. MacCarty begins by saying that 
carcinoma, is not only the inost ‘frequent ¢ castric lesion 
but it is the most frequent form of cancer “found in the 
human body, and proceeds to state that he has never 
seen a carcinoma arising from an intact mucosa 
and that the majority of cancers occur in association 
with chronic ylécration. Yet in Chapter XVI., 
which is devoted to the question of carcinomatous 
transformation of gastric ulcer, we are told that the 
frequency with which this change occurs is ‘‘ not of 
primary importance,” and an editorial article is 
quoted with approval which states “the question 
of the percentage of gastric ulcers becoming malignant 
is purely academic.” The authors admit that the 


REPORTS AND ANALYSES 


[yan. 4, 1936 


majority of gastric ulcers are actually benign and 
will remain so, but yet produce a series of hair- 
raising arguments suflicient to convince the average 
reader that extensive resection is a wise precaution 
whenever an X ray reveals the presence of an ulcer in 
the stomach. 

Even when the treatment of duodenal ulcer is 
under discussion we can find nothing but pessimism 
in the authors’ outlook towards medical tre.:tment. 
They admit that the information available is too 
slender to provide a final, authorifative answer 
to a question on the prognosis of duodenal ulcer 
treated medically. As the result of past experience 
they have arrived at the conclusion, ‘‘which is 
reflected in the attitude of life insurance companies 
towards patients who have ulcers,” that such patients, 
as have not been operated on, are substandard 
risks. It may be comforting to the physicians who 
endorsed this statement that in England at any rate 
a man or woman with a past history of duodenal 
ulcer which has responded well to medical treatment 
for some years without relapse is more readily 
acceptable by life insurance companies than a patient 
in an equally happy condition who has undergone 
an operation on the stomach. 


REPORTS AND ANALYSES _ 


RUSSIAN IMPERIAL STOUT 


(BARCLAY PERKINS AND CO., LTD., LONDON, 8.E.) 


Tris well-known stout before the war was exported 
to Russia. The sample which was analysed had been 
21 months in bottle and had a very full and matured 


taste. When analysed the following results were 

obtained :— 

Present gravity 1024-04 

Alcohol] by volume ‘ 10-42 per cent. 

Equivalent to proof spirit 18-20 Y 

Matters in solution 9-66 e 

These include— 
Maltose 2°53 a 
Dextrin 3°22 ae 
Other carbohydrates, hop extract, ke. 2-41 a 
Protein : ak ee 0-72 N 
Acidity (as lactic acid) ih 0-30 ; 
Mineral matter 0-48 j5 
(including phosphoric acid) 0-134 ,, 


This stout on account of its strength and full 
maturity can be regarded as one of the finest products 
of the English brewing industry. Its condition— 
i.e., content of carbonic acid gas—was not excessive, 
and as a beverage it is most agreeable to the palate. 


MONBERNO MEDICATED WINE 
(PREPARED BY THE CISTERCIAN MONKS OF MOUNT Sf. BERNARD 
ABBEY, CHARNWOOD FOREST, LLICESTERSHIRE) 

This red wine has an agreeable flavour and bouquet. 
which is suggestive of port. When analysed the 
following results were obtained :— 


Alcohol . .. 17:5 por cent. by volume, 
Equivalent to proof spirit 30-5 sy 
Volatilo acidity (as acetic acid) 0-025 ,, 
Fixed acidity (as tartaric acid) 042 ,, 
Total solids AF : 15-0 3 
Consisting of— 
Sugar 12-1 s3 
Ash.. ‘ 0-46 ,, 
Phosphoric acid 0:10 ,, 
Meat extract.. 1:20 
Other extractives. 124 ,, 


The claim that this wine contains meat and other 
extractives is supported. 


THE LANCET] 


THE LANCET 


LONDON: SATURDAY, JANUARY 4, 1936 


THE MARRIAGE OF PUBLIC HEALTH 
AND AGRICULTURE 


THE phrase is Mr. Brucn’s. He was speaking 
of the wastefulness of widespread malnutrition at a 
time when farmers long to produce more crops ; 
he was pointing out that agriculture and public 
health have one great need in common; and he 
was urging the governments of the world to divert 
their subsidies from schemes for restricting produc- 
tion to schemes for enlarging consumption. Here 
in England this policy finds one of its best 
exponents in a member of our profession who is 
also in close touch with farming, Sir JoHN ORR 
of the Rowett Institute at Aberdeen. In his 
address to the British Association last September 
he admitted that price-raising methods such as 
quotas and tariffs have saved British agriculture 
from the full effects of the world economic crisis, 
but maintained that they can be justified only as 
emergency measures. At a time, he said, when 
there is a so-called glut of all kinds of food, the 
continued existence of diseases due to malnutrition 
shocks the public conscience, and public opinion 
forces an increase of the already heavy expenditure 
on social services in an endeavour to get them 
eliminated. Cheaper food would reduce the cost 
of such services, for it means less poverty and less 
disease due to peverty; and Sir JOHN went on 
to demonstrate that agriculture, as much as public 
health, stands to gain from an expansive pro- 
gramme. Inquiries jointly made by the Rowett 
Institute and the Market Supply Commission show 
that consumption of the “ protective” foods— 
milk, eggs, fruit, and vegetables—trises uniformly 
with income, and that generally speaking it is not 
until we reach families with about £1 a week per 
person that the diet, according to modern standards, 
is adequate for maintaining health. At present 
some 20 million of the population are below this 
scale and if everyone in the country were brought 
up to the £1 5s. scale, which probably repre- 
sents an optimum, the market for food would be 
20 per cent. larger. He calculates that if we all 
had as much food as we ought the percentage 
increases in consumption would be: milk 42, 
butter 27, eggs 28, fruit and vegetables 53— 
which ‘‘ gives an indication of the limit to which 
agriculture could be developed in this country 
without reducing imports and therefore without 
prejudicing our export trade or the interests of 


THE MARRIAGE OF PUBLIC HEALTH AND AGRICULTURE 


[san. 4, 1936 31 


our overseas investments.” The Bishop Auckland 
potato experiment, in which unemployed men 
bought their potatoes direct from a depdt at 4d. 
instead of 7d. a stone, showed that there is an 
ample market for food at lower prices and indicated 
one way in which these prices can be attained. 
The better organisation of distribution by marketing 
boards could, in itself, lower retail prices, and the 
remaining difference between the price the public 
can pay and the price the farmer must charge 
should be made good, in Sir JoHN ORR’s opinion, 
by direct subsidies to these boards from the State 
—subsidies to be regarded as more in the interests 
of public health than of agriculture. ‘“‘ All the 
money going to the farmer flows back immediately 
to the towns, invigorates industries and reduces 
unemployment. None of it is lost to the country... 
The next five years should be devoted to a great 
constructive policy, based on increased consumption 
and better utilisation of our wealth, a policy 
designed to bring about a prosperous agriculture, 
a better fed people, and increased internal trade.” 


A voice crying in the wilderness? No. For 
when Mr. Boorusy brought forward some of these 
arguments in the debate on the Address last 
month the Government spokesman, Lord EUSTACE 
PrRcy, took pains to show that the investigations 
on which Sir JOHN ORR’s conclusions are founded 
were made at the instance of the Government 
itself, and published in order to awaken public 
attention to the need for, and possibilities of, a 
policy of nutrition. Lord DE La Wark, as Parlia- 
mentary Secretary to the Ministry of Agriculture, 
told the League of Nations’ Assembly in September 
that it is not enough to resist a policy of restriction ; 


‚something more positive is needed—namely, 


deliberate action. On Dec. 18th Lord EUSTACE 
PERCY, receiving a deputation from the Children’s 
Minimum Committee, said, that a broad nutrition 
policy must be one of the main aims of social 
administration in the immediate future ; indeed, he 
went further and declared that on the main issues 
there was no conflict between the views of the 
Government and those of the deputation. If this is 
true it suggests a definite change of front—a deter- 
mination, now that trade is recovering, to think in 
terms of permanent social advantage rather than 
the requirements of crisis. For’the deputation’s 
memorandum set out clearly their demand for a 
more positive approach to the problem of nutrition, 
their discontent with the abandoned scales of the 
Unemployment Assistance Board, their anxiety 
about the painful reports that come from distressed 
areas and distressed homes, and their belief that 
“a great. deal more can be done immediately by 
a more generous development of existing services 
to safeguard and improve the health of the 
two sections of the community for whom proper 
nutrition is of supreme importance—children, 
and mothers during the child-bearing period.” 
The sharpest edge of the depression, they 
said, is falling on families with young children, 
and they outlined schemes by which this 
national evil can at least be mitigated. Lord 
Eustace Percy was right when he replied that 


32 THE LANCET] 


MORE ABOUT INFLUENZA 


[yan. 4, 1936 


a realty broad policy can hardly be based on 
attempts to deal merely with cases of poverty, 
and that its most important aim must be rather 
to promote the establishment of sound normal 
standards of nutrition and physical fitness. But 
he might equally well have said that such a policy 
must be based on the recognition that proper 
feeding is the first necessity for national health— 
a necessity more urgent and compelling even than 
good housing or the control of infection or any 
other of our hygienic aims. At present we are 
wasting our agricultural resources. and we are 
wasting our human material. In Sir JoHN ORR’s 
words, we need a national food policy, into which 
both agricultural and public health interests can be 
fitted and reconciled. 

The science of nutrition has shown the way to 
a more economical economy, to a more tolerable 
state of society. It has revealed deficiency 
diseases; it has described the means whereby 
they can and must be prevented.’ But we shall 
be very much mistaken if we look on this science 
as merely the analysis of starvation; we should 
think also of the constructive contribution it may 
make to human progress. Dr. JAMES MCLESTER 
took this as his theme for the presidential address 2 
he gave to the American and Canadian Medical 
Associations last summer, when he spoke of the 
highly significant discovery that under certain 
circumstances an animal’s life may be greatly 
improved by the addition of appropriate foods to 
a diet previously thought satisfactory. In twenty 
years, he said, OSBORNE and MENDEL were able to 
treble the growth-rate and double the standard 
weight of their albino rats; they produced what 
was in fact a new species, simply by intelligent 
alteration of the rations. Can the same thing be 
done for man? The Chinese in Hawaii, the 
Japanese in San Francisco, grow larger than their 
compatriots in China and Japan. In this country 
F. G. Parsons believes that hygiene and better 
food have raised the height of the upper classes, 
while H. H. Basurorp reports that Post Office 
messengers get bigger (though not necessarily 
brighter) from year to year. Where must the 
process stop? “The mere survival of a com- 
munity,” Sir Gowxtanp Horkis has remarked, 
“is too often taken as proof that the nutrition of 
its constituent individuals is adequate”; but 
“the community, while managing to survive, 
may yet be functioning at levels far below those 
possible to its innate capacities.” In other words, 
McLESTER says, adequate and optimum are not 
synonymous, and it may be possible, through 
improved nutrition alone, to bring mankind to a 
higher level of physical development—to a larger 
stature, greater vigour, increased longevity, and a 
higher level of cultural attainment. Ultimately 
this is a problem of education and of government ; 
and the first step towards solving it is to ensure 
that the marriage now arranged between public 
health and agriculture shall shortly take place. 


1 Sce the Report on the Physiological Bases of Nutrition 
drawn up by the Technical Commission of the Health Com- 
mittee of the League of Nations, p. 1434, reproduced in our 
columns on Dec. 21st, 1935. 

3 Jour. Amer. Med. Assoc., 1935, civ., 2144. 


MORE ABOUT INFLUENZA 


AN important communication by C. H. 
ANDREWES, P. P. Latpuaw, and Witson Smirra 
marks a further advance in our knowledge of 
influenza. Ever since this team of workers first 
announced that they had succeeded in isolating 
a filtrable virus from cases of epidemic influenza, 
and advanced reasons for thinking it to be the 
prime cause of this disease,” their findings in sub- 
sequent outbreaks have been eagerly awaited. 
Would it prove that epidemic influenza was due 
to one and the same virus the world over or would 
more than one etiological agent be found? And 
what about sporadic influenza; would this also 
turn out to be a virus disease ? It was clear from 
Sir Patrick Larpuiaw’s Linacre lecture * that a 
virus, similar to those recovered from influenza 
in 1933, had been encountered during 1934 and 1935, 
but it is only now that the full details of this work 
have been forthcoming. The winter of 1933-34 
saw little influenza in London, but from a small 
outbreak in March, 1934, a fresh strain of virus 
was isolated. The next winter, however, proved 
more propitious for the investigations and eight 
new strains were obtained, six from an outbreak 
amongst the troops in Dover and Shorncliffe 
and two from cases which occurred in London in 
the early months of 1935. All these new strains 
have been shown to be identical with those 
obtained in 1933. 


To these findings must be added evidence 
coming from other parts of the world. In America 
T. Francis,4 of the Rockefeller Institute, has 
isolated several strains of virus from cases of 
influenza and shown them to be the same as the 
English strains. Further, the Hampstead workers 
have had the opportunity of examining two of 
these American strains and of confirming the con- 
clusion arrived at by Francis. A recent paper by 
F. M. Burnet ° reports the isolation of a strain of 
virus from cases of epidemic influenza in Australia ; 
this also was shown to be similar to the English 
ones. There is thus good reason for thinking that 
epidemic influenza, wherever it occurs, has the 
same virus for its prime cause. The causation of 
sporadic influenza, however, still remains unsolved. 
Material from 12 such cases has been examined 
for the presence of virus by the Hampstead team, 
with completely negative results; and negative 
also were the results obtained with nasopharyngeal 
washings from six cases of a type of upper respira- 
tory infection prevalent in the Woolwich garrison 
in the early months of 1935 and diagnosed clinically 
as influenza. In the past many have doubted 
whether all cases labelled influenza constituted an 
entity and these findings tend to confirm the 
suspicion. 

This latest paper from the National Institute 
for Medical Research ? records two disappointments. 
Attempts were made to infect human volunteers 


1 Andrewes, C. H., Laidlaw, P. P., and Smith, W.: Brit. 
Jour. Exp. Path., 1935, xvi., 566. 
2 Tue LANCET, 1933, ii., 16. 
3 Ibid., 1935, i., 1115. 
* Proc. Soe. Exp. Biol. N.Y., 1935, xxxii., 1172. 
è Med. Jour. Australia, 1935, ii., 651, 


THE LANCET] 


with the influenza virus, but without success. It 
should be pointed out, however, that only two 
volunteers were inoculated and that the authors 
advance very reasonable explanations for this 
failure, so that these negative results do, not really 
mean very much. The second disappointment 
concerns the possibility of infecting mice direct 
from man. When about 18 months ago ANDREWES, 
Laiptaw, and SMITE ® reported the successful 
inoculation of mice with ferret-passaged influenza 
virus, it was hoped that it would be possible to 
infect mice direct from man and thus bring 
influenza research within the reach of laboratories 
without facilities for keeping ferrets. Unfor- 
tunately this hope has not been realised. Human 
material which took readily in ferrets has regularly 
failed to infect mice; only after ferret-passage 
does the virus become infective for the mouse. 
A further piece of work calls for mention. WILSON 
Smit ’ has cultivated influenza virus. He tried 
two methods: (1) cultivation in the developing 
egg, which has been used successfully with a 
number of viruses, and (2) cultivation in a simple 
medium consisting of minced chick embryo tissue 
and Tyrode’s solution. The latter method proved 
by far the most successful and should be of use 
in providing suitable material for immunisation 
purposes. 


ARTERIAL EMBOLECTOMY 


Reports of arterial embolectomy by British 
surgeons owe their chief interest to the rarity of 
the operation in this country. Sweden, on the 
other hand, has a larger experience of it, and 
J. P. StR6MBECK ê is able to report the late results 
in 61 cases in which the circulation was restored. 
These are the successes out of a total of 327. The 
investigation covers the years 1913-32 and, as it 
was made in 1934, at least one and a half years 
had elapsed since the last operation. The imme- 
diate mortality in the 327 cases was, of course, 
considerable, and in STROMBECK’S words 207 
(63 per cent.) were “discharged from hospital 
dead.” But these deaths were by no means 
always directly attributable to the operation, since 
the disease causing the embolism—most often 
cardiac—is often fatal in itself. Of the 37 per 
cent. surviving operation, 18 per cent. required 
subsequent amputation, while the other 19 per 
cent. were discharged alive, with circulation 
restored; and it is with these 6l cases that 
STROMBECK’S paper is chiefly concerned. 

Only one of the patients was not traced. Of the 
others, 49 were alive after three years; 43 after 
five years; and 16 after ten years. At the time 
of the investigation 41 had already died, the cause 
of death in all but 2 having apparently a direct 
connexion with the disease originally causing the 
embolism. In 28 the cause of death is given as 
heart failure or as chronic myocarditis or cardio- 
sclerosis ; other complications of the basic heart 
affection were hemiplegia, renal infarcts, cerebral 
thrombosis, and chronic nephritis. The after- 

* THE LANCET, 1934, ii., 859. 


7 Brit. Jour. Exp. Path., 1935, xvi., 508. 
* Acta chir. Scand., 1935, xi., 229. 


ARTERIAL EMBOLECTOMY.—CO-EDUCATION 


‘(san. 4, 1936 33 


history of the patients also revealed a tendency 
to cerebral circulatory disturbances and to repeated 
embolism. STROMBECK sums up the prognosis 
after successful embolectomy by saying that, as 
regards expectation of life, it is essentially the 
prognosis of the underlying cardiac disease. 
Further inquiry into the working capacity after 
operation, and into the local damage to the part 
of the body affected, showed that the proportion 
of patients getting back to something like a good 
working capacity was definitely greater in those 
that lived longest. Of those who died within 
three years, at least 70 per cent. never got back 
to work, and many of them were bedridden. The 
local results tended to be good; small areas of 
necrosis, sensory disturbances, and peroneal paresis 
were reported in one-eighth of the cases. 


Mr. GEOFFREY JEFFERSON’S paper read at the 
annual meeting of the British Medical Association 
in 1934 stimulated interest in embolectomy, and 
our issue of last Nov. 30th contained two records 
of successful operation, together with useful 
suggestions about technique. Mr. Victor RIDDELL 
pointed to the danger of secondary thrombosis at 
the site of an embolectomy, and proposed that the 
artery should be ligatured, above and below 
the incision through its wall, in cases where the 
collateral circulation, restored by unblocking of the 
lumen at the. bifurcation of the vessel, appeared to 
be efficient. Mr. G. R. GIRDLESTONE believed 
that an attempt might often be made to massage 
the clot from its situation at the bifurcation of an 
artery into the less important branch—a plan 
which would have the advantage of avoiding 
injury to the intima, and so of lessening the risk 
of subsequent secondary thrombosis. This sug- 
gestion was also made by JEFFERSON. The 
importance of securing a lasting restoration of the 
circulation is obvious, and STROMBECK describes 
this as the only means by which we can hope to 


_ lower the present high mortality from the operation. 


A secondary amputation, where embolectomy fails, 
involves great immediate danger. The only other 
method available for lowering the mortality is to 
choose the patients who present the best operative 
risk, but any improvement in results thus attained 
is of course more apparent than real. It is clear, 
however, from STROMBECK’S valuable study of after- 
histories that no very cheerful prognosis is justified 
as regards restoration to normal life or length of 
survival. 


CO-EDUCATION 


OF the human race as a whole at least a half 
and probably more are co-educated, yet co-educa- 
tion is often spoken of as a difficult problem. 
It becomes a difficulty under two conditions: 
(1) when it is not simply a matter cf boys and 
girls learning together, but also of spending most 
of their leisure together; (2) when co-education 
is not the usual custom of the community. In 
England both of these conditions are present. 
Co-education in day-schools is not the problem 
that it is in boarding-schools, and in the latter 
there are further complications associated with 


34 THE LANCET]: 


the social class which sends its children to these 
establishments. Those whose playground is the 
street, those who have no special play-room at 
home, are in general, on account of their home 
= experience, less likely to find co-education a 

personal difficulty, and their parents will in general 
view it with less alarm—and see fewer dangers— 
than those who live in an atmosphere of greater, 
even perhaps too great, exclusiveness. 


Boarding-school co-education is in England 
inevitably regarded as different from ordinary 
schooling ; the sex-segregated schools are thought 
of as normal, the others as a little peculiar. Under 
these circumstances it is difficult to exclude the 
atmosphere of an experimental undertaking, even 
though the schools in question may have been 
founded for a long time, because each generation 
of parents and teachers has to step out of the 
traditional groove when deciding on this type of 
school. Parents and staff are apt to become 
self-conscious regarding co-education, and self- 
consciousness in the face of a sexual question 
never helps towards clearness of judgment. The 
self-consciousness is attributable at least in part 
to the sense of danger, real or imagined, which 
attaches to an experimental situation, and is not 
perhaps quite unrelated to the self-consciousness 
and the heightened expectancy which precedes 
the contact of the sexes in later years; at any 
rate, there are similarities. Whatever may be 
the real dangers (we must not underestimate the 
- prudence not to speak of the fears of adolescents), 
the imagined ones in the minds of adults some- 
times assume the vividness and even the termino- 
logy of actual illicit sexual relations. In addition 
: there is a special sociological terror, the assump- 
tion being that pleasure in associating with the 
opposite sex away from the guarding eye of an 
adult will, if indulged prematurely (i.e., before the 
person is economically able to support a home), 


lead to an insidious dissolution of all the standards © 


of conduct and character acquired in the home, 
and is therefore destructive to the culture which 
it is hoped that the next generation will maintain, 
if need be with the same amount of effort expended 
by the last. 


A discussion of co-education that avoids these 
questions, like the “straight talks ” to the young, 
goes straight past the difficultics. The problem 
needs simplification, and tho first step is to look 
directly at the psycho-sexual life of the child and 
adolescent. Co-education was the topic of the 
December (an “open ”) meeting of the Medical 
Section of the British Psychological Society, 
and the observations of medical psychologists were 
presented by Dr. Laura Hurron. The first fact 
to emerge is that there is not one but three problems 
of co-education, corresponding to three phases 
of psycho-sexual development. The first stage 
covers approximately the years from six to eleven, 
and is characterised by a relatively slight degree 
of sexual feelings, boys and girls tend to treat 
each other alike. They play and work together 
and don’t think twice about it. The second 
stage is from eleven to fourteen, in it there is a 


CO-EDUCATION 


[san. 4, 1936 


prepubertal awakening of interest, but at the 
same time an affectation of despising or osten- 
tatiously avoiding the opposite sex. This 
contumely is not genuine and partly arises from a 
secret shame of sexual feelings, and a dread lest 
anyone should detect their presence. The scorn 
is a mask for anxieties which though not objective 
cannot be neglected. The third stage is that of 
puberty proper; it begins with a secret acknow- 
ledgment of the mutual attraction, but now the 
defensive aggressive attitude is directed not to the 
opposite sex as a whole, but to any special and 
public manifestation of the attraction. When 
there is an opportunity for the sexes to mix during 
the third phase there is a period of more rational 
and quiet friendships, to give place later to deeper 
feelings directed specially to particular individuals. 
To speak, therefore, of co-education without 
considering the changes of the psycho-sexual 
impulse in the pupils is likely to lead to a drift into 
meaningless generalities. l 

A recognition of these changes may illuminate 
also the special problems of the children in sex- 
segregated schools—viz., a narrowing of experience 
at a time when it should broaden, and a tendency 
to remain at one of the defensive (but normally 
transitory) positions already mentioned. For 
example, it is sometimes suggested that the sex- 
segregated schools are more likely to foster homo- 
sexual tendencies than the co-educational, since in 
the latter (if there is not overt or implicit intimi- 
dation) the pupils have opportunity for discovering 
their feelings for the opposite sex. Investigation 
shows that homosexual practices in schools do not 
as a rule have permanently serious consequences. 
There is however a less transitory kind of homo- 
sexual interest which is so deep rooted that it 
would not be influenced materially by the oppor- 
tunity afforded by co-education. It is unwise to 
organise education about a particular sexual 
problem. 


The whole matter requires more investigation 5 
as yet a parent has no criteria to help him decide 
whether to choose a co-educational or sex-segregated 
school. The absence of criteria is partly due to the 
difficulty of the subject, partly to the fact that 
the child’s schooling is one of the last and not least 
cherished fields for the enforcement of parental 
authority, and a kind of last ditch in which parental 
discipline puts up its vicarious fight. Education 
should not get too much involved in these struggles 
or it becomes a forcing-ground for faddism, and 
since there is so much for the pupil to master 
intellectually in these busy, brainy days it is 
undesirable for his school ‘years to’ be burdened 
by emotionally toned problems of school organisa- 
tion; those who think the pupils are not keen 
critics of educational theoreticians know nothing 
of the facts. So for the sake of pupils and schools 
alike, there is need for a clearer statement of 
those matters. 

The medical psychologists give us another 
clinical observation which speaks neither for 
nor against co-education or sex-segregated schools, 
but which should do something to dispel alarmist 


THE LANCET] 


views as to the dangers of “tampering with 
education.” It appears that character and a 
Weltanschauung are formed in the pre-school 
period ; there is little need to fear that even 
the most experimental of schools will produce 
freaks in those having no strong tendency to 
freakishness ; a good school helps the child to 
develop a strong interest in the people and things 


ACID IN THE STOMACH 


[san. 4, 1936 35 


(and occasionally even in “ problems”) which 
he finds around him. If the school is to be adapted 
to the potentialities of the child as well as to the 
need for continuity of culture in the community, 
whether the decision be ultimately in favour of 
co-education or sex segregation, the basis for a 
wise decision must be a deeper study of the psycho- 
sexual development of the child. 


ANNOTATIONS 


THE ACTION OF DUST ON THE TISSUES 


Ir is now generally agreed that the essential 
process in the development of pneumoconiosis is 
the solution of the inhaled dust particles; the mere 
mechanical irritation of accumulated insoluble mineral 
particles is not sufficient to produce that degree of 
fibrosis which we associate with silicosis. This 
conception of the silicotic process is largely due to 
observations on the tissue reactions which result 
when silica and other minerals are introduced into 
other parts of the body than the lung. L. U. Gardner 
and D. E. Cummins! have used the intravenous 
route and have studied the behaviour of silica intro- 
duced in this way into the liver and the spleen. 
E. H. Kettle? observed the behaviour of dusts 
injected into the subcutaneous tissues, and J. W. 
Miller and R. R. Sayers ? investigated the results of 
injecting dusts into the peritoneal cavity. These 
observations showed fairly clearly that whereas 
certain dusts caused a very definite tissue reaction, 
others appeared practically inert, and it at once 
became apparent that here was a method which 
should make it possible to determine whether any 
particular dust might be expected to produce pneumo- 
coniosis if inhaled into the lungs. In a recent pub- 
lication * Miller and Sayers have carried the matter 
still further. Using the peritoneum as their test 
tissue they have examined 16 different dusts and 
have found that they may be divided into three 
clear-cut groups. 

In the first or absorptive group the dust was absorbed 
or disappeared without causing any gross visible 
damage ; calcite, limestone, -precipitated calcium 
carbonate, gypsum, and portland cement fell into this 
group. In the second or proliferative group—pure 
crystalline quartz (two samples) and a highly siliceous 
chert—the dust initiated cellular proliferation followed 
by fibrosis and retrograde changes. And in the 
third, inert group, anthracite coal (two samples), 
bituminous coal (two samples), hematile, carborun- 
dum, precipitator ash, and soapstone, the dust 
remained inert in the tissues, neither being absorbed 
nor causing gross proliferation. Microscopic examina- 
tion of the lesions demonstrates the essential differences 
between them. In the early stages of the absorptive 
group reactions there is a little necrosis, possibly 
traumatic, but this rapidly disappears, and only a 
very minor degree of fibrosis results. In the 
proliferative group both necrosis and fibrosis tend to 
be progressive. In the inert group there is never any 
necrosis and fibrosis is always slight in amount. 
The authors do not refer to the secondary reactions 
in the associated lymph nodes to which Kettle 5 


1Amer. Jour. Path., 1933. ix., 751. 
? Jour. of Path. and Bact., 1932, xxxv., 395. 
3 Jour. Amer. Med. Assoc., 1934, ciii., 907. 
4 Public Health Reports, U.S. Pub. Health Service, 


1935, 1. 1619. 
. S THE LANCET, 1934, i., 889. 


attaches considerable importance, but from the 
observations accompanying their article the lesions 
they have produced seem to be sufficiently distinctive 
to justify their claims that the pneumoconiotic 
potentialities of a dust may be estimated by their 


technique in as short a period as 60 days. 


ACID IN THE STOMACH 


ExacTLy three years ago we commented on an 
aspect of acid secretion which promised to have 
important bearings on the causation and treatment 
of gastric diseases as well as of certain general dis- 
orders. About this time F. L. Apperly and M. C. 
Crabtree had shown that the concentration of the 
gastric hydrochloric acid during a fractional test- 
meal seems to depend on the bicarbonate content 
of the blood-plasma; in other words, that the 
secretion of acid is determined more by conditions 
of the blood than by what is going on inside the 
stomach itself. Further studies on the same lines 
are reported in our present issue in which Prof. 
Apperly continues his interesting inquiry into the 
significance of gastric acidity. In bringing together 
those causes which lead to variations in the plasma 
CO, it is seen that a number of diverse conditions 
have at least one common factor, For example, 
direct loss of carbon dioxide may be produced by 
the over-breathing which occurs in a hot bath, in 
some fevers, and at high altitudes; it may also be 
secondary to the formation of lactic acid after severe 
exercise or to the ingestion of ammonium chloride. 
There are records showing that in all these conditions 
gastric acidity is low ; likewise it is said to be reduced 
in the anoxemia associated with hemorrhage. 
Apperly’s experiments suggest a further step in 
his argument—namely, that anoxemia is not the 
first consideration, but that hemoglobin variations 
in the blood (upon which anoxemia largely depends) 
may be correlated with changes in gastric acidity. 
Thus he goes so far as to assume that when the 
hemoglobin content of the blood falls to about two- 
thirds of its normal value gastric acidity disappears, 
and in patients with post-hemorrhagic anemia he 
has found that this in fact happens. The idea that 
the relationship is as simple as this arouses doubts, 
however, as well as interesting speculations. It 
seems to be established that in some cases at least 
achlorhydria often precedes anemia by long periods, 
and that some gastric abnormality is the predisposing 
cause of the blood changes; and though this does 
not exclude the possibility that in others the gastric 
anacidity 1s secondary to the anemia, it will often 
be hard to find a primary cause of the initial blood 
changes. Further, there are undoubtedly some 
patients in whom the hemoglobin in the blood is 
not above 50 per cent., but whose gastric acidity is 
little if at all below normal. But even if his con- 
clusions are not entirely acceptable Prof. Apperly's 
paper is valuable because it brings once more to 


30 ‘THE LANCET] 


the front the non-gastric factors in the regulation 
of the acidity of the stomach and emphasises the 
importance of thinking of the general condition of 
the patient with gastric disorders and not merely 
of diet and treatment with acids and alkalis. His 
demonstration of the action of warmth in reducing 
gastric acidity shows the importance of general 
measures in the management of conditions associated 
with hyperchlorhydria, and the well-known effect 
of fevers in causing anacidity may possibly explain 
some of the benefit that apparently follows the use 
of protein substances by injection in cases of peptic 
ulcer. 


UNEXPECTED RICKETS AND SCURVY 


Dr. Alan Moncrieff shocked the Physiological 
Society the other day with a communication entitled 
“rickets on a diet with adequate cod-liver oil, and 
scurvy on a diet containing adequate orange juice.” 
The case-records now published 1 illustrate, as he 
says, difficulties in the simple ætiology assumed for 
the deficiency diseases. The rickety child, 17 months 
old, had been artificially fed from birth on a rational 
diet, supplemented by cod-liver oil in doses of one 
or two drachms daily or by ‘“‘another preparation 
reputed to be 25 times as rich as cod-liver oil in 
vitamin D,’ of which she got 1} drachms a day. 
Despite this she had all the physical and radiological 
signs of rickets, and also evidence of tetany (facial 
irritability and laryngismus stridulus); the serum 
calcium was 4:3 mg. per 100 ¢.cm. (ionic calcium 1-9) 
and the inorganic phosphorus 3:2. ‘There was no 
evidence of renal disease or coeliac disease, and slow 
improvement took place under treatment with 
vitamin D and calcium intravenously. This is a 
case apparently at the opposite pole from that 
recorded by Dr. Thatcher on p. 20 of our present 
issue in which death from hypervitaminosis followed 
the use of cod-liver oil in doses by no means extremely 
large. Dr. Moncrieff’s second case, moreover, is 
at least as remarkable, for here the patient developed 
typical scurvy at ten months, although he had had 
a good mixed diet and orange juice since birth 
amounting to half an orange daily for many months. 
In view of the apparent non-absorption of vitamin C 
he was given 400 mg. of ascorbic acid intravenously, 
after which he made a rapid recovery, and it might 
be interesting to know how he later responds to 
test doses of the vitamin. These cases are pre- 
sumably to be regarded as examples of ‘“‘ condi- 
tioned ’’ deficiencies, akin to the ‘‘ starvation 
in the midst of plenty” of the sufferers from 
coeliac disease, 


DENTAL CARIES AND DIET 


A SMALL inquiry into the relation between sound 
teeth and diet is reported by Dr. Arthur Collett ? 
of Oslo. Of two groups of children under school 
age, Group A belonged to a closed institution, while 
Group B consisted of children attending a nursery 
school but living at home. The latter group stayed at 
the school from 8.30 A.M. to 4 P.M. daily ; their teeth 
were brushed there and they received a third of a litre of 
milk and a hot meal; but at home they were allowed 
plenty of sweets and soft bread, as well as fruit, vege- 
tables, meat, and fish, and the state of their teeth was 
deplorable. Among 40 children between the ages of 
three and seven years, there were 584 holes in the teeth 
—i.e., 14:6 holes per child. (Every ruined or extracted 
tooth counted as two holes; the 42 teeth thus 


ur. of Physiol., 1935, Ixxxv., 26 P. 
* Tidssk. t. N Norske Lacgcfor. ., Nov. 15th, 1935, p. 1246. 


UNEXPECTED RICKETS AND SCURVY 


(san. 4, 1936 


classified accounted accordingly for 84 of the 584 
holes.) Very different was the dental lot of the 
11 children of similar age in Group A. They had 
209 milk teeth and 14 permanent teeth, and only 
19 holes, 16 of which were already stopped, could 
be found. These 19 holes were distributed among 
11 teeth, and no less than 9 of the 19 belonged to 
one and the same child who had been admitted to the 
institution at the comparatively late age of 2-3 years. 
All the 19 holes were in the milk teeth. The contrast 
is evident from the fact that while the A children had 
only 1-7 holes per child and 0-08 holes per tooth, 
only 4:9 per cent. of the teeth being holed, the B 
children had 14:6 holes per child. The numerical 
difference between the two groups was the more 
striking when correlated with the difference in the 
size of the holes in the two groups, those in Group A 
being minute, those in Group B painfully evident. 
Dr. Collett traces this difference in large part to the 
dietary of Group A which contained hardly any sweets 
and included over half a litre of milk (for the older 
children), home-baked bread containing 50 per cent. 
whole meal, margarine (no butter), a dessertspoonful 
of cod-liver oil every day throughout the year, and 
plenty of vegetables and some fruit. Every meal 
ended with uncooked fruit or carrots. The tooth- 
brush and local dental hygiene were dispensed with, 
apart from the stopping of holes. 


ANAESTHETICS AND SHOCK 


THE interrelationship of shock and anesthesia, 
a matter of much practical importance, is by no 
means easy to determine. There is common agree- 
ment that insutlicient narcosis may, on the advent 
of a painful nerve stimulus, lead to serious or even 
fatal shock. These cases are comparable with those 
in pre-anesthetic days when a patient fainted or 
suffered fatal syncope at the first stroke of the knife. 
They are also comparable with that ‘ psychic shock ”’ 
which anesthetists have learned to fear, when the 
disastrous stimulus is a mental or emotional one. 
In all these instances it is the absence of anæsthesia or 
much too light a dose which has made that shock 
possible. Sir Frederic Hewitt used to say that if 
consciousness is thoroughly abolished, at any rate 
when ether is the anxsthetic used, reflex fatal shock 
of this kind never occurs. At the other extreme, 
excessive anesthesia through overdosage can produce 
a condition analogous to and hard to distinguish 
from surgical shock. The same effect occasionally 
follows an endothecal injection. There is, then, 
close association between insufficient anesthesia 
and shock, and between excessive anesthesia and 
shock. What may be termed normal anesthesia 
is, however, regarded as one of the chief means of 
preventing shock during surgical operations. The 
efficiency for this purpose of various anesthetics 
and certain methods of anmsthesia have been so 
clearly demonstrated by Crile that they are now 
generally accepted. At a recent discussion on 
surgical shock, given in our columns, one speaker 
is reported to have said? that “ fluctuating depths 
of anwsthesia invariably causo shock.” If the 
fluctuations are so extensive as to reach the two 
extremes, no doubt the statement is incontrovertible. 
But if as appears hkely from the context, the speaker 
had in mind variations in anwsthesia within “normal ”” 
limits of depth, for example with the corneal reflex 
at one time abolished and at another allowed to 
return, we cannot agree with him. Variations of 


a nS, 


1413. 


1 See THE LANCET, 1935, il., 


THE LANCET] 


this kind are constantly allowed in practice by good 
anesthetists. During long abdominal operations 
narcosis is intentionally lightened throughout the 
period when some anastomosis or other surgical 
procedure is carried out on insensitive viscera. When 
the peritoneum has to be dealt with and the abdomen 
closed the anesthesia is deepened. In this way the 
patient receives far less of the drug than he would 
if he has been kept deeply under throughout the 
operation, irrespective of its stage or of the sensi- 
tivity of the tissues being cut or sewn. Far from 
facilitating shock, variation of depth in this manner 
is prone to lessen the risk of shock by reducing the 
chance of excessive anesthetic. 


THE NEW POISONS LIST 


On New Year’s Day the Home Office issued the 
new list of scheduled poisons, leaving four clear 
months for its study before the new rules come into 
force on May Ist. The list is divided into two parts. 
In Part I. are those substances the sale of which is 
to be restricted to authorised sellers of poisons, 
i.e., registered pharmacists. In Part II. are those 
substances which may be sold only by registered 
pharmacists and persons registered for the purpose 
under the Pharmacy and Poisons Act, 1933; this 
part includes various poisons commonly used for 
agricultural, horticultural, sanitary, and domestic 
purposes. The new rules impose certain additional 
restrictions, including, notably, regulation of the 
transport of poisons, prohibition of the sale to the 
public of certain potent medicinal poisons except 
upon a prescription given by a qualified medical, 
dental, or veterinary practitioner, and prohibition 
of the sale of strychnine except for medicinal purposes. 
Copies of the Poisons List, the Poisons Rules, and 
the form prescribed for application to be made to the 
local authority for registration for the sale of the 
substances in Part II. of the Poisons List may now 
be had from H.M. Stationery Offce. 


EFFECTS OF HORMONES ON THE PITUITARY 


So much is written about the way in which the 
anterior pituitary acts on other endocrine organs 
that one is apt to forget that these other organs 
also influence the anterior pituitary. The latter is 
not really a “‘master gland,” since it is in some 
respects subordinate ‘to the activities of its “‘sub- 
jects’; it is only one of several factors in a dynamic 
equilibrium. Thus for some years it has been known 
that histological changes are produced in the anterior 
pituitary by castration of either male or female, 
and in castrated animals concurrent increases in 
the content and output of gonadotropic hormones 
have been observed. Administration of ostrin to 
the castrated female has been found to inhibit the 
histological changes, or to restore the histological 
picture to normal; but so far the restoration of the 
anterior pituitary has not been achieved with, andro- 
sterone, the excretory form of the male hormone,? 
although it has been reported by Migliavacca ? for 
a hormone preparation from urine, and by McCullagh? 
for a water-soluble fraction from testes. It remains 
to be seen whether the recently isolated testosterone 
will have this effect. As regards less radical changes 
in the anterior pituitary, which take place without 
gross histological signs, evidence is rapidly accumu- 


3 Croo: A. C., aa RENE: V.: Proc. Roy. Soc. 


Med., 1935, xxvili. 
„$ Migliavacca, A.: Boll. Soc. Ital. Biol. Sperim., 


J. 
3 McCullagh, D. R.: Science, 1932, Ixxvi., 19. 


EFFECTS OF HORMONES ON THE PITUITARY 


1935, X., 


\ 


[yan. 4, 1936 37 


lating which bears on the reciprocal action of the 
anterior pituitary and the gonads and on the mechanism 
of the menstrual cycle. Many authors have described 
inhibitory effects of cstrin administration upon 
ovarian growth and development in the normal 
animal, but the results in this field are often con- 
fusing and contradictory, evidently because of wide 
variation in factors now recognised to be important, 
such as amounts and form of hormone administered, 
period of treatment, and the condition of the animal. 
As an example of recent work, in which detailed 
analysis of the effects has been made, we may quote 
Lane,‘ who injected cestrin into infantile female 
rats for varying periods and then examined the 
pituitaries by removing them and implanting them 
into a second series of rats. The follicle-stimulating 
hormone was at first increased in amount above 


-normal, and then inhibited, ultimately completely. 


Secretion of the luteinising hormone, on the other 
hand, seemed to be increased throughout the experi- 
ment. A stimulating effect of cstrin on the anterior 
pituitary has been recorded by other authors, for 
instance by Deanesly,> who observed ovulation in 
pseudopregnant mice after administration of cstrin, 
probably as a result of appropriate enhancement of 
the secretion of follicle-stimulating and luteinising 
factors. 

Dahlberg ê has applied the idea of a balance 
between cestrin and anterior pituitary hormones to 
explain the inhibition of ovulation in the human being 
after the liberation of one ovum and the continued 
repression of ovulation during pregnancy, though 
he favours the assumption of a direct antagonism 
in the ovary rather than the mechanism of pituitary 
inhibition. The experiment in support of this theory 
consisted in the inhibition, by injection of follicular 
fluid, of the ovulation normally induced in the 
mouse by injection of urine of pregnancy (containing 
prolans). Zondek failed to confirm this phenomenon 
with injections of æœstrin, but other evidence indi- 
cated that an inhibition of this type might exist, 
and Dahlberg claims that the discrepancy is due to 
differences in the mode of administration. It 1s 
known that continual small doses are more effective 
than a single large dose, owing probably to the 
rapid destruction and excretion of the water-so:uble 
hormone; oral administration, although the fraction 
absorbed is less, ensures more continuous absorption, 
and under these circumstances the original experi- 
ments have been confirmed. It seems, therefore, 
that in the pregnant woman there is enough estrin 
continuously in the circulation to prevent ovulation, 
but not enough to injure the ovaries. When such 
blood is injected into a mouse in the usual pregnancy 
test the single dose of estrin, quickly absorbed and 
quickly excreted, is not sufficient to interfere with 
the ovulation produced by the prolans. 

Now the anterior pituitary, in spite of the multi- 
plicity of the endocrine-stimulating functions attri- 
buted to it, has only three distinguishable types of 
cell—chromophobes, basophils, and acidophils—the 
accepted view being that the first type is a reserve 
or foundation cell which may develop into either of 
the other two. It is therefore reasonable to suppose 
that doses of cestrin which affect the gonadotropic 
activity of the anterior pituitary will have a parallel 
effect on the other activities if these are exercised 
by the same cells. Actually suppression of the 


t Lane, C. E.: Amer. Jour. Physiol., 1935, ex., 681. 
> Deanesly, R. : Jour. of Physiol., 1931, lxxii., 62. 
a Dahlberg, G.: Jour. Obst. and Gyn. Brit. Emp., 1935, xlii., 
9J. 


38 THE LANCET] 


HEPATIC LESIONS IN CONGENITAL SYPHILIS 


[san. 4, 1936 


a a 8 a a a a 


diabetogenic activity by cestrin has been demon- 
strated,’ but Shumacker and Lamont ® failed to 
find any effect of cestrin (in doses of 9 “rat units ” 
per day) on the somatogenic, thyrotropic, adreno- 
tropic, or even gonadotropic activities, as indicated 
by the changes in weight of the body and separate 
organs after a period of 67 days. Engel? found that 
the effect of growth hormone on rats was not modi- 
fied by the simultaneous administration of male 
hormone or estrin. On the other hand, Bernhard 
Zondek, in a paper published in our present issue, 
has demonstrated that administration of massive 
doses of œstrin to young rats over a long period not 
only represses development of ovaries or testes, but 
has a most striking effect in inhibiting growth, 
reducing body-weight by as much as 43 per cent. 
as compared with control animals. In addition, he 
forecasts the publication of data showing effects 
on the thyrotropic and other activities of the pitui- 
tary, as well as changes in the anterior pituitary 
itself. Correlating these observations with the 
recorded result of thyroid feeding on the anterior 
pituitary and secondarily on the cestrous cycle of 
rats 1° it seems that we are on the threshold of a 
closer understanding of the interrelationship of the 
anterior pituitary and the other endocrine organs, 
and of the manifold effects of administering a single 
hormone. Such understanding should lead to a yet 
more rational system of hormone therapy. 


CARRIER LICENCES 


THERE would not at first sight appear to be much 
of particular interest to medical men in a treatise 1! 
on “The Law Relating to Carriers’ Licenses, under 
the Road and Traffic Act, 1933,’ unless indeed they 
wished for some strenuous intellectual exercise. The 
numerous full and complicated enactments from the 
Railway and Canal Traffic Act of 1854 to that of 
1933 offer an intricate study for anyone rash enough 
to attempt their understanding without a training 
in the law. Mr. Maxwell has set out to make their 
principles and precepts clear to all those concerned 
with transport on the roads. And it is here that the 
doctor will find his curiosity justified if he looks into 
this volume ; indeed, he may see a certain cause for 
alarm. Mr. Maxwell shows him that he is, according 
to the wording of the law, subject to penalties in 
which he could not expect to be involved by the 
ordinary use of his car. Here is one passage from the 
chapter on offences: ‘the conclusion can hardly 
be avoided that every motor car fitted with any 
kind of convenience for carrying the luggage or 
effects of passengers or any other kind of load is a 
goods vehicle, and that a license is required to carry 
anything in any motor car in connection with a 
business. . . .” This definition seems certain to 
include the car in which the doctor carries his case 
of drugs, his emergency outfit, his anesthetic bag, and 
soon. Later on comes the more specific statement : 
“jif an engineer needs a license to carry his tools 
a surgeon should need a license to carry his instru- 
ments,” and the author goes on to show that the 
typist might need one to carry his typewriter, and 


7 Barnes, B. O., Regan, J. F., and Nelson, W. O.: 
Amer. Med. Assoc., 1933, ci., 926; Nelson, W. O., and Over- 
holzer, M. D.: Proc. Soc. Exp. Biol. Med., 1934, xxxii., 150. 

* Shumacker, H. B., Jun., and Lamont, A.: Proc. Soc. Exp. 
Biol. Med., 1935, xxxii., 1568. 

t Engel, P.: Klin. Woch., 1934, xiii., 1540. 

2° Campbell, M., Wolfe, J. M., and Phelps, D.: Proe. Soc. 
Exp. Biol. Med., 1934, xxxii., 1205. 

11 The Law Relating to Carriers’ Licenses under the Road and 
Rail Traffic Act, 1933. By Eric F. M. Maxwell, of the Inner 
Tomple and Northern Circuit,- Barrister-at-Law. London: 
Swect and Maxwell Ltd. 1936. Pp. 330. 15s. 


Jour, 


syphilis as seen in the liver. 


perhaps the barrister to carry his briefs. It appears 
that much of the drafting of the bills governing 
traffic is faulty, making the clear meaning of the 
law difficult to discern and indeed, if taken strictly, 
not seldom reducing the law to absurdity. Mr. Maxwell, 
an authority on railway law, has been impressed with 
the necessity of clearing up the muddle if people 
are to have a fair chance of evading liabilities for 
which they are unlikely to realise their responsibuity, 
and his book should be of service to the many persons 
who become involved in litigation through incidents 
of road travel of one kind or another. 


HEPATIC LESIONS IN CONGENITAL SYPHILIS 


THE morbid anatomist nowadays sees relatively 
little of the lesions of acquired syphilis, at any rate 
in a frank and easily recognisable form ; the gumma 
has become a rarity and even syphilitic aortitis is 
nothing like as common asit was. Still more uncom- 
mon are the lesions of the congenital form of the disease, 
for antenatal and infant welfare and venereal disease 
clinics are making their influence felt, not to speak of 
the increased vigilance in this direction of the 
general practitioner. Nevertheless, from time to time 
an unhappy infant slips through the therapeutic 
net and may in due course present very puzzling 
problems to the unwary pathologist. In a scholarly 
article in the recently established Indian Journal 
of Venereal Diseases (1935, i., 183) Dr. P. Ramachandra 
Rao discusses in detail the manifestations of congenital 
This organ, as he 
points out, is particularly liable to be affected by the 
disease, for the maternal blood passes directly to it 
through the umbilical vein and only reaches the 
rest of the body after it has passed through its 
capillaries. The intense saturation of the liver with 
spirochetes, with the accompanying fine fibrosis 
and the development of miliary gummata, is the 
form of congenital syphilitic disease of the liver which 
is familiar to everybody. Less well recognised are 
the later or more chronic manifestations, for, as 
Dr. Rao observes, it may be impossible to demonstrate 
spirochetes in them. Often enough the syphilitic 
nature of the lesions can only be presumed from the 
clinical history or the recognition of more charac- 
teristic changes elsewhere in the body. Among these 
more obscure hepatic lesions Dr. Rao includes chronic 
periportal pylephlebitis, pericholangitis, and endo- 
phlebitis of the hepatic vein, illustrating his thesis 
by descriptions of interesting cases occurring in the 
autopsy practice of the King George Hospital of 
Vizagapatam, A number of helpful photomicrographs 
are included and the value of the article is enhanced 
by a very complete bibliography. 


USE OF MENTHOL IN CHILDHOOD 


IN an annotation on the treatment of the common 
cold in France, published a fortnight ago, we men- 
tioned the apparent unpopularity of menthol as a 
remedy. In adults toxic symptoms due to the use 
of this drug must be extremely rare, but as long ago 
as 1912, it seems, R. Leroux wrote in no uncertain 
terms of the danger of its use in childhood, and 
particularly in infancy, even when given by intra- 
nasal instillation in vaseline. Ile thought that it 
was liable to produce reflex inhibition of both respira- 
tion and cardiac action, and that its action and 
dangers were exactly comparable to those of chloro- 
form anxsthesia in its early stages. It happens that 
Dr, Champeau has just recorded ! severe disturbances 


1 Bull. de l’Acad. de Méd., 1935, cxiv., 448. 


THE LANCET] 


in a child 44 years old which he attributes to the 
ingestion of 6 mg. of menthol. Having previously 
suffered from adenoids, she was given three sweets, 
each containing 2 mg., at the onset of an upper 
respiratory infection. The menthol was in high 
concentration (1 in 100), since each sweet was only 
approximately 20 cg. in weight. An hour after 
the drug had been administered, the child suddenly 
appeared tired and asked to be put to bed; she 
then became very pale, with coldness of the extremi- 
ties and cyanosis of the face. Respiration was 
spasmodic, and the pulse rapid and irregular, ceasing 
entirely for periods of several seconds during which 
the diaphragm was in spasmodic contraction; she 
also vomited. The crisis lasted in all about three- 
quarters of an hour, the condition improving after 
injection of camphorated oil. At Champeau’s sug- 
gestion, the Medical Society of Evreux, at its general 
meeting last October, unanimously recommended 
that all menthol products should be clearly labelled 
as containing a drug for adult use and dangerous to 
children, and that the medical and pharmaceutical 
faculties should have their attention drawn to the 
danger of prescribing menthol in early life. We 
may note that Martindale and Westcott’s ‘‘ Extra 
Pharmacopezia ” already contains a similar warning : 
“It is dangerous to apply an ointment containing 
menthol to the nostrils of infants, e.g., for treat- 
ment of catarrh,—may cause instant collapse.” The 
same’ caution is applied to camphor. 


THE HEALTH OF THE AIR FORCE 


DurincG the year 1934 the Royal Air Force main- 
tained its good health and the incidence of dis- 
abilities fell, in fact, by more than 5 per cent. There 
was a total of 19,344 cases of sickness, an incidence 
of 632 per 1000 of strength which, compared with 
the periods 1928-33 and 1921-27, showed a decrease 
of 48 and 362 per 1000. This incidence equals that 
of 1932, which was the lowest since the reports 
began in 1920. The number of deaths of those 
invalided from the service and of venereal infections 
was each the lowest on record. The chief causes of 
disability were injury and venereal disease, respec- 
tively 77 and 9-9 per 1000. Of the 94 deaths, injury 
accounted for 58, and 24 of these were due to flying 
accidents. As in previous years, pulmonary tuber- 
culosis and psychoneurosis were the commonest 
causes for invaliding 155 men out of the service. 
Disease and injury as causes of sickness bear the 
usual relation to one another, the former consti- 
tuting 80-5 per cent. of the total. A notable decrease 
occurred in the number of cases due to influenza, 
respiratory disease and diseases of the skin. Though 
an epidemic of dysentery in Iraq produced a sharp 
rise to 156 cases, the incidence of malaria and sandfly 
fever fell to 373 and 283 respectively. After injury, 
the commonest cause of sickness was disease caused 
by infection, with diseases of the digestive system 
second on the list. The average duration of each 
case was 17 days. Expansion of the service has led 
to an increase in the routine work of the central 
medical establishment, and a study has been made 
of the effects of strain resulting from the rapid develop- 
ment of aircraft. During the year the results were 
published of research in the significance and treat- 
ment of heterophoria and in the relationship between 
body-build and functional efficiency, when it was 
shown that overweight men were more capable of 
enduring both physical and mental strain than those 
under weight. In the pathological laboratories at 


1 THE LANCET, 1934, i., 1377 and 1399; 


THE HEALTH OF THE AIR FORCE 


[yan. 4, 1936 39 


Halton there has been research into the etiology of 
tonsillitis and droplet infections among the aircraft 
apprentices. A report of the possibility of yellow 
fever at places in the Sudan used for landing grounds 
by both the Air Force and the civil airways led to 
an investigation throughout the country. Sero- 
logical tests proved that though yellow fever prob- 
ably had been present in the past there was little 
risk of foreigners contracting the disease, and there- 
fore there was no interference with the air services 
beyond quarantine examination and disinfection. 


THE POPULATION PROBLEM IN INDIA 


From a study of the growth of populations} 
Colonel C. A. Gill, I.M.S., has advanced the view that 
various population types can be differentiated, each 
representing a different stage of growth from 
“infancy” to “old age.” The passage through 
these stages is dependent, he believes, on natural 
laws of populations which secure the progressive 
evolution of the human race. In general it appears 
from his argument that the stage of growth reached 
must govern the legislative and administrative action 
required for the needs of specific populations. In 
particular in British India, which Gill classified as 
in the “nascent ” stage, any appreciable and con- 
tinuous reduction of the birth-rate must, he asserts, 
place a check upon progressive evolution unless 
it is associated with a corresponding reduction of the 
death-rate. He therefore argues that any endeavour 
to popularise the use of contraceptives in that country 
would be a biological blunder. 

From these views, outlined in our columns early 
this year,? Lieut.-Colonel A. J. H. Russell, Public 
Health Commissioner with the Government of India, 
and Prof. K. C. K. E. Raja, of the department of 
vital statistics and epidemiology of the All-India 
Institute of Hygiene and Public Health, dissent 
completely. Neither in vital statistical indices nor 
in the evidence relating to fecundity marshalled by 
such workers as Carr-Saunders do they find any 
support for Gill’s theory of a decreasing urge of 
prolificity as a biological phenomenon when we pass 
from primitive to mature population types. It 
seems that the regulation of numbers has exercised 
the mind of man at all times and various means of 
achieving this regulation were present in primitive 
pastoral communities as well as in countries of 
modern civilisation. It is certainly difficult to see 
why we should be running counter to the purposes 
of nature by adopting contraception in preference 
to abortion and infanticide. If India, in particular, 
is to reach and maintain a higher standard of living 
the question of family limitation must, Russell and 
Raja urge, become one of increasing importance. 
The present picture they draw of her population is 
that of a community living at an extremely low 
standard and growing at a pace which is outstripping 
or threatening to outstrip its food-supply. Even 
if some allowance is made for a speedier development 
of her natural resources the attainment of higher 
standards of health and comfort, demand, they say, 
some retardation of the present rate of growth. 

This conclusion can hardly be regarded as an over- 
statement. The position is frankly regarded as 
disturbing by such observers as Sir John Megaw 
whose opinion is quoted inthis paper. ‘‘Thereis every 
reason to believe,” he has said, “that the maximum 
increase which can be hoped for in the production 


1 Jour. of Hyg., 1934, xxxiv., 502. 
3? THE LANCET, 1935, i., 563. 
3 Ind. Jour. Med. Res., 1935, xxiii., 545. 


40 THE LANCET] 


of the necessaries of life will: not keep pace with 
the growth of the population so that there is a prospect 
of a steady deterioration in the state of nutrition of 
the people.” Does evolution really demand this 
high natality and the high mortality to which it must 
apparently lead? On another page of our present 
issue is set out Sir John Megaw’s own answer to 
this question. In India, he says, a comprehensive 
food policy is needed to save that country from a 
relapse into barbarism. Educated Indian opinion 
already recognises this and he is hopeful of the 
success of a concerted national movement. 


NEW YEAR HONOURS 


Tue decorations and dignities conferred by the 
King this New Year are few compared with those 
granted in last year’s list of Birthday honours, 
which commemorated the Silver Jubilee. Of the 
five new knighthoods, Dr. Knuthsen’s is a promotion 
in the Royal Victorian Order, two are given for 
services in India, and two go to surgeons of high 
distinction, Prof. Wilkie of Edinburgh, and 
Mr. Devine of Melbourne. Outside ‘the straiter 
bounds of medicine we are glad to note that the list 
of new knights includes the name of Prof. Arthur 
Harden, F.R.S., biochemist and Nobel prizeman, 
while others closely associated with medical activities 
are Mr. Percival Hartley, D.Sc., director of the 
Department of Biological Standards, Mr. J. F. 
Marshall, director of the British Mosquito Control 
Institute at Hayling Island, and Miss Olga Nethersole, 
founder of the People’s League of Health, all of whom 
are created C.B.E. Sir Gomer Berry, who receives 
a peerage, has been for many years an open-handed 
supporter of hospitals and the medical efforts 
associated with them. To these and to all whose 
names are set out on p. 60 we offer congratulations. 


THE LITERATURE OF BLOOD TRANSFUSION 


FIFTEEN years ago a bibliography of blood trans- 
fusion would have consisted of one to two hundred 
entries dealing chiefly with the early experiments 
on the technique. Since 1920 the subject has grown 
enormously and its ramifications are still spreading 
as the difficult subject of blood groups and reactions 
is slowly unravelled, and as the indications for 
transfusion increase. A bibliography of the whole 
field has now been compiled by Dr. E. Koenig? 
in Russia, and although this only covers the period 
1900-33 the number of entries runs to 4323. It is 
improbable that even so it is complete, but it is 
comprehensive enough to be extremely valuable to 
everyone working on any aspect of the problem. 
The bibliography “has been compiled by the Scientific 
Research Institute for Blood Transfusion in Leningrad 
and is published conjointly by the Institute and the 
Vestnik Chirurguii. The titles of the Russian, 
German, English, French, and Italian papers are 
printed in the original languages, and there are in 
addition German translations of the titles from Czech, 
Danish, Dutch, Estonian, Gcorgian, Hungarian, 
Japanese, Norwegian, Polish, Portuguese, Rumanian, 
Serbian, Spanish, Swedish, Ukrainian, and White- 
Russian sources. The whole subject has been 
divided into 22 sections and 77 subsections, the 
headings of the sections being printed in the first 
five languages mentioned. The book is therefore 
a model of what an international bibliography should 


1 International Bibliography on the Problems of Blood 
Transfusion and the Theory of Blood Groups, 1900-1933, By 
Dr. E. Koenig. Leningrad: Vestnik Chirurguli. 1935. 
Pp. 226. R.12 k.50 


NEW YEAR HONOURS 


[JAN. 4, 1936 


be, and it is difficult to see how its plan could be 
improved. Its general accuracy can only be properly 
assessed by use, but it seems possible that the index 
of names could be made fuller; for example, one 
name which appears six times in the bibliography 
is only given two entries in the index. The compila- 
tion of the list is still proceeding, and a supplement 
will be published when sufficient material has 
accumulated. Suggestions will be welcomed by the 
Institute for Blood Transfusion in Leningrad. 


Tre second International Congress of Micro- 
biology will be held in London from July 25th to 
August Ist under the presidency of Prof. J. C. G. 
Ledingham, F.R.S. The congress will have its 
headquarters at University College, and its meetings 
have been arranged under the “following sections : 
general biology of micro- organisms (president, Prof. 
E. Gotschlich, Heidelberg) ; viruses and virus 
diseases in animals and plants (Prof. R. Doerr, 
Basle); bacteria and fungi in relation to disease in 
man, animals, and plants “Mr. E. J. Butler, F.R.S., 
London, and Prof. H. Zinsser, Boston); economic 
bacteriology, soil, dairying, and industrial micro- 
biology (Prof. R. E. Buchanan, Iowa); medical, 
veterinary, and agricultural zoology and parasitology 
(Prof. E. Brumpt, Pars); serology and immuno- 
chemistry (Prof. K. Landsteiner, New York); micro- 
biological chemistry and specific immunisation in 
the control of human and animal disease (Prof. 
W. II. Park, New York). The hon. general secretary 
for the congress is Dr. R. St. John Brooks, Lister 
Institute of Preventive Medicine, Chelsea Bridge- 
road, London, S.W. 1. 


INFECTIOUS DISEASE 


IN ENGLAND AND WALES DURING THE WEEK ENDED 
DEC. 21sT, 1935 


Nolifications.—The following cases of infectious 
disease were notified during the week: Small-pox, 
0; scarlet fever, 2522; diphtheria, 1216; enteric 
fever, 14; acute pneumonia (primary or influenzal), 
1073 ; puerperal fever, 30; puerperal pyrexia, 107 ; 
cerebro-spinal fever, 173; acute poliomyelitis, 6 ; 
acute polio- encephalitis, 1; encephalitis lethargica, 
10; dysentery, 48; ophthalmia neonatorum, 72. 
No case of cholera, plague, or typhus fever was 
notified during the week. 

The number of cases in the Infectious Hospitals of the London 
County Council on Dee. 27th was 3590, which included : Scarlet 
fever, 1171; diphtheria, 1204; measles, 250; whooping - 
cough, 3997 puerperal fever, 20 mothers (plus’ 15 babies); 
encephalitis lethargica, 280 ; poliomyelitis, 3. At St. Margaret’ S 
Hospital there were 14 babies (plus 2 mothers) with ophthalmia 
neonatorum. 


Deaths.—In 121 great towns, including London, 


there was no death from small-pox, 4 (1) from enteric 
fever, 39 (4) from measles, 8 (0) from scarlet fever, 


' 20 (6) from whooping-cough, 55 (9) from diphtheria, 


39 (9) from diarrhæa and enteritis under two years, 
and 67 (8) from influenza. The figures in parentheses 
are those for London itself. 


Portsmouth, Manchester, and Grimsby each had 1 death from 
enteric fever. Liverpool "reported 12 deaths from measles, 
Manchester 6, Bootle 3, Blackburn, St. Helens, and Stockton-on- 
Tees each 2. Liver pool also reported 5 deaths from whooping- 
cough. Tho deaths from diphtheria were reported from 30 
great towns ; 5 from Birmingham, 4 from Hudderstield, 3 each 
from Bradford and Sunderland. The mortality from influenza 
is scattered over 34 great towns, Manchester and Birmingham 
each reporting 6, Liverpool 5, Southampton 3, no other great 
town more than 2 


The number of stillbirths notified during the week 
was 254 (corresponding to a rate of 42 per 1000 total 
births), including 49 in London. 


THE LANCET | 


fyan. 4, 1936 41 


PROGNOSIS 


A Series of Signed Articles contributed by invitation 


| LXXXIII 
PROGNOSIS IN TRIGEMINAL’ TIC 


CHRONIC paroxysmal neuralgia of the trigeminal 
nerve, or trigeminal tic, may be said never to be 
cured by drugs, or to disappear spontaneously. It 
may start gradually, with shoots like toothache, or 
it may leap suddenly into consciousness with a 
shattering explosion of pain in the face. Once 
started, the pain is bound to recur again and again, 
though there may be in some cases intervals of years 
of complete freedom in the earlier stages. Gradually 
the attacks become more frequent, and usually more 
severe as the years pass, till ultimately scarcely a day 
passes without numerous stabs of almost intolerable 
agony in jaw, tongue, nose, and sometimes eye and 
forehead. 

I have seen two women who had suffered for over 
fifty years, one having commenced the paroxysms 
at the early age of twelve. Often, but not always, 
as time goes on the neuralgia may spread from the 
original site in one or other jaw, or possibly the 
eyebrow, until it involves all three divisions of the 
trigeminal area on one side. Sometimes the pain 
remains located in upper or lower jaw alone, but 
invariably if the pain starts in the first division, in 
eyebrow and forehead to top of head, the neuralgia 
ultimately spreads downwards to involve the nose 
and upper lip and cheek, spreading from the first 
into the second division, though several years may 
elapse before this takes place. 

Inheritance of the disease is not very rare, the 
neuralgia almost invariably appearing at a younger 
age in “the second generation, and again younger in 
the third. I have had two patients of a family in 
which nine members suffered, three in each of three 
generations, the disease appearing at the age of 16 
in two sisters, and at 20 in their brother, in the third 
generation. 

TREATMENT BY ALCOIIOL INJECTION 


The easiest form to treat successfully is third 
division tic, the pain affecting the lower jaw only and 
perhaps the same side of the tongue. A properly 
placed alcohol injection into the nerve at its exit 
from the foramen ovale will instantly numb the lower 
jaw, chin, and lip, and half the tongue, so that the 
tongue movements become free and easy, and no 
longer cause painful spasms, and eating and swallow- 
ing are immediately possible without causing any 
of the distress previously felt. Owing to the numb- 
ness of the left gum and inside of ‘cheek and the 
half of the tongue, it is preferable for the patient 
to eat on the other side of the mouth ; the weakness 
of the biting and chewing muscles on the aflected 
side, produced by the involvement of the motor root 
in the alcohol injection, tends to upset what dentists 
call the ‘‘ bite” and the alignment of the dentures. 
The motor fibres usually recover with 3 months, 
though the anesthesia and freedom from pain may 
be measured by years. I have seen numerous cases 
of five years’ standing and upwards with complete 
freedom after injection of the third division only, 
and I have seen recurrence after 13 years and 15 years, 
while another patient is still quite free after 26} years. 

The reason for the long periods of relief after third 
division injection, as compared with the results after 
second division injection, is that when the alcohol 1s 
injected into the nerve at the foramen ovale, a cer- 


tain amount often enters the Gasserian ganglion 
and destroys a number of nerve-cells in its outer 
part, so that partial numbness and light anesthesia 
is apt to be permanent, sufficient in certain individuals 
to keep the neuralgia at bay almost indefinitely. 
When the second division is injected, at or in 
front of the foramen rotundum, no alcohol will 
reach the Gasserian ganglion, and though complete 
and total anesthesia of the cheek, jaw, and palate 
on that side may result, with immediate relief of 
the neuralgia, yet new nerve-fibres grow down from 
the ganglion cells fairly rapidly, and in twelve months 
or less sensation may be practically normal again, 
and thus no obstacle remains to the passage upwards 
of the painful impulses from the periphery. 


ROOT RESECTION OR GANGLION INJECTION 

Since recurrence of the neuralgia in second division 
cases is usual after a year or two, the question of 
either root resection or ganglion injection must be 
considered. If the second division alone is involved, 
then injection at the foramen rotundum should 
always be done as the preliminary treatment, for 
two reasons: first, because it is possible in a few 
cases to obtain relief lasting many years; and 
secondly, to accustom the patient to the permanent 
numbness that would result from the ganglion 
injection or root resection. A small proportion of 
patients object intensely to the numbness, and the 
preliminary injection will be a test as to whether 
they would prefer to endure the neuralgia, if it 
returns, or to put up with permanent numbness as 
the price of a cure. If the first division is involved 
together with the second, the pain shooting up the 
forehead to the vertex, and perhaps in the eyeball 
itself, then it will probably be useless to inject the 
second division only, and it will be necessary to deal 
with the ganglion at once, or else have the sensory 
root resected. It is possible in these cases to inject 
the inner two-thirds of the ganglion only, leaving 
normal sensation on the unaffected lower jaw and 
tongue, which is a considerable comfort to the patient. 
Though the motor root may be paralysed at first, it 
nearly always recovers within about three months. 
By the open method of operation for root resection, 
it is now possible to save the motor root in most 
cases, and from the method of fractional root resec- 
tion, leaving uncut a small bundle of fibres on the 
inner side of the root, incomplete anesthesia results, 
especially of the ophthalmic branch, 80 that the risk 
of keratitis is much diminished. 


CARE OF THE CORNEA: KERATITIS 


The care of the cornea is very important for the 
first few weeks after total root resection or ganglion | 
injection. If, however, the eye is shaded from the 
first by a close-fitting curved straw-plait shade, no 
lint or wool being used under the shade, and the 
conjunctival sac washed out twice daily with weak 
(1 in 7) boracic lotion, then in almost all cases the 
eye remains healthy, and the shade can be gradually 
discarded after five or six weeks. If, through care- 
lessness, or for other reasons, such as the presence 
of facial palsy, the cornea is insufficiently protected, 
or should there be a pre-existing conjunctivitis or 
trachoma, then keratitis is much more likely to 
supervene, and it will be necessary to close the lids 
by tarsorrhaphy, and not reopen them for several 
months. Hence, before deciding on a total root 


42 THE LANCET] 


resection ‘or ganglion injection, it is important to 
examine the vision of the two eyes; if the eye on 
the side of the neuralgia is the only sound eye, the 
patient’s difficulties are much increased by having 
the eye closed, even for a few weeks, and should 
serious keratitis develop, the loss of vision will be 
tragic. Fortunately, with proper care of the eye 
from the moment of completion of the injection, or 
operation, keratitis should never develop, unless 
facial palsy or conjunctivitis are present. Facial 
palsy is not a rare complication of root resection ; 
it is associated with traction or other interference 
with the Vidian nerve as it runs beneath the ganglion. 


OTHER COMPLICATIONS 


With a ganglion injection, slowly and properly 
performed, facial palsy is very rarely seen, though 
occasionally vertigo, and nystagmus to the opposite 
side, owing to leakage of alcohol backwards to the 
internal auditory meatus, may give trouble for 
periods from a few minutes to an hour or two. Herpes 
on the upper lip and side of nose is common, both 
after injection of the ganglion and root resection, but 
it gives no real trouble and leaves no scars or post- 
herpetic pain. It is not a true zoster, and its serum 
reactions are those of herpes febrilis. Temporary 


diplopia is also met with occasionally, both after: 


injection and root resection. 

With total anesthesia of the third division, there 
is a liability for the patient to bite the lower lip, 
inside of cheek, or even the tongue, during the first 
three days. This tendency is attributable to the 
strange feeling of-the numb parts; but re-education 
is speedy, and no trouble of this kind occurs after 
the first few days, during which soft food only is 
advisable. 

In a small proportion of cases, cure of the par- 
oxysmal neuralgia, whether by injection or root 


THE SERVICES 


[JaAN. 4, 1936 


resection, may be followed by persistent burning 
sensations in cheek and eye; shooting pains may 
even be complained of, or a sensation of discomfort 
or coldness in the eye. Mostly these sensations 
appear to be of a psycho-neurotic nature. They do 
not appear at once, but a month or two after an 
operation which appears at first to have been the 
usual success. Possibly sympathetic nervous dis- 
turbance is a factor in some cases, and I have had 
one case in a young woman in whom stellate 
ganlionectomy relieved the symptoms. 


BILATERAL TiC 


In 4 to 5 per cent. of the cases similar neuralgic 
pains attack the other side; occasionally from the 
commencement both sides may suffer, though the 
pain on one side is usually much more severe at 
first; ultimately it is probably equally severe on the 
two sides, sometimes alternating. Women suffer 
from trigeminal tic much more frequently than men, 
perhaps twice as often, and when the disease is 
bilateral, the proportion of women to men is, as 
might be expected, doubled, about four to one. 

Bilateral injection of the foramen ovale, if the two 
injections are performed within three months of each 
other, will cause jaw drop, and soft food will be 
necessary. Fven though the anesthesia remains 
total and permanent, the motor roots usually recover 
in a few months, as their trophic-cell nuclei are in 
the pons. If root resection is done, the motor root 
can usually be saved, but, if it is cut, it never 
regenerates. Bilateral facial anesthesia does not 
worry the patients much, though the processes of 
eating may require practice with a mirror. 


WILFRED Harris, M.D., F.R.C.P. 


Senior Physician, Hospital for Epilepsy and Paralysis, 
Maida Vale; Consulting Physician, St. Mary’s 
Hospital, London. 


THE SERVICES 


ROYAL NAVAL MEDICAL SERVICE 


Surg. Lt.-Comdr. T. L. Cleave to President for course. 

Surg. Lts. J. M. Fitzpatrick to Enterprise; N. C. 
Hepburn, W. F. Viret, and F. H. Lamb to Pembroke for 
R.N.B.; H. G. Silvester and D. Simpson to Victory for 
R.N.B.; A. E. Ginn, D. Shute, and J. Lees to Drake 
for R.N.B.; and J. Carlton to Hood. 


ROYAL NAVAL VOLUNTEER RESERVE 


Surg. Lt. P. C. Lewis to R.M. Barracks, Plymouth. 
W.S. Walton entered as Proby. Surg. Lt. 


ARMY MEDICAL SERVICES 


Col. J. P. Helliwell, C.B.E., late A.D. Corps, to be 
Maj.-Gen. . 

Lt.-Col. J. V. M. Byrne, from A. D. Corps, to be Col. 

Maj.-Gen. J. P. Helliwell, C.B.E., from Asst. Dir.-Gen. 
Army Med. Servs. (for the Dental Serv.), to be Dir. Army. 
Dental Serv. 


ROYAL ARMY MEDICAL CORPS 


ARMY DENTAL CORPS 


The undermentioned Majs. to be Lt.-Cols. :— 

A. B. Austin, F. H. W. Beer, J. P. Duguid, A. Gibson, 
and R. J. Condie. 

The undermentioned Capts. to be Majs. :— 

W. Wormington, J. B. Cowie, M.M., F. H. R. Davey, 
F. F. Anslow, W. J. R. E. Edwards, F. S. S. Whiter, 
D. C. Blyth, F. G. Amold, R. H. N. Osmond, W. G. 
Bradbeer, and B. J. Swyer. 

The undermentioned Lts. to be Capts. :— 

H. C. Dobbie, G. M. Sinclair, H. W. South, C. E. Howell, 
K. H. Coulton, J. E. C. Robinson, and R. H. Green. 


ROYAL AIR FORCE 


The undermentioned promotions are made with effect 
from Jan. Ist, 1936 :— 

Air Commodore to be Air Vice-Marshal: Alfred William 
Iredell, K.H.P. 

Wing Commanders to be Group Captains: Gerald 
Struan Marshall, O.B.E., and Raymond William Ryan. 

Squadron Leaders to be Wing Commanders: George 
Henry Hope Maxwell, William Edward Barnes, James 
Daly Leahy, M.C., Edward Cyril Knowles Henry Foreman, 
and William John Greaves Walker. 

Flight Lieutenant Leonard Freeman is promoted to the 
rank of Squadron Leader. 

Dental Branch.—F lying Officer William Vernon Anthony 
Denney, L.D.S., is promoted to the rank of Flight 
Lieutenant. 

The undermentioned are granted short service commis- 
sions as Flying Officers for three years on the active list :— 

C. F. R. Briggs, H. D. Conway, L. M. Crooks, W. J. 
Fowler, I. K. Mackenzie, H. C. de B. Milne, D. J. Sheehan, 
and R. F. Wynroe. 

Dental Branch.—R. M. Brown and W. E. Nelson are 
granted non-permanent commissions as Flying Officers 
for three years on the active list. 


INDIAN MEDICAL SERVICE 

Lt.-Cols. P. S. Mills and D. C. V. Fitzgerald, M.C., 
to be Cols. 

The King has approved the award of the Distinguished 
Service Order for gallant and distinguished service in 
action in connexion with the recent Mohmand opera- 
tions, North West Frontier of India 1935, to Capt. F. J. 
Doherty, M.B., I.M.S., attached 5th Battalion (Queen 
Victoria’s Own Corps of Guides), 12th Frontier Force 
Regiment, Indian Army. 


THE LANCET] 


[san. 4, 1936 43 


SPECIAL ARTICLES 


MEDICAL EDUCATION AND MEDICAL 
RESEARCH* 


By W. W. C. Torrey, M.D. Camb., F.R.C.P. Lond., 
F.R.S. 


PROFESSOR OF BACTERIOLOGY AND IMMUNOLOGY IN THE 
UNIVERSITY OF LONDON AT THE LONDON SCHOOL OF 
HYGIENE AND TROPICAL MEDICINE 


td 


WE should all, I fancy, be hard put to it, if asked 
to explain what medical research means. For our 
present purpose we may take it as a convenient label 
covering a multitude of interrelated activities, all 
concerned, immediately or remotely, and sometimes 
very remotely, with the study of disease in man. 
Proceeding from this ad hoc definition, we may con- 
sider how our present medical curriculum fits people 
to work in different parts of this very extensive 
field. 

Before doing so I should like to make two things 
clear, Firstly I am, in the main, thinking in terms 
of the whole-time research worker—the man who 
intends to devote himself to research, or to research 
and teaching, as opposed to practice. Secondly, I 
am airing personal opinions with which I have no 
reason to suppose that anyone would agree. 

Words are tricky things, and I may easily fail to 
convey the meaning I intend, or to put the emphasis 
in the right place; so that I propose to start at the 
end, and state my conclusions quite clearly before I 
give my reasons for them. The theses that I am 
attempting to maintain are these: 

(1) That the present medical curriculum, in its 
usual form and including all such modifications of 
it as are in sight, however adequate it may be for 
the purposes for which it was designed, fails badly 
asa method of providing recruits for medical research, 
except, perhaps, in the strictly clinical field. 

(2) That the reason why the medical curriculum 
fails, from the research point of view, is that, except 
in the strictly clinical field, the success of a research 
worker will depend more on his knowledge of the 
basic sciences on which medicine is founded than on 
his detailed knowledge of practical medicine or surgery 
in the clinical sense. 

(3) That medical research, at least on its laboratory 
side, is not an activity that can profitably be adopted 
as an alternative to practice at some late stage of 
a student’s career, but must be consciously prepared 
for, from his earlier university days onward. 


The Background Needed for Research in 
Various Fields 


In giving my reasons for these statements, it will 
be convenient to start by taking samples of different 
kinds of research workers, and considering the things 
they must know in order that they may work 
etlectively. 


CLINICAL RESEARCH 

To preserve a proper sequence I am forced to start 
with a subject on which I can speak with no authority 
at all—medical research in what is, perhaps, its 
strictest sense, the acquirement of new knowledge in 
egard to disease by observations carried out at the 
bedside. The proper name for this is clearly clinical 
research. Speaking as an outsider, it has always 
seemed to me that clinical research, in the true sense 


* Based on an address delivered to the Cambridge University 
Medical Society on Oct. 23rd, 1935. 


of that term, demands a combination of qualities, 
and a breadth of knowledge, of a very exceptional 
kind. It may, I think, be laid down as an axiom 
that no one is likely to make any real advance in 
our knowledge of disease unless he has the scientific 
outlook—science and pseudo-science are poles apart. 
Pseudo-science is even harder to define than medical 
research ; but since it is a very horrid and insidious 
intellectual infection, to which we medicos are freely 
and frequently exposed, it may be worth noting 
some of its signs and symptoms. One of the worst 
is the uncritical application to practical medicine of 
procedures derived from physiological or patho- 
logical principles under conditions where there is no 
evidence that those particular principles are applic- 
able. I suppose that the exploitation of hormones, 
or of bacterial vaccines, can supply some of the 
most fearsome examples, just as, when used as they 
should be, these reagents afford some of the most ' 
Striking instances of the scientific cure or prevention 
of disease. Another symptom of medical pseudo- 
science is a confusion of apparatus with method, a 
belief, for instance, that things done in a laboratory 
are necessarily more scientific than things done 
outside it. In the absence of a clear grasp by a 
clinical worker of the implications of laboratory 
tests, or of a close and personal liaison between 
workers in the laboratory and in the ward, this form 
of the disease can be very harmful. Perhaps the 
most insidious form in which pseudo-science can 
attack us is that of rationalisation—the tendency we 
all have to make up reasons as to why we do things, 
or why things happen, without submitting our 
reasoning to the tests of repeated observation and 
experiment that science dictates. If we give way 
to this, if we mistake a guess for a working hypo- 
thesis, and a working hypothesis for a well-established 
theory, then we are lost. 


But the scientific outlook—the determination not 
to go beyond our evidence and to test each link in 
our chain of reasoning—is much easier to maintain 
when the things we are thinking about do not matter 
very much to ourselves or anybody else. The more 
they matter, in this emotional sense, the harder it 
is to regard them as data for consideration, or problems 
for investigation, rather than as practical problems 
that have to be tackled somehow or other, and as 
quickly as possible. Now clinical medicine does 
matter very much, and I should say that the purely 
scientific outlook is, for the ordinary person, entirely 
impossible. If it were possible it would, I think, 
defeat itself; because the subject of clinical research 
is not sickness, but the sick person, and a lack of 
emotional understanding will render the clinician 
blind to half his problem. So we must make many 
demands of our clinical research worker. He must 
be able to separate from the mass of data with which 
his experience presents him those that can be dealt 
with on strictly scientific lines. These will, of course, 
often include the emotional reactions of the patient ; 
but the clinician, in his capacity of investigator, 
must try to regard them as though they were figures 
in a sum, or the results of titrations, or steps in an 
argument. But also, and at the same time, he must 
do the best he can for his patient, and this means 
that he must often use measures which, as a scientist, 
he would regard as based on a very doubtful founda- 
tion of ascertained fact. The thing can be done. It 
has been done, and done supremely well by some of 
the great clinicians. It is of the utmost importance 


44 THE LANCET] 


MEDICAL EDUCATION AND MEDICAL RESEARCH 


‘ 


[yan. 4, 1936 


to medical science that it should continue to be 
done well in the future. But it demands a clarity 
and adaptability of mind of a very high order. I 
think, also, though here I speak with the greatest 
diffidence, that this field of work in the future is 
going to make even greater demands than it did in 
the past, when so much of the purely clinical terri- 
tory remained unmapped. I should guess that it 
will not be easy for the clinical investigator of the 
future to go very far unless he is a master of some 
special technique which, in its essence, is non-clinical, 
though it is applicable to clinical problems. Or, 
perhaps, it would be truer to say that the man who 
relies on clinical methods alone—clinical in the 
restricted sense—will find his field of activity greatly 
restricted, while the man who has mastered some 
ancillary technique, chemical, or physiological, or 
pathological as the case may be, in addition to his 
clinical training, will find problems in plenty waiting 
for solution. I do not, of course, mean that he must 
. be a chemist, or a physiologist, in the broad sense, 
as well as a clinician—that, I suspect, would be an 
impossibility. But, if he is to work in any of those 
borderlands that call so urgently for exploration, he 
should be expert in that limited non-clinical field 
which he hopes to apply in his clinical studies. Of 
one thing I feel very sure, clinical research in the 
true sense will never consist in engaging other people 
to make a host of tests and examinations, using 
techniques which one has not mastered oneself, and 
then trying to add the results together. It is, of 
course, obvious that there are medical problems 
that demand for their solution the application of 
methods drawn from several different branches of 
science. But the proper method of approach to 
such problems is the method of team-work—a question 
that I hope to discuss later. Those who desire a 
more detailed and authoritative account of clinical 
rescarch than I can offer should refer to the Iluxley 
lecture given by Sir Thomas Lewis.} 


LABORATORY WORK IN HOSPITALS 


Having ventured over a frontier which, perhaps, 
I should never have transgressed, I can turn to what 
is, to me, more familiar ground. The laboratory 
worker, to use a useful generic label for the multitude 
of scientific activities that are ancillary to medicine, 
has fewer demands made upon him than has the 
research worker in the wards. He is not, in general, 
responsible for the care, or treatment, of the sick 
person, and this makes it much easier for him to 
view his facts dispassionately, and to treat them as 
data which gain significance only in so far as they 
add together to form an ordered whole on which at 
least a tentative conclusion can justifiably be based. 
But it is clear that the term ‘“‘Jaboratory worker ” 
is almost as vague and elastic as ‘‘ medical research.” 
There are those who work in the laboratories attached 
to our great teaching hospitals, and even among these 
there are significant divisions. Of clinical diagnostic 
pathology I do not wish to say much. A great part 
of it, in my personal view, belongs to the domain 
of clinical medicine rather than pathology; for 
I do not see why the clinician’s technical armoury 
should be limited to the instruments and methods 
that past generations happened to employ. The 
clinical pathologist must clearly be at least a 
competent clinician as well as a laboratory worker— 
competent in the sense of having an intimate 
knowledge of disease as it occurs in man, and an 
ability to weigh clinical evidence, though not 


21 THE LANCET, 1935, i., 723. 


necessarily the ability to obtain that evidence for 
himself. 

When we view pathology—including under that 
term bacteriology and chemical pathology—from 
the angle of the hospital medical school rather than 
from that of the ward, the connexion with the sick 
person, as such, becomes more remote. We are 
now hardly concerned at all with the fate of Mr. A. 
or Mrs. B., not at all, in our professional capacity, 
with their happiness or well-being apart from the 
particular disease from which they are suffering. 
Indeed, we never meet them as human beings. In 
so far as our humanitarian aims and aspirations 
are concerned we shall not be attempting to cure 
them of cancer, or tuberculosis, or any other malady, 
but we shall hope that, through our own efforts and 
those of the workers who follow us, the time will 
come when no Mr. A. or Mrs. B. need die of these 
particular diseases. We shall realise, moreover, 
that the more we can put the present Mr. A. and 
Mrs. B. out of our minds, and concentrate on the 
disease as apart from the individual, the more likely 
we are to contribute something at least to the solution 
of our more general problem. Inasmuch, however, 
as we are still largely concerned with disease in man, 
we shall need some clinical background, though not 
so much as the clinical pathologist requires. But, 
if our requirements decrease in terms of clinical 
experience, they increase in terms of the basic sciences. 
More and more is it becoming necessary for the 
research worker in pathology or bacteriology to 
possess a sound working knowledge of organic and 
physical chemistry. Without it, his activities will 
be very seriously limited. 


ACADEMIC MEDICAL WORK 


And now we pass to those laboratory workers 
whose spheres of activity le in universities or research 
institutes, instead of in hospitals. They form a 
continuous series that defies arbitrary division or 
classification. They range from university depart- 
ments of pathology, through the departments of 
physiology, of psychology, of pharmacology, of 
biochemistry, of biology, of chemistry, of physics, 
of mathematical statistics, and so on, their immediate 
relation to disease growing more and more remote, 
and the number of their workers who are in any way 
concerned with medical problems growing propor- 
tionately fewer and fewer. But remoteness from the 
centre does not necessarily denote inactivity or 
unimportance, Sometimes it coincides with a locus 
of particularly active growth. It does not seem to 
me unlikely that many of the major advances in 
medicine will come m the future from branches of 
science that have no immediate connexion with the 
prevention or cure of disease. It is a fairly safe 
guess, because that is the way in which all applied 
sciences have advanced; and medicine has at least 
one example it can never forget—the work and life 
of Louis Pasteur, 

It should, I think, be emphasised that there is a 
significant change in the method of approach as 
we pass from clinical medicine, through pathology, 
physiology, and biochemistry to the remoter ancillary 
sciences—ancillary so far as medicine is concerned, 
The clinician’s problems are inexorably posed for 
him. He has considerable freedom of selection 
among them, but he cannot often adapt his problem 
to his technique, he must try to develop his technique 
to cope with his problem, and even when this tech- 
nique is very imperfect ho must do the best he can 
with it. The pathologist again has many of his 


THE LANCET] 


MEDICAL EDUCATION AND MEDICAL RESEARCH 


(yan. 4, 1936 45 


problems set for him, but his choice among them is 
freer. There is less urgency in his work. He can 
neglect altogether those problems that seem to him 
to offer no hope of solution. He can make free use 
of animal experiment—indeed, pathology is following 
physiology in becoming more and more an experi- 
menta! science—and he can isolate his data and 
phenomena far more than the clinician can, concen- 
trating, if he chooses, on the study of one particular 
factor among the many that are involved in any of 
the manifestations of disease. 

When we pass from pathology to physiology— 
if, in truth, we do pass any frontier beyond a 
convenient difference in academic labelling—we 
meet with a further decrease in the part played by 
the observation of phenomena as nature presents 
them to us, and a corresponding increase in the part 
played by controlled experiment. With this change 
there comes an added freedom. to select problems in 
relation to available knowledge and technique. I 
need not enlarge on the enormous advantage of the 
introduction of new technical methods into physiology, 
or on the advances that have followed the adaptation 
of chemical or physical methods in the solution 
of physiological problems. The point to note is 
that the physiologist, when considering any problem, 
is free to think mainly in terms of technique. If 
he can devise a method of attack that offers reason- 
able hope of yielding a significant answer. he will 
be tempted to proceed. If he cannot, he will probably 
select some other problem, rather than work with 
unsatisfactory tools. I suppose that my physiological 
colleagues would agree with me that Claude Bernard’s 
words remain as true to-day as they were when 
written 70 years ago :— 

“The prudent and reasonable course at the present 
moment is to explain all that part of disease which can 
be explained by physiology, and to leave that part which 
we cannot so explain to be explained by the future progress 
of biological science.” 

Claude Bernard, it may be noted, steadfastly 
refused to recognise any division between physiology 
and pathology, beyond that incidental to an arbitrary 
system of labelling, and I think I may best express 


his outlook on the relation of experimental science > 


to clinical medicine by a further quotation, which 
occurs in the same passage of the same book. 

“But if, instead of this, some delusive approach of 
physiology gives rise to the ambition to explain pre- 
maturely at one step the whole of the disease, then one 
loses sight of the patient, one gets a wrong idea of the 
disease, and, by a false application of physiology, experi- 
mental medicine is hindered instead of being assisted in 
its progress.” 

That, also, is as true to-day as it ever was. 

Is it necessary for the physiologist, or the experi- 
mental pathologist, to have any detailed acquaintance 
with practical clinical medicine? For the moment 
I would merely note that the necessity is clearly 
much less than in the case of the clinical pathologist 
or the morbid anatomist. When we come to the 
biochemist, the experimental biologist, the chemist 
without the bio-, and the physicist, we are on rather 
different ground. In none of these instances is 
there any reason beyond inclination for the research 
worker to concern himself with medical problems in 
any shape or form. If he does so, it will be, or should 
be, because the knowledge and technique at his 
disposal are of a kind that are ripe for application 
to some problem of scientific medicine in its broadest 
sense. One implication is, I think, obvious. In all 
these fields the value of a man’s contributions to 
medical research will depend mainly on his ability 


as a chemist or a physicist. How much medicine 

must he know, or how much biology? It will be 

ae convenient to consider that question a little 
ter. 

I have not, I am sure, exhausted the field of medical 
research in these brief glances at different parts of it. 
I have not, for instance, discussed the important 
subject of psychology, nor the study of the diseases 
of herds that is the domain of the epidemiologist. 
But it will, I think, be apparent that the territory 
covered is of very wide extent; and we should, I 
take it, all agree that any wise policy that takes the 
long view must aim at keeping the whole of it healthy, 
and active, and coordinated. 


The Modern Team 


This brings us naturally to the question of team- 
work; and successful team-work is, I believe, the 
only method that will enable us to advance rapidly 
and surely. The range of knowledge required for 
the solution of most of the problems that face us is, 
I think, beyond the command of any one man, or 
of any group of men trained in the same technique. 
The teams will vary in their character and com- 
position according to the particular field in which 
they are working. At one end of the scale the 
clinically trained members of the team will be the 
dominant partners, doing most of the work and 
seeking help from their non-clinical colleagues. At 
the other end of the scale there will be teams with 
no clinically trained members at all. In between 
there will be every kind of gradation according to 
the knowledge and technique that each problem 
demands. 

I do not want to give an impression that, in regard 
to this question of team-work, I am merely painting 
a picture of what may be in years to come. I am 
giving a picture of things as they are to-day. In 
seeking illustrations it is easier for me to take them 
from the ground I know best—the middle ground 
where pathology and the basic sciences are both 
involved, but clinical medicine does not come pro- 
minently into the picture. 

The two great institutes of medical research in 
this country—research as apart from teaching—are 
the National Institute for Medical Research at Hamp- 
stead, and the Lister Institute of Preventive Medicine 
at Chelsea. If you look at the reports of these 
institutes for last year, 1934, and glance through the 
degrees and qualifications of the scientific staff and 
workers, you will note the following figures. 

At the National Institute for Medical Research there 
were 36 workers: of these 13 had a medical degree or 
diploma, 3 had a veterinary diploma, and 20 had a science 
degree but no medical qualification. 

At the Lister Institute there were 27 workers: of 
these, 11 had a medical degree, while 16 had not. 

Taking them together there were 24 medicals as com- 
pared with 39 non-medicals. 

The non-medical workers were, in fact, about half 
as Many again as those with a medical qualification. 
And it should be noted that the non-medicals— 
mainly chemists and biochemists, with some biolo- 
gists and a few physicists—were not in any sub- 
ordinate position, assisting those who happened to 
be medically qualified with the problems on which 
the latter were engaged. They included, and include, 
heads of divisions and departments; and they 
number among them some of the most distinguished 
scientific workers in our common field. That is the 
sort of world into which those of you who decide 
to devote yourselves to medical research on its 
non-clinical side, are going; though in university 


46 THE LANCET] 


departments, where the teaching of medical students 
is combined with research, you will still find a con- 
siderable predominance of medically qualified workers. 

I have extolled the virtues of team-work; and I 
have given you my reasons for believing that, for 
most of us, there is no alternative. But no human 
system is all virtue and no vice, and teams have 
their dangers as well as their advantages. The 
teams I believe in myself are loose, elastic things, 
easily and naturally modified as need arises, not 
rigid and ordered, with a set hierarchy of workers. 
Most members of a team should, I think, be tackling 
particular problems of their own, as well as those 
on which the team is engaged, though there may 
well be a call for whole-time work over a relatively 
limited period. In any case, I am very sure of one 
thing, that successful team-work depends on mutual 
understanding; and mutual understanding, like 
most things worth having, demands some effort. 
In this case the understanding that is most required 
is an understanding of other peoples’ technique, 
including in that term the way their minds work as 
well as the methods they employ. I do not mean, 
of course, a knowledge of their methods that would 
enable one to do their work oneself, but a sufficient 
acquaintance with the technical processes they 
employ, and the kind of things they do with them, 
to enable one to see a problem, if only dimly, through 
their eyes. To this kindergarten kind of knowledge 
over the general field there should, I think, be added 
a deeper knowledge of some limited part of it that 
lies adjacent to one’s own special sphere of activity. 
We must, I fear, be specialists, but the more over- 
lapping we can manage the better for us all. 


A relatively detailed knowledge of some subject 
ancillary to one’s own can be obtained only as a 
part of a planned educational syllabus; but the 
more general knowledge can most easily and pleasantly 
be grafted on a rudimentary training in the basic 
sciences by personal contacts and informal talk and 
discussion. These arise naturally among the workers 
in any research institute, or university department ; 
but they come more easily, and tend to be much more 
fruitful, if the habit is acquired early in life. You 
will be missing a great part of what a university 
has to give if you do not take every available oppor- 
tunity of discussing scientific problems with your 
non-medical fellows, whether, at the start, you know 
anything about those problems or not. 


What Kind of Curriculum 


And now we may turn to the strictly educational 
side of our subject, and inquire what kind of curri- 
culum is needed to fit a man to work in the wide and 
varied field that we have been describing. 


THE TIME LIMITS OF CAPACITY FOR LEARNING 


Here, again, I must start my argument by raising 
a question that I am ill-equipped to answer. I 
gather, from the reports of this year’s meeting of the 
British Association at Norwich, that the capacity 
for learning does not cease as soon as we had supposed, 
and that even for the fifty-or-thereabouts there is 
some hope left. But I gather also that the tests 
applied were largely memory tests, and the learning 
of languages. So far as scientific knowledge is 
concerned, I am inclined to think that, for most of 
us at least, there is little hope of acquiring facility 
in a new branch of science after the later twenties. 
I do not mean that one could not do it if it were 
possible to drop all other work and devote oneself 
wholly, for several consecutive years, to learning 


MEDICAL EDUCATION AND MEDICAL RESEARCH 


(san. 4, 1936 


the new technique, and the facts and arguments 
derived from it. My feeling is that real knowledge 
of a science is so much the result of an integration 
of thought and action that the subject has to be 
lived with for several years at least before the neces- 
sary background can be attained and the new habits 
of thought acquired. I doubt, for instance, whether 
any ordinary man can gain a working knowledge 
of chemistry, or physics, in his spare time, after he 
has completed his formal education. I know, at 
least, that my own attempts to gain such knowledge 
have been ignominious failures. 

If I am right in this, and if we accept the not- 
illiberal view that the average man cannot devote 
more than six years or so to his whole-time education, 
counting from the commencement of his university 
career, then we have those six years to allocate and 
no more. The research worker will, of course, go 
on learning all his life, indeed, his learning in this 
sense will hardly have commenced by the time that 
his six years are over; but he will be building on 
foundations that have been fixed during his student 
years, and he will not usually be able to acquire new, 
or different, ones. 

It is, then, quite useless to plan our curriculum 
for the medical research worker as though his mind 
were a limitless receptacle, into which one could pour 
a large volume of a standard mixture of educational 
ingredients, leaving room for the addition of more 
detailed and specialised knowledge of the basic 
sciences, as and when required. By the time his 
six years are over he will be an embryo clinician, or 
physiologist, or chemist, or physicist, or so on. He 
will be one of these things, not allof them. He may, 
it is true, have developed along a line that winds 
across one of these arbitrary frontiers; but if, for 
instance, he has grafted a general knowledge of 
physiology on to a basic foundation of chemistry, 
the lines of his future development will be no less 
clearly marked. 


The Merits and Demerits of Vocational 
Medical Training 


Now it is surely clear that the medical curriculum, 
as we know it to-day, cannot possibly cope with the 
educational problem that presents itself. It was 
never meant to. It was designed, and rightly 
designed, as a vocational training for men and women 
who desire to practise medicine, to undertake certain 
duties to the individual and to the State, and to 
enjoy the privileges conferred by a registrable quali- 
fication. To obtain this qualification, by all but a 
very few of the available avenues, takes practically 
the whole of the six years that we have allowed for 
whole-time study. Let us take the thing as it 
stands, and see how it meets, or fails to meet, the 
requirements of the different classes of research 
workers that we have referred to. 


FOR THE CLINICAL INVESTIGATOR 


As regards the clinical investigator I have little 
to say, because I do not know. I should guess, as I 
have said, that he will gain very greatly by having 
carried some preclinical scientific subject well 
beyond the stage prescribed by the ordinary medical 
curriculum. He will gain in two ways. He will 
have acquired a knowledge and technique that he 
can develop and apply in later years, and, what is 
probably more important, he will have studied some 
subject sufficiently deeply to have approached the 
critical stage, and to have gained some insight into 
scientific method. He will thus attack his clinical 


THE LANCET | 


studies with a certain ingrained scepticism, a habit, 
more or less developed, of sifting evidence, that will 
ao him to make better use of his years in the 
wards. 

Is this all that is required ? I should not venture 
on an answer; but I may quote from the address 
by Sir Thomas Lewis to which I have already referred. 
He says: 

“. . . there is room for a university degree in medical 
science, which should not include medicine, surgery, or 
other branch of medical practice as such, but should 
centre upon disease, as this is studied in human beings ; 
and this degree should be intended to mark those con- 
templating an academic career.” 


He is speaking here of a degree in scientific clinical 
medicine grafted on a modified curriculum that has 
led to a registrable qualification; and, clearly, a 
licence to practise is essential for the man who wants 
to become a clinical investigator. I would ask you, 
however, to remember his suggestion, which. seems 
to me an eminently wise one, in view of a possible 
extension of it which I propose to discuss later. 


FOR THE PATHOLOGIST AND BACTERIOLOGIST 


In regard to the pathologist or the bacteriologist, 
it is, as I have already said, my firm conviction that 
he will be at a serious disadvantage if he has not 
obtained a firm grip on some experimental science 
before he studies clinical medicine. I suffer from 
that disadvantage myself and I know what it means. 
It may be urged that a man does not, in fact, make 
up his mind that he wants to become a pathologist 
until he has completed, or almost completed, his 
medical education. But I fear that in the majority 
of cases he will then have made up his mind too 
late, unless he is prepared to spend a year or two 
learning what he could have learned more easily 
at an earlier stage in his career. Is it essential that 
every pathologist in the future should hold a medical 
qualification ? Is it really necessary that he should 
devote three years out of his precious six to attaining 
those multitudinous items of knowledge and technique 
that the General Medica] Council and the various 
licensing bodies demand from those who are going 
to treat sick men and women? At present there 
is no escape; and it will, I should guess, always be 
wise for those who propose to study pathology in 
close contact with the ward to go through the same 
educational mill as their clinical colleagues. For the 
rest of us, whose work lies wholly or almost wholly 
in the laboratory, I am not so sure. It is true that 
one tends to undervalue what one has and to yearn 
for the unobtainable, but I know that I personally 
would gladly sacrifice much that I remember vaguely 
from my hospital days for a working knowledge of 
chemistry. 

I believe that the best solution would probably 
be for some academic pathologists to take a full 
medical curriculum, while others followed the routes 
that I am going to suggest as possible alternatives. 
The research worker is seldom isolated—it is never 
healthy that he should be—and among groups 
working in research institutes or university depart- 
ments it would be all to the good that, even among 
those who are all labelled pathologists, different 
workers should have a rather different background. 
But there must be no differentiation in regard to 
status or opportunity. By whatever road a man 
travels all posts, including the highest, must be open 
to him. At the present time the man who enters the 
pathological or bacteriological field, even on its 
academic side, without a medical qualification will 


MEDICAL EDUCATION AND MEDICAL RESEARCH 


[JAN. 4, 1936 47 


find many posts closed to him ; and this is a risk 
that few can afford to take. 


FOR THE PHYSIOLOGIST AND BIOCHEMIST 


As for the physiologist, those whom I have known 
were marked as physiologists before they approached 
a hospital ward, and were quite deliberately taking 
a medical degree as a preliminary to returning to 
the work of their choice. We know from example 
that three years in the wards, with a medical qualifica- 
tion at the end of it, is not an essential preliminary 
to the highest achievement in the physiological 
field. Js it, on the average, an advantage ? I cannot 
tell. But I am sure that such advantage as there 
is could be purchased much more cheaply; and an 
educational waste in one’s active learning years is 
not to be regarded lightly. 

The biochemist, in so far as he is concerned with 
medical problems, I should class with the physio- 
logist, and here again I would note that some of those 
whose work has contributed most notably to medical 
Science possess no medical degree. 


FOR THE CHEMIST AND PHYSICIST 


And the others, the chemists without the bio-, 
the physicists and so on. No one would seriously 
suggest that they should be forced to take a medical 
qualification. Their training in their own subjects 
will take them four years or more before they reach 
a standard that will enable them to make use of their 
knowledge in the field of medical research. How 
are we to provide for them? For many, of course, 
no provision is required. They will pursue their own 
careers, lending occasional assistance in our problems 
when these have. reached a stage at which they 
have become purely chemical, or physical, as the 
case may be. Medical science can never make 
provision within its own borders for all its needs. 
We shall always be asking for help from our senior 
colleagues in related branches of science. But it is 
quite clearly desirable that some of those who have 
mastered the technique and conceptions of one or 
other of the basic sciences should definitely enter 
the medical field and make a career for themselves 
within it. The men we want will not, and I do not 
think they should, enter this field in any position of 
permanent dependence on their medical colleagues ; 
but if they have no knowledge of physiology and 
pathology they can hardly escape that position. 
Moreover, I do not myself believe that, without 
that knowledge, they will be in a position to grasp 
the fundamentals of the problems which their basic 
training would enable them to attack. 


A Short Training in Medicine for the Scientist 


Is it altogether premature and absurd to suggest 
that there is a real need of a training in medicine 
that will not lead to a licence to practise, nor to a 
position as a clinical investigator, but will give a 
student who is already equipped with a sound founda- 
tion in one or other of the basic sciences on which 
medicine is built sufficient knowledge of disease 
as it occurs in man to enable him to turn his special 
knowledge to account in the medical field? The 
training in the wards would, of course, have to be 
preceded by an adequate training in anatomy, 
physiology, and pathology—adequate that is for 
this particular purpose. But is it really sensible to 
deny to those whose help we badly need any insight 
into clinical problems, except on the condition that 
they work through a long and overcrowded curriculum, 


48 THE LANCET] 


MEDICAL EDUCATION AND MEDICAL RESEARCH 


[yan. 4, 1936 


and jump a number of examinational fences that were 
designed for a quite different purpose ? 


The Ordinary Medical Student 


I have in this address said nothing of the man 
whose future lies in general or consulting practice, 
or in the administrative field of public health. He 
falls, I think, into another category. The choice 
has to be made. You can be a research worker or 
you can be a practitioner. I do not believe that 
you can be both. Medical science, if you wish to 
serve her, demands all your time and energies; so 
does medical practice. The choice will depend, if 
you are wise, mainly on your mental reactions, so 
far as you yourself can judge them. If you let other 
considerations weigh with you, you will risk all the 
discomforts of a square peg in a round hole. There 
are of course no hard-and-fast categories. Some 
men can be happy and succcesful either way; but 
some, I think, cannot. There are minds that have 
a natural liking for searching out unsolved problems 
and folowing them through to a finish, or as near to 
a finish as they can. The problems must be sought 
or selected, not forcibly presented; and the time 
and energy required for their solution must not be 
too greatly encroached on by a host of unrelated 
activities. Such minds will be profoundly unhappy 
if placed in an environment in which this unhurried 
continuous pursuit of some chosen problem is impos- 
sible. Medical practice is no place for them. There 
are other minds that work best under the stimulus 
provided by some insistent practical need, and that 
have the capacity of facing a multitude of problems 
at one and the same time, and enjoying the rush 
and turmoil of it all. Such minds often suffer 
boredom if forced to concentrate for long on a ques- 
tion that has no obvious practical issue. Given the 
requisite skill and sympathy, they will do well in 
practice; but in the research laboratory they may 
find themselves on foreign soil. There is no better 
or worse in it, no higher or lower. It is a question 
of temperament. No one with any sense of values 
would attempt to balance the care of the sick against 
the discovery of new facts about disease. Both 
are things worth doing, and both need doing well, 
and with one’s whole mind. 

I do not mean, of course, that no advance in 
medical knowledge comes from practising physicians 
or surgeons; that would be merely absurd. Their 
contributions have been many and important; but 
any investigations that they undertake are incidental 
to their main work, and are therefore determined 
and limited by it. They have neither the time nor 
the opportunity to tackle problems of the type we 
have been considering. | 

The practitioner’s daily work, however, presents 
him with endless opportunities for observation and 
for the accumulation of data that can be obtained 
by no one else. If his observations are properly 
made, and properly recorded, they may well be .of 
great value, to others as well as to himself. There 
is, I think, a dangerous fallacy hidden in the con- 
ventional division between medical science and 
medical art. They may be regarded as antitheses. 
This is entirely false. Some part of medicine is 
“ scientific,” in the sense that we are able to apply 
clear and definite physiological or pathological know- 
ledge in the diagnosis, prevention, or cure of disease. 
This field is rapidly enlarging, and each enlargement 
means a corresponding increase in the efficiency of 
our work. A large part of medicine would, at the 
moment, fall into the category of “art,” in the sense 


that we have as yet no “scientific °” knowledge to 
apply. But the man who neglected his art whenever 
scientific knowledge was available would be a very 
poor practitioner, and the man who does the best 
he can when facing a practical problem in the light 
of half-knowledge, or with no *‘ scientific ° knowledge 
at all, relying on his own experience and his own 
observations so far as they will take him, is a perfectly 
good scientist. The thing that matters is that he 
should realise clearly what he is doing. He must 
use science, when science can help him; and to use 
it he must have a working knowledge of it. Above 
all, he must avoid pseudo-science like the plague ; 
and that is not always easy. The scientific outlook, 
in this, which is its true sense, is just as important 
in practice as in research, 


The Curriculum Leading to Medical Practice 


I emphasised at the beginning of this address 
that I was discussing the medical curriculum as it 
affects the future research worker. In closing, I 
should like to make it equally clear that I am not 
suggesting that this is the angle from which the 
problem of future changes in that curriculum should 
be approached. It would be absurd, in considering 
any possible reforms, to allow the interests of that 
small band of men and women who intend to devote 
themselves to the academic side of medicine to 
weigh against the interests of the great mass of 
students whose future hes in practice, or in the 
administrative field of public health. All that I 
have done is to stress the importance, to the future 
research worker, of making full use of the preclinical 
years, and to suggest a possible avenue by which 
we might bring into the medical field research workers 
in other branches of science, whose entry as full 
partners is rendered difficult or impossible by our 
present system. If I were tempted to offer any 
suggestion as to the reform of the medical curri- 
culum as a whole it would be that it needs a greater 
elasticity and some degree, at least, of differentiation. 
Apart altogether from the special needs of medical 
research, I do not myself see how a single rigid curri- 
culum can possibly provide for the training of all 
those practitioners, specialists, semi-specialists, and 
medical administrators on whose activities the 
prevention and treatment of disease depends. There 
is, of course, a rapidly growing system of post- 
graduate diplomas and degrees that serve to train 
men and women for specialised medical activities, 
and these will certainly become more and more 
important in the future; but there must be some 
limit to the total curriculum. If something could 
be done to lighten the general burden, to reduce 
the number of facts and the range of technical know- 
ledge that have to be mastered by every medical 
student, so that he had a little time in which to 
think, it would, I believe, be a very great advantage 
to the profession as a whole. I have already referred 
to the suggestion of Sir Thomas Lewis that a modified 
and shortened medical curriculum might be followed, 
for those who wish to become clinical investigators, 
by a special course in scientific medicine. Could 
not this process of simplification and elimination 
during the earlier clinical years, with differentiation 
during the last year or so, be considerably extended, 
to the advantage of all concerned? But such 
questions as these lead inevitably to a consideration 
not only of medical education but of the whole 
organisation of medical practice, and I have neither 
the time nor the courage—perhaps I should say the 
bravado—to enter on so thorny a field of debate. 


THE LANCET] 


SCOTLAND.—IRELAND 


(yan. 4, 1936 49 


SCOTLAND 
(FROM OUR OWN CORRESPONDENT) 


MATERNAL MORTALITY IN SCOTLAND 


IN spite of the fact that some six months have 
elapsed since the publication of the report by two 
medical officers of the Department of Health for 
Scotland as the outcome of an inquiry into maternal 
mortality and morbidity in Scotland resentment is 
still being expressed by general practitioners here 
at what they regard as criticism of their midwifery. 
It will be remembered?! that the report analysed 
the circumstances attending the deaths of 2527 
mothers in childbirth, and estimated that 58-7 per 
cent. of these could have been avoided; 37-1 per 
cent. were attributed to some faulty technique of 
the attendant, including doctor, midwife, and insti- 
tution in this category, and 21-6 per cent. to the 
failure of the patients to obtain advice or to follow 
the advice given. A circular is now being issued to 
all county and town councils in which the Secretary 
of State for Scotland urges them to consider in what 
directions the maternity services of their area may 
be improved. As a first step he suggests that a 
survey of the local maternity services should be 
completed by Feb. 29th, 1936. The circular also 
recommends local authorities to take immediate 
effective action on certain of the recommendations 
contained in the report, particularly as regards the 
provision of antenatal services, and to consider 
whether and on what conditions the services of 
obstetricians would be made available to general 
practitioners for consultative purposes, 
| VOLUNTARY HOSPITALS 

At a meeting shortly before Christmas, Sir John A. 
Roxburgh, chairman of the Western Infirmary, 
Glaszow, described the voluntary hospital system as 
“a priceless possession.” It would be a calamity, 
he held, if the voluntary principle could not be 
maintained and developed. Much could be done 
to maintain it by coöperation with the public health 
authorities. The chairman of the Royal Hospital 
for Sick Children, Glasgow, said that voluntary 
hospitals were entitled to State recognition and 
State protection so long and in so far as they con- 
tinued to function efficiently. The voluntary hos- 
pitals recognised that they could not provide all the 
hospital services required, and were prepared to 
codperate cordially with the rate-aided hospitals. 
Recent demonstrations of the confidence felt by 
Scottish people in this system are not Jacking. The 
trustees of the estate of the late Mr. George Cuth- 
bertson, shipowner, Glasgow, have announced that 
asum of £116,000 will be allocated to various hos- 
pitals, churches, and other charitable bodies in 
Glascow. The Glasgow Royal Infirmary and Glasgow 
Western Infirmary receive respectively £10,000 and 
£9000. 

A Government commission is now sitting in Edin- 
burch to consider the whole subject of the health 
services of Scotland. $ 

DISPENSARY SERVICES IN GLASGOW 

The remarkable increase in the popularity of the 
dispensary services of Glasgow during this century 
is the more striking when we realise that this period 
has seen many additions to the avenues through which 
medical advice may be sought. Dr. A. K. Chalmers, 
in an interesting analysis contributed to the Glasgow 
Herald, attributes the flock of attendances at the 


1? Seo THE LANCET, 1935, ii., 159. 


dispensaries partly to the present drift towards the 
institutional treatment of disease, and partly to the 
gradual reduction in the numbers of the fee-paying 
classes. The figures of attendances at 13 of the 
principal dispensaries indicate that over 300,000 
“first attendances ” and ‘‘new cases,’ and over a 
million attendances were made during 1934. The 
attendances in the year 1901 were less than a third, 
and in the year 1911 little more than half those in 
1934. Dr. Chalmers estimates that a population of 
about’ 1,704,000 is now served by the dispensary 
services in Glasgow. There is unfortunately a lack 
of coöperation between. the dispensary physician 
and surgeon and the family doctor—a large proportion 
of the dispensary clientele coming to the dispensaries 
without any medical reference, and Dr. Chalmers 
fears that this tendency will impair the efficiency 
of both private and consulting practice. 


PHYSICAL EDUCATION IN SCHOOLS 

At the annual congress of the Educational Institute 
of Scotland, recently held in Glasgow, Dr. J. Jardine 
read a paper on physical education. Referring 
to intelligence tests, he said that while these had 
been of great service in educational classification, 
they provided only rough estimates of a child’s | 
natural capacity. No tests at present devised could 
differentiate temperamental manifestations or suggest 
a reason why one child was unstable and another 
stable. Dr. Jardine held strongly that the biological 
needs of the child should receive first consideration. 
He deplored what he described as the atmosphere 
of tension in the primary schools; large classes 
resulted in strain upon the teacher, and, through 
him or her, upon the children. Any system of 
education which demanded that the whole school 
day and all the evening should be given over to set 
tasks of an intellectual character was to deprive the 
child of its biological rights. 


TT 


IRELAND 
(FROM OUR OWN CORRESPONDENT) 


A NATIONAL WEALTH INSURANCE BILL 


On Dec. 18th, 1935, Mr. Sean T. O’Kelly, Minister 
for Local Government and Public Health, introduced 
a Bul to amend the National Health Insurance Acts 
and also the Widows’ and Orphans’ Pensions Act. 
The text of the Bill has since been made public. As 
concerns National Health Insurance two important 
changes are proposed. One has to do with the 
method of electing a committee of management, 
and the other is the bringing of soldiers of the per- 
manent force and members of the reserve force 
into the scope of National Ilealth Insurance as if 
they were in the sole employment of the Minister 
for Defence. At present the Unified National Health 
Insurance Society, which includes all the previous 
approved societies, is governed by a provisional 
committee of three persons appointed by the Minister. 
This provisional committee was to exist for three 
years from the coming into force of the National 
IIealth Insurance Act of 1933, and was then to be 
replaced by an executive committee of fifteen to 
be elected by the insured persons. The effect of 
the present Bill will be to establish a different method 
of appointing the executive committee than that 
contemplated by the Act of 1933. The committee 
will consist of fifteen persons, but it will not be elected 
by the insured members.: The chairman will be 
appointed by the Minister, who will also appoint 


50 THE LANCET] 
three persons to represent employers; the Trades 
Unions Congress will nominate three members ; 
five will be elected on behalf of the insured by an 
‘“ electoral college ° made up of persons nominated 
by the local authorities on behalf of the insured in 
their several areas; the committee will be com- 
pleted by the inclusion of the three trustees for the 
time being of the Unified Society. 

MASTERSHIP OF TIIE COOMBE HOSPITAL, DUBLIN 


Dr. Robert II. J. Mulhall Corbet has been elected 
master of the Coombe Hospital in succession to 
Dr. T. M. Healy, whose term of office had expired. 
Dr. Corbet is a graduate in medicine of the University 
of Dublin, and a fellow both of the Royal College of 
Physicians of Ireland and of the Royal College of 
Surgeons in Ireland. He has been assistant master 
both of the Rotunda Hospital and of the Coombe 
Hospital. The term of office as master is seven years, 
and it is hoped that during the tenure of the new 
master the hospital will move into a modern, 
completely equipped building. 


UNITED STATES OF AMERICA 


(FROM AN OCCASIONAL CORRESPONDENT) 


EMERGENCY TREATMENT OF ACUTE ALCOIOLISM 


Drs. L. S. Robinson and Sydney Selesnick who have 
to treat about 700 alcoholic patients yearly in the 
fifth medical service of the Boston City Hospital 
have devised a very rational and apparently successful 
method of treating the more severe cases of acute 
alcoholism that show coma, stupor, drowsiness, or 
ataxia, Study of the literature shows that the 
administration of carbon dioxide increases the 
respiratory excretion of alcohol, while administration 
of oxygen will save the life of rabbits that have 
received a dose of alcohol lethal to the controls. There 
is evidence that the oxygen is effective rather by 
speeding the oxidation of the alcohol than by relieving 
oxygen-want. The Boston doctors therefore have 
administered a mixture of 10 per cent. carbon dioxide 
in oxygen through an open slot mask. Blood 
chemistry observations were made before administra- 
tion and after 30 minutes’ inhalation of the mixed 
gases. The alcohol content of the venous blood was 
found to diminish more rapidly in treated patients 
than in controls. No carbon dioxide retention 
resulted from the treatment. The high lactic acid 
content of the blood of alcoholics was found to be 
unaffected by the treatment. Clinically the results 
were encouraging. Respiration became deep and 
regular almost at once. ‘The patient changed rapidly 
from a cyanotic cold person to a pinkish warm one. 
After half an hour he would breathe normally left 
to himself; also he could be aroused by painful 
stimuli. The treatment is recommended not as 
routine but as emergency treatment of acute 
alcoholism where danger of paralysis threatens life. 


SURVIVAL OF MICRO-ORGANISMS AT LOW 
TEMPERATURES 


The increasing consumption of frozen fruits and 
vegetables in this country lends interest to observa- 
tions made by the Bureau of Plant Industry (Dept. 
of Agriculture) on survival of micro-organisms at 
low temperatures. Twenty-six species of bacteria, 
yeasts and moulds were isolated from fruit that had 
been stored for three years at 15° F., and were trans- 
planted to freshly made beef infusion agar adjusted 
to pH 7:0. These slant cultures were placed in the 
16° cold-storage room at the Arlington Experiment 
Farm. After three months definite growth even at 


UNITED STATES OF AMERICA.—PARIS 


[yan. 4, 1936 


this low temperature was found to have occurred- 
in three of the transplants—all of them yeasts. 
Between five and seven months growth was observ- 
able in five more cultures. At the end of a year all 
cultures were brought into the laboratory, allowed to 
thaw out, and incubate at room temperature. All 
but 5 of the 26 species showed an ‘ exceptionally 
large amount of characteristic growth ” in 24 hours. 


PARIS - 


(FROM OUR OWN CORRESPONDENT) 


THE CAMPAIGN -AGAINST VENEREAL DISEASE IN 
GRENOBLE 


Dr. Butterlin, who is in charge of the venereal 
disease service of the Department of the Isére, gives 
an encouraging account of the progress effected in 
this Department since the introduction of a minor 
revolution in the control of prostitution and the 
provision of free treatment. While most of France 
continues to cherish hopes of the eflicacy of official 
medical control of prostitution, the authorities of. 
Grenoble have broken with this tradition and, after 
suppressing prostitution as a State-regulated pro- 
fession, have provided a central venereal disease 
service in Grenoble itself, and five branches of this 
service in other parts of the Department. The 
Grenoble service assures the strictest secrecy and is 
open every evening, with one section for men and 
another for women. The treatment given on the 
spot is controlled by serological and bacteriological 
examinations undertaken by the Department’s medical 
staff. Dr. Butterlin’s statistics for the past six years 
show that, with a great rise in the number of attend- 
ances, there has been a fall in the number of new 
cases of syphilis and chancroid. During these six 
years the annual number of attendances has risen 
from 7000 to 27,300. In 1929, 79 syphilitic chancres 
were observed. This figure rose to 144 in 1930, 
and fell in 1931 to 115. The corresponding figures 
for the next three years were 38, 30, and 41. The 
decline in the number of chancroids seen has been 
even more dramatic; from 1924 to 1929 some 
15 to 25 such cases were seen every year, but during 
the last two years chancroid has disappeared more 
or less completely. The figures for gonorrhea are 
less encouraging, presumably because of the notorious 
difficulty of diagnosing early and treating effectively 
the gonorrhoea of women. 


THE DEATH OF PROF, WALTHER 


Prof. Charles Walther, who died just before Christ- 
mas, packed into his long life most varied activities, 
although he was always the scientific surgeon. He 
brought to his studies a methodical and logical 
mentality which marked his actions whether they 
concerned research, operative technique, or adminis- 
tration. Ie was professor in the Paris faculty of 
medicine, chirurgien honoraire des hôpitaux, presi- 
dent of the International Surgical Association, and 
Grand Oficer of the Legion of Honour. Ile received 
the Croix de Guerre for his wartime services which 
included the administration of two important surgical 
centres in Paris (the Val-de-Grâce and the Pitié). 
In 1918 he was elected member of the Academy of 
Medicine, and until 1934 he was a familiar figure in 
the chair at its meetings. Ie had much to do with 
the introduction of the practice of swabbing the 
ficld of operation with tincture of iodine, and he 
made important contributions to the study of appen- 
dicitis, nerve lesions, cancer of the tongue, and local 
anesthesia with cocaine. 


THE LANCET| 


[san. 4, 1936 51 


OBITUARY 


WILLIAM COLLIER, M.D. Camb., F.R.C.P. Lond. 


Now and again there appears in a city a man 
whose life and work make an enduring impression, 
who possesses that mysterious quality, prestige, 
a quality which depends not upon worldly success 
or professional acumen, but upon a subtle combina- 
tion of ability and personality associated with a 
disinterested devotion to ideals of conduet and 
leadership which distinguish him from his fellow 
men. Such a man was Dr. William Collier, whose 
death on Dec. 21st is deeply mourned by all in Oxford 
who knew him as friend, physician, or colleague. 

Collier’s was an interesting life and a chance 
contact was responsible for his adoption of the 
profession which he subsequently came to practise 

and adorn. The youngest of five children of Henry 
l Collier of Staple- 
ford, Cambridge, 
he was born in 
1856, and after 
passing through 
Sherborne School 
he entered Jesus 
College, Cambridge, 
without any clear 
idea as to his 
future. The spirit 
of adventure which 
was a feature of 
his whole career 
led him to give 
up his academic 
course and to join 
an expedition to 
explore the possi- 
bilities of flooding 
the Sahara. In the 
preliminary recon- 
naissance by sailing 
ship of the northern 
| coasts of Africa, 
Collier was afflicted by such disastrous sea-sickness 
that he was compelled to abandon the venture, being 
landed penniless at Teneriffe. Having recovered his 
strength he attempted to secure a return passage by 
a ship sailing for England, but the captain—a cautious 
Scot—refused a cheque, and Collier was sent ashore. 
From this dilemma he was extricated by a passenger 
who voluntarily produced the passage money and 
Collier returned to England and Cambridge. Here 
by chance he met Sir George Murray Humphry, 
whose advice to control his enthusiastic and 
adventurous spirit came to Collier as something of 
ashock. Humphry suggested medicine as a possible 
career and this advice was followed, Collier taking 
a pass degree, all that was possible to him after the 
iuterruption of the African adventure. His wise 
counsellor retained a keen interest and friendship 
for the young man in after years. 

At King’s College Hospital Collier acted as dresser 
to Lister who had come to London in 1876, and on 
qualification (in 1880) he took up the post of house 
physician and pathologist at the Wolverhampton 
General Hospital. A short experience followed in 
a fashionable practice in Hastings, which he found 
distasteful and he gladly presented himself for the 
post of house physician to the Radcliffe Infirmary, 
Oxford, to which post he was appointed in 1881, 
being elected a physician to the hospital in 1885, 
and in this year he obtained his M.D. Cambridge. 


DR, COLLIER 


In 1886 he obtained the membership of the Royal 
College of Physicians to which he was elected a fellow 
in 1892. Asa physician and teacher, while conducting 
his own practice, he built up a reputation as a 
consultant among his colleagues both in the city and 
county, his work being distinguished by a wisdom, 
sympathy, and sound judgment which were character- 
istic of his matured outlook on life. As a proof of 
the high esteem in which he was held by his colleagues 
he was presented, in 1929, with his portrait painted 
by the Hon. John Collier, an exceptionally successful 
likeness which is reproduced with this obituary notice. 

An enthusiastic, vigorous, and far-sighted promoter 
of many schemes for the reform of professional, 
hospital, and social services, Collier was a generous 
opponent, quick to grasp another’s point of view, 
and with a sense of humour which never deserted 
him in debate or intercourse. He once said of himself 
that he ‘‘ had never hated any man,” a rare attribute 
in a man who was a determined fighter in any cause 
which he had taken up, but an observation to the 
truth of which all who knew him will subscribe. 
One very important service which he rendered to the 
Radcliffe Infirmary was the successful organisation 
of the 2d. Contributory Scheme in 1920, the first of 
its kind in a county rural district, a scheme which 
in the past year has produced over £40,000 towards 
hospital services in the area. In a long, active, and 
useful life Collier held many posts of distinction 
and lived to see many of his ideas realised in practice ; 
his memory and his keen interest in people and 
affairs he retained to the end, and his remarkable 
physical activity is evidenced by the fact that at 
the age of 75 he ascended the Pillar Rock in 
Cumberland. 

Dr. Collier married Anna, daughter of the Rev. Dr. 
James Legge, first professor of Chinese in the 
University of Oxford. His widow and two daughters 
survive him. Of his two sons one, Dr. W. T. Collier, 
M.C., F.R.C.P., physician to the Radcliffe Infirmary, 
died at the age of 43; the other, Lieut. Martin 
Collier, R.N., lost his life during the war. A daughter, 
Dr. Ivy Collier, died in 1927. F.G. H. 


ARCHIBALD STANLEY PERCIVAL, M.A. Durh., 
B.Chir. Camb. 
CONSULTING SURGEON, NEWCASTLE-UPON-TYNE EYE HOSPITAL 

Ture death occurred on Dec. 22nd at Shenley, 
Woking, of Mr. A. S. Percival, the ophthalmic surgeon 
who for some 30 years was a leading authority on 
many aspects, especially the mathematical ones, 
of his specialty. 

The son of Mr. Stanley Percival of The Hermitage, 
Woking, he received his preliminary education 
at Repton, proceeded to Trinity College, Cambridge, 
as a science scholar, and graduated in 1884 with a 
first class in the Natural Sciences Tripos. He went 
to St. George’s Hospital for his clinical training, 
graduated as M.B., B.Chir. Camb., and held various 
house appointments, including that of house surgeon 
at the Royal Westminster Ophthalmic Hospital. 
His experience there determined his future career, 
for shortly afterwards he was appointed ophthalmic 
surgeon to the Children’s Hospital, Newcastle-on- 
Tyne, and in Newcastle he practised as ophthalmic 
surgeon until his retiremeut in 1928. 

Percival was from the very beginning of his career 
attracted by the mathematical side of his specialty, 
and although all his elaborate work was in his own 
intention directed towards the improvement of 


52 THE LANCET] 


clinical methods and the smoothing away of difficulties 
both in diagnosis and treatment of ophthalmic 
disorders, his contributions to the subject assumed 
for their comprehension a mathematical knowledge 
and perception denied to most clinicians. Percival 
was always unaware that there are people who 
cannot read and detect at a glance the significance 
of elaborate equations, but his writings were mostly 
confined to the special journals, where the appeal 
was to an instructed audience. Ile contributed 
to the Archives of Ophthalmology, to the Ophthalmic 
Review, to the British Journal of Ophthalmology, 
as well as to the Transactions of the Ophthalmological 
Society articles on bifocal lenses and the action of 
prismospheres and decentred lenses; on the action 
and uses of prismatic combinations; on periscopic 
lenses ; on the correction of astigmatism by tilting 
spherical lenses; on colour phenomena; and on 
decentration and oblique cylinders. To the Trans- 
actions of the Northumberland and Durham Medical 
Society he was also a frequent contributor, writing 
on convergent and divergent squint, errors of refrac- 
tion in relation to headache, and faulty tendencies 
of the ocular muscles. 

In 1899 he wrote his first book entitled ‘‘ Optics, 
a Manual for Students’? which showed him 
immediately as an original worker along the mathe- 
matical side of optics, the attempt being to arrive 
at the knowledge of the laws underlying observed 
phenomena and to devise means for the attainment 
of certain results. Here Percival was a direct follower 
of Isaac Newton, and his manual, although by the 
implication of its title directed to students, was really 
an advanced mathematical treatise going far beyond 
the ordinary restrictions of algebra and geometry 
observed in any teaching text-book. For example 
a knowledge of the properties of caustics is essential 
to a due comprehension of the theory of optical 
instruments, and for spherical reflectors most of those 
properties can be studied in the generating epicycloid. 
With this object the reflector is usually referred to 
rectangular coérdinates, the first differentials of 
which define the position of the reflected ray and the 
second differentials the locus of the intersection of 
two consecutive rays. Percival materially simplified 
this complicated part of the subject by a new and 
ingenious application of mathematics. Ile published 
in 1913 a short volume, entitled ‘‘ Geometrical 
Optics,” which may be regarded as an expansion 
and simplification of the more elementary chapters 
of the earlier treatise, and those students who had the 
necessary grounding, or were not discouraged by the 
abundance of algebraic symbols, were rewarded by a 
conception of the optical problems of ophthalmology 
which might be of high value in ophthalmoscopic 
work and the correction of refractive errors. He 
also wrote a useful treatise on practical integration, 
and an elementary work on the principles of 
perspective in drawing. l 

Mr. Percival retired from practice eight years 
ago, returning to his native town of Woking. He 
married Winifred, the daughter of the late Mr. William 
Warner, who predeceased him by many years. 


FREDERIC HIBBERT WESTMACOTT, C.B.E., 
B.Sc. Vict., F.R.C.S. Eng. 


Colonel Westmacott, who died in Manchester on 
Dec. 20th, was a man of striking personality. Tis 
native town, which knew him as “ Freddic” 
Westmacott, noted his love for the military side of 
medicine, and for the law and order which goes 
with it, and will miss his presence much. Had he 


OBITUARY 


[yan. 4, 1936 


devoted himself entirely to the Army medical 
services he would have risen to high position, but 
otology and Manchester would have been poorer. 


Related to Richard Westmacott whose sculpture 
of the Good Samaritan adorns the seal of the 
Manchester Royal Infirmary, Frederic Hibbert 
Westmacott was born in 1867 at Crumpsall Grove, 
Manchester, Educated at the Grammar School 
and at Owens College, he qualified in 1890 and became 
F.R.C.S. Eng. four years later. His early clinical 
experience was acquired at the Royal Infirmary, 
the Children’s IIospital, Pendlebury, and the Barnes 
Convalescent Hospital, Cheadle. Then for a time 
he travelled in the East, going out on the Bibby Line 
8.8. Shropshire and joining in the Burma Expedition, 
for which he earned the first of his many military 
medals. Before returning to Manchester, having 
decided to adopt otology as his specialty, he spent 
a year in the aural clinics of Vienna; in his early 
days he was 
hampered for want 
of hospital beds, 
until in 1913 he 
became assistant 
aural surgeon to the 
Royal Infirmary, 
succeeded Sir 
William Milligan in 
1924, and retired 
in 1927 on reaching 
the age limit. He 
held other posts at 
the Pendlebury 
Children’s Hospital 
and St. John’s 
Hospital. After 
retiring from 
hospital work he 
carried on a busy 
private practice, 
recently spending 
some of the winter 
months at Monaco. 
For the last few 
years his health had declined, although he was 
unwilling to save himself as he might have done 


COLONEL WESTMACOTT 


{Photograph by F.W Schmidé 


Westmacott’s military life started as a private in 
the (then) 2nd volunteer battalion of the Manchester 
Regiment, later he was transferred to the local 
R.A.M.C., becoming surg.-lieut. of that corps. At 
the outbreak of war he was registrar of the local 
territorial hospital, the 2nd Western General. A year 
later when J. W. Smith relinquished the post he 
became officer in charge and spent his time between 
this hospital and the 57th General Hospital which 
served in France and Italy. Jle was for some time 
A.D.M.S. at Marseilles. The size and importance of 
the 2nd Western, to a large extent a product of 
Westmacott’s energy, may be realised from the 
235,900 patients admitted during the war, the 
107,801 medical boards held there, and the 75 medical 
oflicers who were attached to it in addition to 27 civil 
practitioners. In 1920 he was appointed A.D.M.S. 
to the reorganised 42nd (East Lancashire) Territorial 
Division, Ilis quick grasp of a situation, his sense 
of what might be improved and how to do it, combined 
with his mastery of ritual never left him at a loss 
whether in his masonic or his military work. lis 
capacity for enforcing obedience was a by-word and 
his organising capacity was seen at its best as 
chairman of the entertainments committee when the 
British Medical Association visited Manchester in 


THE LANCET] 


1929. It was during the work of that eventful week 
that he had a heart attack which made many of his 
friends anxious. 

He received many honours. The one that he 
appreciated especially was that of honorary surgeon 
to the King conferred in 1927. He was deputy 
lieutenant of the County of Lancaster, and Knight 
of Grace of the Order of St. John of Jerusalem. He 
was appointed C.B.E. in 1919. In 1904 he married 
Margaret Carlota, third daughter of Alexander 
Howden, who survives him. 


An old friend writes: ‘‘ Though holding decided 
views which he did not hesitate to advocate forcibly 
yet his obvious sincerity and his genial manner 
assisted in overcoming opposition, so that West- 
macott usually succeeded in obtaining his own way. 
A dogged perseverance obtained most of the objectives 
upon which he had set his heart. His career as a 
medical student had not been brilliant and fellow 
students smiled when he announced his intention of 
taking the F.R.C.S., yet after a slight disappointment 
at the primary examination he confounded his critics 
by passing the final at the first attempt. Another 
goal he desired was to be A.D.M.S.—the highest 
office in the A.M.S. attainable by a non-regular— 
and in the later years of the war he was appointed 
A.D.M.S. to the Marseilles area and the 42nd Division. 
He was undoubtedly a great organiser and adminis- 
trator, first as registrar and O.C. of the 2nd General 
Western Hospital and afterwards as O.C. of the 
57th B.G.H. in France. His knowledge of French 
and German proved most useful in the early days 
of the 2nd Western, when so many wounded Belgians 
and German prisoners-of-war were admitted. His 
organisation of entertainments at the B.M.A. Man- 
chester meeting of 1902 was so well remembered 
that in 1929 all the committees dealing with enter- 
tainments and transport were combined under his 
chairmanship. First-aid and ambulance work always 
had a great attraction for him; his experience as a 
judge of competitions between ambulance teams 
must have been unique. Westmacott had many 
social interests and engagements into which he 
entered with untiring energy. He-enjoyed life to the 
full and will be sadly missed by a wide circle of 
friends.” 


ARTHUR EDWARD GILES, M.D., M.R.C.P. Lond., 


F.R.C.S. Edin. 
CONSULTING SURGEON, CHELSEA HOSPITAL FOR WOMEN 

WE regret to announce the death at Welwyn, 
Herts, on Dec. 26th, of Mr. A. E. Giles, the well- 
known surgeon and gynæcologist. 

Arthur Edward Giles was the son of Mr. Samuel 
Giles of Bombay, where he was born in 1864. He 
had a varied preliminary education, being a student 
at the City of London School, the Havre Lycée, and 
the Manchester Grammar School, while he completed 
his medical training at Owens College, Manchester, 
where he entered in 1883. At Owens College he was 
Platt physiological scholar; he graduated as M.B., 
Ch.B. Vict. in 1888, and M.B. Lond. in 1891, securing 
first-class honours in obstetric and forensic medicine. 
In 1892 he proceeded to the M.D. Lond., qualifying 
for the gold medal, and then undertook a long course 
of post-graduate work in Berlin, Vienna, and Paris. 
In 1893 he took the diploma of M.R.C.P. Lond., and 
a little later that of F.R.C.S. Edin. After holding 
residential posts at the Manchester Royal Infirmary 
and the Crumpsall Ilospital, Manchester, and the 
General Lying-in Hospital, Lambeth, Giles secured 
in succession appointments to the staffs of the St. 


OBITUARY 


[yan. 4, 1936 53 


Pancras and Northern Dispensary, the Chelsea 
Hospital for Women, the Prince of Wales’s General 
Hospital, Tottenham, and the Marylebone Dispen- 
sary, and by his strenuous and enthusiastic work he 
made for himself a prominent position as a gynæco- 
logical surgeon. His connexion with the Chelsea 
Hospital for Women was a very long and valuable 
one. He was elected on the staff of the institution 
as assistant surgeon over forty years ago, and was 
consultant surgeon at his death. Through his work 
here he became a recognised authority on the tech- 
nique of gynecological surgery—possibly not so 
widely recognised as he deserved, for he was a great 
clinician, 

As a writer Giles at the earlier stages of his career 
was profuse but practical. He wrote the article on 
gynecological operations in Carson’s ‘ Operative 
Surgery,” and that on hysterectomy in Eden and 
Lockyer’s “System of Gynecology.” It would 
serve no purpose to enumerate the many clinical 
articles which he contributed at various times to our 
own pages and those of our contemporaries, but the 
communications generally arose from experiences 
in his varied institutional practice and had the stamp _ 
of personal knowledge. Early in his career he partici- 
pated with Sir John Bland-Sutton in the produc- 
tion of a book which ran through some nine or ten 
editions and the 
teaching of which 
is still essentially 
sound. This book 
—the ‘‘ Diseases of 
Women, a Hand- 
book for Students 
and Practitioners ”’ 
—set out to relate 
facts and describe 
methods in con- 
nexion with gynæ- 
cology in such a 
way that students 
might find the in- 
formation valuable 
in their training 
and practitioners 
realise the advan- 
tages to their 
patients that fol- 
lowed prompt and 


proper surgical MR. GILES 
treatment. The [Photograph by Histed 
book laid itself 


open, despite its title, to being largely a manual of 
operative surgery, so slight was the stress laid on 
the value of medical treatment, and in other direc- 
tions did not meet with universal approval, but the 
personal opinions were honestly given, and the 
teaching, within its limitations, was seen to be sound. 


In recent years Giles took a deep interest in two 
subjects loosely related to each other—namely, the 
occurrence of sterility in woman and the need for 
medical teaching on birth control. In a short book 
on sterility Giles summarised much of the accepted 
knowledge on the matter, and attempted to deter- 
mine the percentage of cases in which where a mar- 
riage had been sterile the fault lay with the male. 
He was only able to show, however, how difficult it 
must be to arrive at any certain conclusions, though 
he thought that the husband might be at fault in 
from 10 to 50 per cent. of the cases, a figure which 
clearly has little informative value. IIe estimated 
that the proportion of sterile marriages in this country 


54 THE LANCET] 


in the era succeeding the war was 10 per cent. for 
the working population and 16 per cent. for the leisured 
classes, and he closed his monograph, which con- 
tained a number of -original observations, with a 
pathological and clinical classification of the causes 
ofthecondition. His views on birth control were made 
known in an address delivered before the Manchester 
Medico-Chirurgical Society (vide THE LANCET, 1927, 
ii., 165) in which the medical and gynecological 
crounds for birth control were adequately set out 
and a clear description was given of the methods to 
be adopted. His general conclusion was to the effect 
that birth control being a necessity in certain cir- 
cumstances, and expedient in a few cases, the medical 
profession should lay down its indications and point 
out its limitations. 

During the war Giles served with the rank of 
major in the R.A.M.C., and was surgeon in charge 
of the Anglo-French military hospital at Tréport in 
1915, and civil surgeon to the Hampstead military 
hospital in the following years. At Tréport he 
suffered from an acute septicemia following an acci- 
dental wound while operating at Lady Murray’s 
hospital. At the. close of hostilities he went to 
live at Welwyn, where for many years he had 
had a week-end cottage, and was already con- 
sulting surgeon to the Queen Victoria Cottage 
Hospital. His skill as a surgeon and his unvary- 
ing kindness and courtesy to the patients greatly 
increased the utility and reputation of this small 
institution, and to the end of his life he took 
an interest in its working. While he still practised 
from his London address he lived in Welwyn, and 
was at the beck and call of the whole community 
in a consulting or operative capacity, going to the 
hospital at any hour of the night in response to calls. 
The new building of the hospital was opened in 1934 
by the Duchess of York, and he performed the first 
operation which took place in its wards. And when 
he became ill only shortly before Christmas he entered 
æ private ward of the hospital and died there on 
Dec. 26th, mourned by the whole neighbourhood. 

Giles was consulting gynecological surgeon to the 
Prince of Wales’s Hospital, to the Chelsea Hospital, 
and the Sutton and Wood Green Hospitals. He had 
served as president of the section of obstetrics and 
gynecology in the Royal Society of Medicine, and 
was a vice-chairman of the council of the East 
' London Hospital. He was a past master of the 
Drapers Company, and music was among his wide 
interests ; one of his compositions was played recently 
at a conversazione at the Royal Society of Medicine. 
He married May Hartree, daughter of the late Mr. 
A. A. Tindall. 


MEDICINE AND THE LAW 


Agranulocytosis and Amidopyrin 


AN inquest on another case of suspected agranulo- 
cytosis was held at St. Pancras Coroner’s Court on 
Dec. 27th, within a week of that recorded in our 
last issue. The victim was a man aged 47 who 
had been in poor health for two years and had been 
treated for fibrositis by diathermy, but not, according 
to his widow, by drugs until two months ago when 
he had bought a bottle containing 100 five-grain 
tablets of Novalgin. Between them husband and 
wife had consumed 91 tablets, the husband accounting 
for about 60. The widow said that she had not 
mentioned the tablets before because she did not 
think that the drug had anything to do with her 


MEDICINE AND THE LAW 


[JAN. 4, 1936 


husband’s symptoms—1i.e., shivering and sore-throat. 
Sir Bernard Spilsbury said that the microscopical 
changes in the body were remarkably like those 
of the previous case, but that it was difficult post 
mortem to prove any effects upon the blood. The 
striking absence at the autopsy of any marked change 
in the organs had made him suspicious. He was now 
satisfied that death was attributable to the drug. 
The coroner, Dr. Bentley Purchase, said that from 
the beginning the case had struck him by its similarity 
to the other, but it was not until the widow had 
mentioned novalgin that any connexion was revealed. 
Pyramidon and novalgin, though differing in their 
constitution, contained a common chemical group 
(pyrazolon). He again emphasised that though this 
type of drug was valuable its use needed great care ; 
he proposed to refer the case to the Poisons Board 
and returned a verdict of death by misadventure. 


Sale of Dentist’s Practice 


The sale of a dentist’s practice in Wimpole-street 
has raised a doubtful point of income-tax law. The 
purchase agreement specified a “ primary ° price of 
£15,000, subject to variation as subsequently explained. 
Of this sum £5000 was to be paid forthwith; the 
purchaser was to pay the balance by annual payments 
over the next ten years in the form of 25 per cent. 
of the net profits of the year ; these ten-year payments 
were to increase or diminish the ‘‘ primary’ price 
of £15,000 according as they came to more or less 
than £10,000. They were to be regarded as capital 
sums paid in respect of the purchase price. This 
arrangement gave the buyer the advantage that he 
would be paying according to the actual value of the 
practice. He sought the further advantage of 
deducting these annual payments from inccme for 
the purpose of his super-tax returns. In a particular 
tax year the payment turned out to be £886. He 
claimed that this was in the nature of income and 
not a capital sum, and that it could therefore be 
deducted in ascertaining his own taxable income. 
The Special Commissioners agreed and allowed the 
deduction. So did Mr. Justice Finlay. The Court 
of Appeal, however, took a different view last month. 
The Masters of the Rolls said the question was whether 
the purchase agreement contemplated the payment 
of a sum of money (payable in instalments or other- 
wise) or an annuity. The agreement fixed £15,000 
as the purchase price from beginning to end; the 
ten-year percentage payments might have the effect 
of varying the total of this lump sum, but they did 
not alter the legal position. They were not annuities 
but instalments of a definite lump-sum price. It 
followed that the £886 could not be treated as income. 
It was capital and it could not be deducted from 
income for purposes of super-tax return. And now 
the experts who assist professional men over the 
purchase of a practice will perhaps turn back to the 
idea of payment in the form of annuities. It will 
depend on whether they are advising a prospective 
buyer or a prospective seller, The seller in the 
Wimpole-street case would probably have been 
surprised if income-tax had been claimed from him 
on the instalments of the purchase price. 


ns "i Din 


ROYAL PORTSMOUTH JIOSPITAL —Over £79.000 has 
been spent upon extensions to this hospital. Subscrip- 
tions received during the year amounted to over £7000 
bringing the total sum collected to over £75,000, while 
about £10,000 more has been promised. Three of the 
wards of the new block have been in occupation for 
some months, 


THE LANCET] 


[san. 4, 1936 55 


CORRESPONDENCE 


ROYAL MEDICAL BENEVOLENT FUND 
To the Editor of THE LANCET 


Sirn,—I have once more the pleasant duty of 
thanking you for the help you have given the com- 
nittee of the Royal Medical Benevolent Fund in 
respect to the Xmas gifts for our beneficiaries. 

The response of our medical brethren has been 
very prompt and generous, the amount raised is 
£819 4s. 3d., an increase of £148 9s. over last year. 

The replies of the beneficiaries are, many of them, 
pathetic, indicating how this gift has been most 
useful in respect to fuel, and other Xmas comforts. 

Believe me, 
Yours sincerely, 


Wimpole-street, W., Jan. Ist, 1936. THos. BARLOW. 


PAIN AND EUTHANASIA 
To the Editor of THE LANCET 


Sır — You have been admonished by Dr. Piney for 
opening your columns to the discussion of voluntary 
euthanasia. There is little doubt that the general 
practitioner, on whose shoulders falls the responsi- 
bility of seeing these unfortunate patients through 
the penultimate stage of their illness, and who can 
speak with authority on the matter, is deeply 
interested in the subject. There is, moreover, a large 
section of the lay public who read THE LANCET and 
look for intelligent guidance from medical men on a 
subject which concerns the community as a whole. 

Mr. Bankart and Prof. Rogers remind the medical 
profession of another palliative measure to relieve 
pain, namely, chordotomy, but all practical surgeons 
are familiar with this procedure, and equally familiar 
with the extremely limited scope of this operation. 
Their reminder is given with a bland assurance which 
is apt to mislead, and to leave the impression that 
with chordotomy the problem is solved. Only too 
well we know that for cancer of the tongue and 
pharynx, of the thyroid and larynx, and of that 
terrible disease, cancer of the esophagus, chordotomy 
is impracticable. 

There is a widespread belief that incurable and 
lingering cases of fatal disease are ministered to by 
trained and sympathetic nurses and by every resource 
that can be devised by medical science in hospitals 
or homes for incurables. The hideous truth is that 
the majority of these cases are discharged from 
hospital and terminate their pitiable existence in 
working-class homes or even in slum dwellings. Even 
in hospitals, when all cases which can be given 
effective palliative treatment have been discounted, 
there still remains a residuum, for whom alone this 
Bill is designed, the relief of whose sufferings 1s 
beyond the skill of our profession. 

The root of the matter is not the mental distress 
of relatives, nor the abstract conscientious scruples of 
those who are not themselves suffering pain; it is 
for these cases, which are alleged to be few in number, 
that a method of escape from intolerable pain of body 
and distress of mind is sought. How few or how 
many these cases may be, remains to be seen, but 
I suggest that the testimony of the family doctor is 
the most valuable on this point. It is marvellous 
with what equanimity we bear the misfortunes of 
others, comforting them with the spectacle of the 
Thief on the Cross, the duration of whose sufferings, 
by the by, was measured in hours not in weeks or 
even months, and whose punishment for his erimes 


was in accordance with the code of justice that 
obtained 2000 years ago. 
I am, Sir, yours faithfully, 
H. H. GREENWOOD, 


Member of the Consultative Council of the Voluntary 
uthanasia Legalisation Society. 
Swindon, Dec. 30th, 1935. 


LORD NUFFIELD’S GIFT 
To the Editor of THE LANCET 


Sir,—Lord Nuffield, it will be remembered, has 
already done great things for cripples. First came 
his magnificent gift of £70,000 for the rebuilding 
of the Wingfield-Morris Orthopedic Hospital in 1933 ; 
then early in 1935 he gave £60,000 to’ New Zealand, 
and soon after £50,000 to Australia, toward the dis- 
covery and treatment of children crippled or attacked 
by some crippling disability. For a long time Lord 
Nuffield has been anxious to help forward this work 
in Great Britain, in order that in every area adequate 
provision may be made for the early and efficient 
orthopadic treatment of every child, adolescent, or 
adult in need of it. And now, as recorded in your 
last issue, he has given the sum of £125,000 for this 
purpose. The major part of this sum will be allocated 
to a Lord Nuffield Central Fund which is to be applied 
at the discretion of the trustees during the next 
four or five years to develop the discovery, cure, 
and care of cripples in the various districts where 
this work is not being at present specifically under- 
taken, or is being undertaken on an entirely inade- 
quate scale. Much credit is due to the Central 
Council for the Care of Cripples that many parts 
of the country are already well organised. But 
there are districts where a great deal remains to be 
done ; their requirements will be explored and recom- 
mendations made to the trustees of the Fund for 
grants in aid of new work. 

Lord Nuffield is devoting another part of his 
benefaction to the endowment of a scholarship in 
orthopedic surgery; this is to be tenable for two 
years at the Wingfield-Morris Orthopedic Hospital, 
Headington, Oxford, with a travel period of three 
months to follow. He hopes this will attract and 
be of value to young surgeons who are specialising . 
in orthopedic surgery. It will provide an oppor- 
tunity of working in an orthopedic hospital of the 
most modern design, and with a well-established 
outside organisation for the early discovery of poten- 
tial cripples, their out-patient treatment, and their 
after-care. It is proposed that the regius professor 
of medicine of Oxford and the president of the British 
Orthopedic Association shall be on the small electoral 
body for this scholarship. 

I am, Sir, yours faithfully, 
Oxford, Dec. 27th, 1935. G. R. GiRDLESTONE. 


NARCO-ANALYSIS 
To the Editor of THE LANCET 


Sir,—Recent allusions in the newspapers to the 
use in America of ‘‘ truth serum ”? ignore the fact 
that certain drugs facilitate not only the divulgence 
of carefully guarded secrets but also the restoration 
of forgotten memories. Such possibilities are of 
interest not only to the criminologist but also to the 
psychiatrist. The successful combination of narcosis 
with psychotherapy would be a real advance in mental 
treatment, Many writers have referred to the value 
of such a combination, but so far as I know the 


56 THE LANCET] 


PLEURAL SHOCK AND/OR AIR EMBOLISM.—ATEBRIN POISONING 


[san. 4, 1936 


narcopsychological approach has not progressed 
beyond the method of simple suggestion. This is 
due to the stupefying effect of the narcotics employed. 


In an attempt to extend this line of investigation, 
I have experimented with Somnifaine, Sodium 
amytal, Sodium soneryl, Nembutal, and a combina- 
tion of Evipan with Avertin. I find nembutal the 
most effective in producing sedation with the minimum 
of confusion. I have evolved a technique which 
I call “ narco-analysis.”’ 

The usual routine examination is made and the 
patient is then prepared as for a general anesthetic. 
A state of light narcosis is produced by the slow 
intravenous injection of a 2} per cent. solution of 
nembutal. During the injection every effort is made 
to make the patient amenable to hypnotic analysis. 
The resulting willingness of the patient, the release 
of inhibitions, and the ability to recall experience, 
recent or remote, makes analysis relatively simple 
and speedy. In an hour the physician obtains a 
quantity of relevant information which he would 
not have obtained in a month by ordinary methods. 
A true hypnotic state is induced, and this facilitates 
suggestion, which must be given with great care and 
forethought. It is directed in all cases towards 
restoring the contact of the patient with the realities 
of his hfe and environment. 

The séance is prolonged for about half an hour 
and then merged into deep narcosis by a further 
injection of nembutal. The same technique can be 
repeated if necessary on successive days. The 
following is a typical case :— 

A single woman, aged 37, was brought to hospital for 
temporary treatment under Section 5 of the Mental 
Treatment Act, 1930. The recommendations stated that 
for six weeks she had been abnormally depressed, deluded 
as to her identity, and grossly disorientated. A week 
after admission her condition was unchanged. Narco- 
analysis was begun on the eighth day. She at once 
became calm and codperative, and recalled significant 
forgotten memories which were of value in re-establishing 
environmental contact. Two séances secured a total of 
50 hours’ sleep. On waking she described a dream 
symbolising her recovery. From this moment sho 
remained bright, cheerful, and amenable. A fortnight 
later she was discharged recovered. 


This case is illustrative of some 130 treated by the 
same method. The results have been encouraging 
in all of them, and I hope in due course to report the 
results in detail. Iam indebted to Dr. P. W. Bedford, 
medical superintendent of this hospital, for permission 
to publish the above case. 

I am, Sir, yours faithfully, 


J. STEPHEN JIORSLEY, 


Senior Assistant Medical Officer, 
Dorset Mental Hospital. 


Dec. 10th, 1935. 


PLEURAL SHOCK AND/OR AIR EMBOLISM 
To the Editor of THE LANCET 


Sir,—Whilst agreeing with the conclusion reached 
in the editorial article in Ture LANCET of Dec. 28th— 
namely, that this accident of artificial pneumothorax 
may well be avoided altogether by careful technique— 
I do not think the methods suggested are necessary 
or even wise, nor do I think the usual mechanism 
of air embolism can be that which you describe. As 
this complication occurs more frequently during 
refills than during inductions, it does not seem very 
likely that it is caused by puncture of the lung or 
of an adhesion, both of which must take place much 
more frequently during the first attempted injection 
than later. Even from a mechanical point of view 
this seems an unlikely accident. Most apparatus is 


reasonably airtight, and the volume of air contained 
in the accessory tubing must be a good deal less 
than 75 c.cm., but let us suppose for the sake of 
argument that this large volume of air is contained in 
the tubing, and let us further suppose that the suction 
in the vein entered is equal to a pressure of 13 cm. 
of water or 1 cm. of mercury. It is of course most 
unlikely to be so high, as experience of manometer 
readings shows that records of this order are never 
obtained except when the point of the needle is in 
the pleural cavity. Experience also shows that 
there is considerable resistance even in a fairly wide 
bore needle, which damps manometer fluctuations 
and obstructs the rapid flow of air, but let us ignore 
this resistance. The volume of the air therefore in 
the tubing will expand under the reduced pressure, 


7 
and a volume 75 x 75 —75 = 1le.em. of air will be 


free to enter the vein. Is it possible for so small a 
quantity of air, after being churned up and partly 
absorbed by the blood in the heart and great vessels, 
to cause serious symptoms? We have considered 
an extreme possibilty; in ordinary circumstances 
the volume which could in this way enter the vein 
would be far less, and moreover would enter slowly 
owing to friction in the needle. I cannot believe 
that this is the mechanism of air embolism, provided 
of course that air from the storage compartment is 
not allowed to flow through the needle before assur- 
ance is made that the point is in the pleural cavity. 

On the other band, during either inductions or 
refills adhesions may be torn by the retracting lung. 
These are, moreover, more likely to contain lung 
tissue when lacerated by the powerful retraction of 
an already partly collapsed lung, that is during 
refills, than when severed by the comparatively feeble 
pull of the almost fully expanded lung, that is during 
inductions. Spontaneous pneumothorax complicating 
artificial pneumothorax and due to laceration of an 
adhesion is not an infrequent happening. It is, 
therefore, easy to conceive of air embolism being 
caused by a tearing of an adhesion containing a 
branch of the vein, and thus allowing air from the 
pleural cavity to enter the circulation freely, in just 
the same way that air may flow from the air passages 
into the pleural cavity, should the adhesions contain 
portions of the ling in communication therewith. 

The prevention of air embolism is therefore, I 
hold, the adoption of a technique which does not 
produce extreme tension in any adhesion, unless 
this is felt to be desirable after a careful considera- 
tion of all aspects and of all dangers, and then 
taking care to ensure that this tension is not 
suddenly applied. 


I am, Sir, yours faithfully, 


C. O. S. BLYTH BROOKE, 


Tuberculosis Otlicer, Borough of Finsbury. 
Dec. 23rd, 1935. 


ATEBRIN POISONING 
To the Editor of Tur LANCET 


Simr,—I read with interest the report by Drs. 
Fernando and Wijerama of a fatal case of Atebrin 
poisoning, published in your issue of Nov. 9th. 
The followmeg case, admitted to the Mysore Govern- 
ment Mental Ilospital, Bangalore, presented neuro- 
logical and psychiatric symptoms, following the 
administration of atebrin, which may be worthy 
of notice :— 

The patient, a flabby male aged 32, was referred on 
Nov. 19th, 1935, by his medical attendant for protective 


THE LANCET] 


observation because he showed acute maniacal symptoms. 
He had been having daily attacks of malaria for the past 
three weeks, and quinine administered during the first 
week had given no relief. During the eight days before 
admission he had two pills of atebrin daily, and three 
injections of atebrin mussonate. Fever had subsided, but 
24 hours before admission he had become destructive and 
violent. | 

Physical Examination.—The patient was very restless, 
throwing about bed-clothes, and had to be restrained. He 
was deeply jaundiced. The liver and spleen were not 
palpable, and there was no evidence of hepatic pain; the 
tongue was thickly coated and the breath foul. The pulse- 
rate was rapid, 120 per minute, of low tension, irregular, 
missing one in every 10-12 beats. The apex-beat was 
within the nipple line, but a soft unconducted, systolic 
murmur replaced the first sound in the apical and pul- 
monary areas. The pupils were moderately dilated and 
reactive, but there were coarse, rapid, nystagmoid jerks, 
about 16 per minute, making it almost impossible for the 
patient to fixate. He had fine tremors of the tongue and 
hands. Speech was slow and hesitating, but there was no 
dvsphasia. The reflexes were sluggish except the knee- 
jerk, which was ++ ++. No Babinski sign. 

Mental Examination.—Restless ; psychomotor activity 
increased of both the small and large joints ; disorientated 
with reference to time and space; he would shout that 
snakes and fantastic animals were crawling on the floor, 


PUBLIC HEALTH 


[san. 4, 1936 57 


and reacted to such visual hallucinations with fear, violence, 
and emotional instability. 

Laboratory Findings—No malarial parasites found. 
Urine scanty, reaction acid, no sugar or albumen found ; 
no bile pigments or atebrin were present. Feces foul- 
smelling, but yellow and not clay-coloured. 

Progress and Treatment.—The patient was given imme- 
diately a magnesium sulphate enema, and on account of 
his restless and non-codéperative state, a paraldehyde 
enema. He passed a quieter night. He was put on daily 
injections of cyclotropin (five days) and strychnine 
gr. 1/20 b.d., and general treatment like daily warm 
sponging. His mental symptoms cleared up within three 
days and his jaundice on the seventh day. On Nov. 29th, 
11 days after admission, he was discharged recovered, 
though somewhat weak. 


The case is of interest as showing mental symptoms 
suggestive of delirium tremens (the patient was a 
total abstainer) and neurological symptoms suggestive 
of an involvement of the labyrinthine cerebellar 
extrapyramidal pathways. I have seen several cases 
of santonin poisoning with similar symptoms. 


l am, Sir, yours faithfully, 


M. V. GOVINDASWAMY, 


Superintendent, Mental Hospital, 


Dec. 12th, 1935. 
Bangalore. 


PUBLIC HEALTH 


The Two-Shift System 


THE two-shift system of employment was legalised 
in 1920, but the trade depression has discouraged 
many employers from introducing it. Two shifts 
of eight hours each are worked between 6 a.m. and 
10 P.M., so that machinery can be kept running for 
88 hours a week, though no worker is employed for 
more than 48 hours. A report issued in 19281 
contrasted the output, lost time, and Jabour turn- 
over of the same workers employed on either system. 
The hourly output of the shift workers was greater, the 
voluntary rest pauses fewer, although, as the working 
hours were shorter, the output per worker was 4 per 
cent. less than in the ordinary system. An employer 
who changed from day-work with a 48-hour working 
week to shift-work of 82 hours might expect an 
increase of output per machine of over 92 per cent. 
There was no definite advantage in either system with 
regard to the sickness experienced by the workers. 

At the present time 36,000 women and young 
persons are working in double shifts. The system 
has been very carefully examined by a departmental 
committee, particular attention being paid to the 
health and the social and home life of the workers. 
The single disadvantage, about which there has been 
no general complaint, is the relative lateness of 
certain of the meal-times. In the .morning shift, 
for example, the midday meal cannot be taken until 
2p.M. The advantages are the shorter hours, the 
greater leisure during the day, and the increased 
opportunities of fresh air and exercise. These 
led the committee to the conclusion that the system 
did not in any way injure the health of the workers. 

Moving the second reading of the Employment 
of Women and Young Persons Bill in the House of 
Commons on Dec. 17th, Mr. Geoffrey Lloyd. Under- 
Secretary of the Home Office, said that the Bil was 
to continue this scheme with certain modifications 
and safeguards. The rejection of the Bill was moved 


3? The Two-Shift System in Certain Factories. 
Smith and M. D. Vernon. 
es Nee H.M. Stationery Office. 1928. See THE LANCET, 

Y28, i., 740. : 


By Mary 


Industrial Fatigue Research Board. 


by Mr. Rhys Davies because of the increasing liability 
of young persons to accidents at their work, due to 
the greater speed of working. He objected to the 
double-shift system on this ground and because it was 
contrary to the social habits of the British people. 
The medical aspects of the system were discussed 
by Dr. Howitt, who had served as an adviser on the 
committee. He assured the House that the system 
could have no adverse effect upon the health of the 
workers. This was the opinion of the great majority 
of the doctors, welfare workers, factory inspectors, 
and supervisors, and also of the workers themselves, 
not only in evidence before the committee, but also 
in answer to inquiries conducted in the factories. 
The chief medical inspector had assured them that 
he had not had a single complaint from any worker 
on a double shift about the system. The scheme 
eliminated the long periods of overtime which were 
particularly bad for women and young persons, 
Another advantage was the greater supervision 
and the higher standard of amenities which the 
Home Secretary demanded before he would grant 
an order. The workers appreciated the break in 
the monotony of factory work given by the shorter 
hours and particularly the alternate free week-ends. 
Mr. Hollins (Lab., Stoke-on-Trent) however was 
able to cite some evidence that double-shift workers 
suffered more than day workers from headache 
and respiratory diseases. After the Home Secretary 
had given an undertaking that the Government would 
appoint an advisory committee, the second reading 
of the Bill was carried. 


HUDDERSFIELD MUNICIPAL HospitaL.—Hudders- 
field health committee are proposing to build a new 
municipal hospital in the town which, it is estimated, 
will cost about £100,000. 


LEITH Hospiran.—The managers of this hospital 
have issued an appeal for £60,000 for the reconstruction 
of its buildings. The existing medical block is to be 
demolished and a five-storey block erected which will 
contain male and female medical wards and administrative 
and sun-ray departments. 


58 THE LANCET] 


[san. 4, 1936 


MEDICAL NEWS 


University of Cambridge 


At recent examinations the following candidates were 
successful :— 


THIRD EXAMINATION FOR M.B. AND B.CHIR. 


Pari I., surgery, Midwifery, and Gynxcology.—L. J. Bacons 
R. G. Bickford, A. Binning, G. L. Broderick, S. C. Buck, 
W. A. Burnett, RK S. Castle, E. M. Darmady, R. B. Davis, 
J. ‘Diver, F. A. Doran, E. W. Dorrell, Ra C. Droop, C. H. C. 
Ferguson, 7 D. Fraser, ae N. Fulton, B. S. C. Gaster, M. H. 
Harding, E. W. Hart, F. E. S. Hatfield, C. M. Heath, A. L. 
Jackson, D. D. Keall, R. G. M. Keeling, J. W. Landells, 
D. C. Lavender, A. B. Lintott, L. N. G. Lytton, J. MacKellar, 
F. C. Maddox, D. N. Matthews, H. K. Meller, J. Minett, 
T. J. Morton, B. C. M. Palmer, J. W. Parks, W. J. E. Phillips, 
G. C. L. Pile, J. M. Ranking, G. R. Rawlings, G. Rigby-Jones, 
O.N. Roussel, H. P. Rutřell Smith, R. S. Saxton, D. R. Seaton, 
R. H. A. Swain, W. H. a a J. H. Ward, S. Ward. D. J. 
Watterson, A. S. Wigfield, J. R. C. Williams, H. T. H. Wilson, 
J. R. J. Winter, H. R. Wynne, B. J. Travers, E. H. Western, 
E. L. Wilis, and E. M. W right. 


Part II., Principles and Practice of Physic, Pathology. and 
Pharmacology. —L. J. Bacon, W. M. Beattie, N. B. Betts, K. O. 
Black, A. C. Hondt, R. E. Bonham- Carter, F. Braithwaite, 
G. L. "Broderick, Rave a W. T. Cooke, E. M. Darmadry, 
D. H. Davics, H. rs De. C. A. Dowding, R. D. Ewing, C. U. 
Gregson, G. N. StJ. Hallett, J. W. Hannay, C. Hardwick, 
J. R. G. Haree, A. E. Hartley, N. T. Holden, C. 5. 
Humphries, H. Jobnson, J. R. Kerr, J. W. Lacey, D. C. 
Lavender, J. F. Lowe, K. G. F. Mackenzie, I. W. MacKichan, 
D. N. Matthews, 5. G. Mayer, R. S. Morris, J. R. Owen, R. J. 
Porter, C. N. Pulvertaft, C G. ori A. G. Salaman., D. S. Scott, 
P. G. Scott, J. A. Seymour-Jones, A. F. Stallard, F. Stansticld, 
W. H. Valentine, H. J. Wallace, B. L. Wiliams, J. R. J. 
Winter, M. Ball, S. L. Bhatia, E. L. Willis, and W. F. Young. 


University of London 


At recent examinations the following candidates were 
successful :— 
M.S. 


Branch I, (Surgery).—T. W. Mimpriss, St. Thomas’s Hosp. 
a III. (Ophthalmology).—Jean M. Dollar, Royal Free 

osp. 

Branch IV. 


(Laryngology, Otology, and Rhinology)—W. H. 
Bradbeer, Guy’s 


Hosp. 


DIPLOMAS IN CLINICAL PATHOLOGY 


D. H. Haler, King’s Coll. Hosp. (external diploma): 
A. A. Razzak, Middlesex Hosp. 
diploma). 


and 
(academic post -graduate 


University of Durham 


On Dec. 2lst at tho College of Medicine, Newcastle, 
the following degrees and diplomas were conferred :— 


M.B., B.S.—XK. G. Scott Bavidge, F. W. Boon, M. J. Bruno, 
A. W. Chester, H. P. Clark, Dorothy M. Clarkson, J. Dagg, 
C. W. Elphick, W. A. S. Falla, S. Hurwitz, G. B. Jamieson, 
Jean D. McKellar, B. de F. Pieris a Rosenbloom, T. A. Shaw, 
and M. Taws. 


B.Hy.— Edna T. Everdell, Dorothy D. Nichol, and Eleanor 
Patterson. 

D.P.H.—E. G. Brewis, Edna T. Everdell, Dorothy D. Nichol, 
Eleanor Patterson, and Agnes A. Schotield Russell. 


L.D.S.—F. N. Hutchinson Gargett, E. M. Pickering, and 
W. Robson. 


University of Edinburgh 


On Dec. 20th the following degrees and diploma were 
conferred :— 


M.D.—John Bennet, B. S. Bindra (in absentia), tJohn 
peg E. H. Duff, tH. J. Gibson, fIsrael Gordon (in absentia), 
tJ. J. B. Martin (in absentia), H. S. E. Murray, tD. C. Osborne, 
tT. Me J. stewart, J. L. Swanston, *Mary B. Walker, and 
John White (in absentia). 

M.Ch.—tIan Aird. 


* Awarded gold medal for thesis. tHighly commended for thesis. 
tł Commended for thesis. 


M.B., Ch.B.—A. F. H. Aeria, C. 
Bannerman, E. G. Barnes, W. M. 
R. J. C. Campbell, T. 


H. Bannerman, FP. W. Q. 
Burgess, A. P. Burnett, 
M. S. Clark, A. H. Crichton, Winifred 
M. Dempster, Harold Ferguson, W. G. S. Harden, H. O. 
Howat, R. P. Jack, J. M. M. Jamieson, P. M. Kirkwood, 
R. K. M‘AllLT. A. MacGibbon, A.J. M‘isendr ‘ick, D.S.M‘ Kenzie, 
Duncan MacKenzie, K. I. E. Macleod, A. B. Milligan, T. R. N. 
Parhar, R. G. Parker, Isabella A. Purdie, A.S. L. Rac, A. N. 
Reid, R. J. S. Smith, Robert Somerville, Alfred Stern, H. H. 
Stott, and G. L. W alker. ; 


D.P.H.—T. A. Don. 


Dr. Mary Walker was awarded the gold medal for 
her thesis on myasthenia gravis, which incorporated her 
discovery of the action of physostigmine and prostigmin 
in its treatment. 


Society of Apothecaries of London 


At recent examinations the following candidates were 
successful :— 

Surgery.—\V. C. Heunis, Lond. Hosp.; J. M. Lea, Guy’s 
Hosp.; and N. O. Lueas, Univ. of Oxford and Guy’s Hosp. 


Medicine.—C. W. Mills, St. Bart.’s Hosp.; J. F. O’Malley, 
Guy’s Hosp.; and G. M. Williams, London Hosp. 


Forensic Medicine.—C. W. Mills, St. Bart.’s Hosp.; and 
J. F. O’Malley, Guy’s Hosp. 
Midwifery.—G. Kk. Coombes, King’s Coll. Hosp. ; B. Anderson, 


Charing Cross Hosp. ; and H. Bentovim, Univ. of Manch. 


The following candidates, having completed the final 
examination, are granted the diploma of the society 
entitling them to practise medicine, surgery, and 
midwifery : B. Anderson, N. O. Lucas, and G. M. Williams. 


Queen’s University, Belfast 
On Dec. 2ist the following degrees were conferred :— 
M,D.—J. C. C. Crawford, J. V. Hurford, and T. W. H. Weir 
(with commendation) ; ; and E. A. J. Byrne (in absentia). ; 


, B.4.0.—J. E. Morison (second class bonours) ’” 
s, J. P. Cosgrove, W. W. Davey, W. McKeown’ 
C: C. D. Martin, B. V. Megarry, W. D. Miles, N. J. Y. Simpson» 
Louise Skillen, and W. McL. E. Topping. 


L.D.S.—I. St. C. Alderdice and S. Hill. 


University of St. Andrews 


At a meeting of the court on Dec. 26th Mr. R. C. 
Alexander was appointed professor of surgery and Mr. 
R. S. Melville lecturer in clinical surgery. 


Mr. Alexander was educated at the University of Edinburgh 
where he graduated in arts, and in 1908 obtained the degree 
of M.B. with honours. After further study in Paris he returned 
to Edinburgh, where he became a fellow of the Royal College 
of Surgeons in 1911, and was appointed assistant surgeon to 
the Chalmers Hospital. In 1921 he went to Dundee where 
he became surgeon to the Royal Infirmary and lecturer in 
clinical surgery at the University of St. Andrews. During the 
war he served with the British Expeditionary Force, holding 
rank as major in the R.A.M.C. He is a contributor to the 
Encyclopædia of Medicine, and has written on the surgery of 
many ditferent conditions, including cysts of the liver, adenoma 
of the bile-ducts, and anuria. He is an examiner in operative 
surgery and surgical pathology for the Royal College of Surgeons 
of Edinburgh, and consulting surgeon to the Memorial Cottage 
Hospital, St. Andrews, and the County and City of Perth Royal 
Infirmary. 


Regulation of Warfare 


An international committee of the Congress of Military 
Medicine and Pharmacy has for some time been con- 
sidering the regulation of warfare, and a conference to 
discuss the subject will meet at Monaco from Feb. 10th 
to 12th. Prof. Dehousse, of Liége, will describe the 
present state of the law towards war, especially as regards 
the protection of the civilian population, and Dr. Voncken, 
director of the Office International de Documentation de 
Médecine Militaire, will discuss ambulance services in the 
war of the future. The third purpose of the meeting will 
be the establishment of an Association Universelle pour 
la Protection Internationale de VPHumanité. Further 
information may be had from Dr. Voncken, Quai de 
Plaisance, Monaco. 


Conference on Mental Health 


The National Council for Mental Hygiene is holding its 
fourth biennial conference on mental health at the Central 
Hall, Westminster, from Jan. 23rd to 25th. The Duke 
of Kent, president of the council, will open the conference 
and will take the chair at the first session when Lord 
Allen of Hurtwood and Dr. William Brown will discuss 
mental hygiene and international relations. Other 
subjects and speakers which have been announced are : 
the organisation and correlation of mental health services 
in local areas (Prof. R. M. F. Picken and Dr. T. Saxty 
Good); problems of marriage and the establishment of 
courts of domestic relations (Dr. Helen Boyle); and the 
priest and the doctor in the treatment of nervous and 
mental disorders (Dr. H. Crichton-Miller). There will be a 
symposium on education for living, comprising mental 
health, those first eight years (Dr. R. G. Gordon, Dr. Maria 
Montessori); ‘‘ moulding ” the mind, eight to fourteen 
(Dr. Emanuel Miller); and the “finished” product, 
fourteen onwards. The secretary of the council may be 
addressed at 78, Chandos House, Palmer-street, London, 
S.W.1. 


+ 


THE LANCET] 


MEDICAL NEWS.—APPOINTMENTS.—VACANCIES 


(san. 4, 1936 59 


Royal Institution of Great Britain 

On Jan. 3lst the Friday evening discourse will be 
given at 9 p.m. by Prof. Edward Mellanby, F.R.S., who 
will speak on recent advances in the treatment of disease. 
On March 10th, 17th, 24th, and 31st, at 5.15 P.M., he 
will give a series of lectures on drug-like actions of some 
foods. The address of the institution is 21, Albemarle- 
street, London, W:1. 


Lectures on Industrial Law 

The Industrial Welfare Society is arranging a course 
of lectures which will give those interested in administrative 
work in industry and commerce a practical knowledge 
of the branches of the law which they will need. The 
lectures will be given by Mr. H. Samuels on Wednesdays 
from Jan. 22nd at the headquarters of the society, 
14, Hobart-place, Westminster, S.W., at 6.30 P.m. 


British Ambulance Unit in Abyssinia 

This unit, which was originally planned for work in 
the Ogaden, has, at the express wish of the Emperor, 
now gone to Dessie. 
unit for the northern armies in Abyssinia. This change 
has incurred heavy additional expenditure. Donations 
may be sent to Sir Arthur Stanley, British Red Cross 
Society, 14, Grosvenor-crescent, London, S8.W.1, or to 
the hon. treasurer of the British Ambulance Service in 
Ethiopia (Mr. A. W. Tuke), Barclays Bank, 54, Lombard- 
street, E.C.2. 


Fellowship of Medicine and Post-Graduate Medical 

Association 

The following all-day courses will be available during 
the first two months of this year: cardiology at the 
National Hospital for Diseases of the Heart (Jan. 13th 
to 24th); proctology at St. Mark’s Hospital (Feb. 3rd to 
8th); gynecology at the Chelsea Hospital for Women 
(Feb. 10th to 22nd). Week-end courses will be held in 
heart and lung diseases at the Royal Chest Hospital 
(Jan. 18th and 19th) ; in physical medicine at the St. John 
Clinic and Institute of Physical Medicine (Feb. 8th and 
9th); in children’s diseases, Princess Elizabeth of York 
Hospital (Feb. 22nd and 23rd). On Tuesdays and 
Thursdays at 8.30 P.M., from Jan. 14th to March 5th, 
surgical tutorial classes (specially suitable for F.R.C.S. 
candidates) will be given at the National Temperance 
Hospital, and an evening course in anatomy and physiology 
(in preparation for the primary F.R.C.S. examination) 
fron Feb. 24th to April 24th, at the Infants Hospital, 
Vincent-square, S.W. Further information may be had 


from the secretary of the Fellowship at 1, Wimpole- 
street, W.1. 

Appointments 
LANGLEY, G. F., Ch.M. Brist., F.R.C.S. Eng., has been 


appointed Senior Resident Medical Otlicer at the East 
Sutfolk and Ipswich Hospital. 

MacIVER, DONALD, M.D. Edin., D.P.H., Medical Oflicer of 
Health to Walton and Weybridge Urban, and Bagshot 
Rural, Councils. 


Hospital for Epilepsy and Paralysis, Maida Vale.—The following 
appointments are announced :— 

ELKINGTON, J. ST. CLAIR, M.D. Camb., F.R.C.P. Lond., Second 
Honorary Assistant Physician ; 

NEVIN, S., M.D. Belf., M.R.C P. Lond., 
Assistant Physician; and 

Mchuissock, WYLIE, M.S. Lond., 
Assistant Surgeon. 

London County Council Hospital Staff.—The following appoint- 
ments and transfers are announced: A.M.O. (II.) = 
Assistant Medical Otticer, Grade 1l. :— 

DonaLpD, A. B., M.B. Aberd., A.M.O. (1I.), North Western ; 

Lewis, J. T. R., M.B., D.P.H., A.M.O. (II.), South Western ; 

Picton, W. H. A., B.M. Oxon., A.M.O. (II.), Park ; 

CAMPBELL, R. M., M.B. Aberd., A.M.O. (11.), Grove ; 

JaMEs, M. F., M.B., A.M.O. (II.), Brook ; 

Gipson, M. O., M. B. Glasg., D.P.H., A.M.O. (11.), North 
Western ; 

CARDWELL, E., L.R.C.P. Edin., A.M.O. (II.), Southern ; 

LIDDELL, V. L., M. A.M.O. (II.), Western ; 

BATEMAN, L. L., LB. . A.M.O. (II.), Nortbern; and 

WILSON, E. M. R., M.B., A.M.O. (II.), South Western. 


Third Honorary 


F.R.C.S. Eng., Honorary 


It thus becomes the chief Red Cross 


V acancies 


For further information refer to the advertisement columns 


Birmingham City Mental Hospital.—Jun. Asst. M.O. £350 
Birmingham and Midland Eye Hospital. —Res. Surg. O. £200. 
Baas Sellu Oak Hospital.—Jun. M.O.’s. Each at rate 


of £ 
Chad’s Hospital.—Jun. Res. M.O. At rate 


Birmingham, St. 
of £150. 

Birmingham United Hospital.—Bacteriologist and Clin. Patho- 
logist. £500. 

Holinpbroks Haspital, Wandsworth Common, S.W.—H.P. Atrate 


Charing Cross Hospital, W.C.—Hon. ue thet; 
CNR T: Royal West Sussex Hospital.—Jun. H.S 


Ə 

Connaught Hospital, Walthamstow, E.—Cas. O. £100. 
Coventry and Warwickshire Hospital.—H.S. to Aural and Ophth. 

Depts. At rate of £125. 
Croydon Mental Hospital, Upper W arlingham.—Asst. M.O. £350. 
Doncaster Royal Infirmary. —H.S. £175 
Eastbourne, Royal Eye Hospital, Pevonsey- -road.—H.S. £100. 
dana g iai Mental Hospital, Gartravel.—Asst. Physician. 


Halifax Hospital for Infectious Diseases.—Res. M.O. £350. © 
ANNE County Council.—Asst. County M.O.H., &c. 
Hove General Hospital.—Hon. Physio-therapeutist. 
Huddersfield County Borough.—Asst. School M.O. £500. 

Hull Royal Infirmary.—Cas. O. At rate of £150. 


At rate of 


- Ilford Council Maternity Home.—Res. M.O. £350. 


Institute of Ray Therapy and Electrotherapy, 152, Camden- 
road, N.W.—Part-time M.O. At rate of £100. 

Isleworth, West Middlesex County Hospital.—Res. Anesthetist. 
£400. Also Cas. M.O. £350. 

Keliering and District General Hospital.—Second Res. M.O. At 
rate of £125. 

Leeds General Infirmary.—Res. Aural Officer. £149. 

Liverpool, David Lewis Northern Huspital.—Cas. O. At rate 
of ee Also four H.S.’s and two H.P.’s. Each at rate 
(0) 

Liverpool, Mill-road Infirmary.—Res. Deputy Med. Supt. £150. 

Liverpool, Royal Children’s Hospital.—Two Res. Phy.’s and two 
Res. Surg.’s, for City Branch, Myrtle-street. Also Res. M.O. 
and Res. Sure. O. for Heswall Branch. f 

Liverpool Royal Infirmary.—Sen. _Cas. O. At rate of £120. 
Also Jun. Cas. O. and H.S. to Skin Dept. At rate 
of £60. 

Also 


London Hospital, E.—Med. Ist Asst. and Reg. £300. 
Asst. in X "Ray Dept. £100 

aono d Jewish Hospital, Stepney Green, E.—Out-patient Asst. 

London Skin Hospital, Filzroy-square, IV.—Hon. Asst. Physician. 

London University. —Readership in Surgery. £800-£ 1000. 

Manchester, Ancoats Hospital.—Res. Surg. £200. 

M euler ae Pot Hall Hospital for Children.—Res. Jun. Asst. 

e s4 ) 
Manchester Royal Infirmary.—Four H.S.’s, H.S. to Aural, 


Gyn., and Ophth. Depts., H.S. to Neurosurgical Dept., 
H.S to Orthopwdic Dept. Also four H.P.’s. Allat rate 


of “E50 

Metropolitan Hospital, Kingsland- road, i.—Res. Cas. O. £100. 

Newcastle General Lospital.—Two H.S.’s and two H.P.’s. Each 
at rate of £150. 

a upon-L'yne, Barrasford Sanatorium.—Res. Med. Asst. 
£: 

Neucastle-upon-Tyne, An a Jor Sick Children.—Res. Surg. O. 
£250. Also H.P. and H.S. Each at rate of £100. 

Nottingham General [ospital. —H.s. At rate of £150. 

Princess Louise Kensington Hospital for Children, St. Quintin- 
avenue, }V.—Clin. Asst. 

Pumy Hospital, Lower Common, S.W .—Jun. M.O. At rate 


Queen’s Hospital for Children, Hackney-road, E.—Three Ants- 
thetists. One guinea per attendance. ; 

Rochdale Infirmary and Dispensary.—Sen. H.S. £250. 

Royal Masonic Hospital, Ravenscourt Park, W.—Surgeon. 

St. Bartholomew’s Hospital, #.C.—Asst. Physician. Also Asst. 
Physician and Asst. Director to Medical Professorial Clinic. 

St. Mary’s Hospital, W.—Cas. H.S. At rate of £100. eae 


South London Hospital for Women, Clapham Common, 
Out-patient M.O. £100, 

pases A nena! Mental Hospital, Larbert—Third Asst. M.O. 

Stoke-on- "Trent, Longton Hospital.—H.S. £160. 

Swansea General and iye Hospital.—Cas. O. At rate of £150- 


£175. Also H.P. and H.S. Each at rate of £150. 
Victoria Hospital for Children, Tite-street, Chelsea, S.W .— 
Cas. O. At rate of £200. Also H.P. and H.S. Each at 


rate of £100. 

Walsall General Ifospital.—H.8. 

Warrington County Borough.—Asst. 

Mareen County Mental Hospital, 

vo 

West End Hospital for Nervous Diseases, Gloucester-gate, N.W .— 
Res. H.P. £125. 

West End Hospital for Nervous Diseases, Welbeck-street, W.— 
Hon. Clin. Asst. to Out-patient Clinic. 

Willesden Borough.—Anwsthetist. Also Throat, 
Ear Surgeon. Each £2 12s. 6d. per session. 

Worksop, Victoria Hospital.—sen. and Jun. Resident. 
of £150 and £120 respectively. 

The Chief Inspector of Factories announces Vacancies for 
Certifying Factory Surgeons at Mocbrum (Wigtown), 
Stanley (Perth), and Cheltenham (Gloucester). 


At rate of £150. 
M.O.H. £450. 
Weinwich.—Asst. M.O. 


Nose, and 


At rate 


60 THE LANCET] 


NEW YEAR HONOURS 


TuE list of honours issued on Wednesday contains 
the names of the following members of the medical 
profession :— 

K.C.V.O. 


Louis Francis Roebuck Knuthsen, C.V.O., O.B.E., M.D. 
Physician-in-ordinarv to the Princess Royal; consult- 
ing physician to the London Skin Hospital. 


Knights Bachelor 


Colonel Charles Isherwood Brierley, C.I.E., M.R.C.S., 
I.M.S. (retd.) 


Lately inspector-general of civil hospitals and jails, 
North-West Frontier Province, 


Hugh Berchmans Devine, M.S. 
Vice-president of the Royal Australasian College of 
Surgeons. 


Mangaldas Vijbhucandas Mehta, O.B.E., F.R.C.P.I. 
Medical practitioner, Bombay. 


David Percival Dalbreck Wilkie, O.B.E., F.R.C.S. 


Professor of surgery in the University of Edinburgh. 


C.B. (Military) 
Major-General F. G. FitzGerald, D.S.0., L.R.C.P.I. 


Deputy director of medical services, Eastern 


Command. 
C.M.G. 
Rupert Briercliffe, O.B.E., M.R.C.P. 


Director of medical services, Ceylon. 


Colonel Arthur Murray Cudmore, F.R.C.S. 
Surgeon to Adelaide Hospital; consulting surgeon 
of the Australian Army Medical Corps Reserve. 


C.I.E. 
Major R. S. Aspinall, F.R.C.S.E., I.M.S. 


Civil surgeon, Ajmer-Merwara and chief medical 
officer, Rajputana. 


James Cairns, 0.B.E., M.D. 


Chief medical officer, North-Western Railway, Punjab. 


Lieut.-Colonel W. R. Stewart, F.R.C.S.E., I.M.S. 
Surgeon to the Viceroy of India. 


C.V.O. 
Wiliam Gilliatt, F.R.C.S. 


Obstetrical and gynecological surgeon 
College Hospital, London. 


Howell Gwynne-Jones, M.R.C.S. 
(Dated Dec. 12th, 1935). 


C.B.E. 
Lieut.-Colonel A. M. Dick, 0.B.E., F.R.C.S., I.M.S. 


Professor of ophthalmology in the King Edward 
Medical College, Lahore. 


O.B.E. (Military) 
Surgeon-Commander F. G. Hitch, M.B., R.N. 


O.B.E. (Civil) 

Wiliam Kenneth Bigger, M.C., M.R.C.S. 

Senior medical officer, Palestine. 
Cyril Charles Herbert Cuff, l.R.C.S.E. 

Surgical specialist, Cyprus. 
Robert William Dodgson, M.R.C.P. 

Director of shellfish services, Ministry of Agriculture. 
John Griffiths, M.R.C.S., D.P.II. 

Medical offcer of the Neath rural district council. 
John Hutson, M.B.E., M.B. 

Of Barbados. 


Robert Jamison, F.R.C.S. 


Principal medical officer, Swaziland. 


to King’s 


NEW YEAR HONOURS.—BIRTHS, MARRIAGES, AND DEATHS 


[san. 4, 1936 


William Brownlow Ashe Moore, L.R.C.P.I. 


Deputy director of medical services, Hong-Kong. 


Mrs. Mary Josephine Were, L.R.C.P.I. 
Lady medical officer, Federated Malay States. 


M.B.E. 


Robert McLean Gibson, F.R.C.S.E, 
Of Hong-Kong. 


Rai Sahib Achhru Ram. 
Civil surgeon, Uganda. 


Kaikhusro Sorabji Sethna, L.M. and S. 
Health officer of the Delhi municipality. 


Miss Janet Welch, M.B. 
Medical officer, Church of Scotland Mission Hospital, 
Blantyre, Nyasaland. 


Hon. M.B.E. 
Fuad Dajani, M.R.C.S. 


Kaisar-i-Hind Medal 


Ramkrishna Narayan Parmanand, L.M. and S. 
Chief medical officer, Adams Wylie Memorial Hospital, 
Bombay. 


Births, Marriages, and Deaths 


BIRTHS 


ABpPTLAN On Dec. 7th, tbe wife of Dr. A. D. Abdullah, 

of a son. ` 

FISHER.—On Dec. 24th, at Abingdon, Berks, the wife of Dr. 
Jobn Fisher, of a son. 

IKkipp.—On Dec. 27th, the wife of H. A. Kidd, F.R.C.S. Edin., 
of a daughter. 

MULHOLLAND.—On Dec. 22nd, at Whimple, Devon, the wife of 
H. H. Mulholland, M.B. Belf., of a daughter. 

PARKINSON.—On Dee. 24th, the wife of Ellis Parkinson, M.B. 
Birm., of Wyke Regis, Weymouth, of a son. 

STARKIE.—On Dec. 24th, at Devonshire-place, W., the wife of 
E. T. W. Starkie, M.A., B.Chir., of Creaton Sanatorium, 
Nortbants, of a daughter. 


MARRIAGES 


GREENWAY—STRIDE.—On Dee. 21st, at FEastergate Parish 
Church, Dr. Geotfrey Hudson Greenway to Peggy, younger 
daughter of the late Mr. F. Stride of Barnhbam, Sussex. 


DEATHS 


ALLEN.—On Dee. 28th, at Oulton Heath, Stone, Maria Shepherd 
Allen, L.R.C.P. Edin., aged 58. 

ARUNDEL.—On Dec. 28th, at Wrecclesham, Farnbam, Robert 
James Arundel, M.D. Dub., Capt., R.A.M.C., retd. 

BALLARD.—On Dee. 23rd, at Shepherdswell, Dover, Pbilip 
Ballard, M.R.C.S. Eng., late of Smarden, Kent, in hbis 
Sist year. 

CoTTon.—On Dec. 23rd, at Sheffield, Robert Hugh Cotton, 
M.R.C.S. Eng., in his 55th year. 

DANIEL.—On Dec. 25th, at Ealing, Robert Napier Daniel, 
M.R.C.S. Eng., aged 69. 

GILES.—On Dec. 26th, at Welwyn, Herts, Arthur E. Giles, 
M.D. Lond., F.R.C.S. Edin., aged 71. 

GORDON-WATSON.—On Dec. 21st, 1935, Alice Geraldine Mary, 
dearly loved wife of Sir Charles Gordon-Watson, of 8&2, 
llarley-street, W.1, after a long and painful illness, most 
bravely borne. 

HEWETT.—On Dee. 27th, at The Wilderness, Hampton Hil, 
Lieut.-Col. Augustus Hewett, F.R.C.S. Edin. (late 
R.A.M.C.), aged 82. 

HOWELL.—On Dece. 21st, at Middlesbrough, Robert Edward 
Howell, M.B. Idin., aged 70. 

MATTUEWS.—On Dee. 28th, at a Brighton nursing-home, Gladys 
Matthews, M.R.C.S. Eng., late of the C.M.S., Punjab, India. 

PERCIVAL.—On Dece. 22nd, at Shenley, Woking, Archibald 
Stanley Percival., M.A. Durh., M.A., M.B. Camb. 

SINCLAIR.—On Dee. 23rd, at 25, Elvaston-place, S.W.7, James 
Edward Sinclair, L.R.C.P. Edin., formerly of Queen Anne’s- 
gate, and Wyndham House, Aldeburgh. 


N.B.—A fee of Ts. Gd. is charged for the insertion of Notices of 
Births, Marriages, and Deaths. 


ROYAL SANITARY INSTITUTE.—Recent develop- 
ments in sewage treatment and disposal at the London 
County Council works will be the subject of a paper 
to be read by Mr. J. H. Coste, the chief chemist of the 
Council, at a sessional meeting of this institute (90, 
Buckingham [alace-road, London, S.W.), to be held 
on Tuesday, Jan. 14th, at 5.30 P.M. aa 


THE LANCET] 


[san. 4, 1936 61 


NOTES, COMMENTS. AND ABSTRACTS 


PUBLIC HEALTH IN INDIA* 


RETROSPECT AND PROSPECT 


By Major-General Sir Joun MEGAwW, K.C.I.E., 
D.Sc., M.B. R.U.I. 


MEDICAL ADVISER TO THE SECRETARY OF STATE FOR INDIA > LATE 
DIRECTOR-GENERAL OF TBE INDIAN MEDICAL SERVICE 


Retrospect 


IN ancient times certain ceremonials and customs 
pointed to the interest taken in hygiene by certain 
classes of Indians. Eugenics have played an impor- 
tant part in the life of the Brahmins for many 
centuries. Yet for India as a whole, throughout the 
ages the one and only health officer has been Nature, 
whose methods have been excessive reproduction 
counteracted by disease and famine. Man has 
added his special checks to population in the form 
of war and infanticide. 

Little is known about the population of India in 
ancient times. One authority estimates that it was 
80 millions in 1650 and 130 millions in 1750, while 
Sir Frederick Nicholson thinks it was only about 
100 millions in 1800. Probably for thousands of 
years before 1700 the population showed mighty 
fluctuations between the figures of 30 millions and 
100 millions. 

Two new factors were introduced by Western 
influences and the spread of education. (1) The 
effort to prevent deaths from disease and famine. 
(2) The increase in production of crops and com- 
modities combined with improved distribution. Under 
these influences the population increased rapidly 
and, up to a point, the economic condition of the 
people improved. Great differences of opinion exist 
as to whether or not the people are now better off 
than they were 50 years ago, but the really important 
matter is their present condition and their future 
prospects. One basic principle is and will always 
remain the same: good standards of health and 
well-being cannot be maintained if the numbers of 
the people are excessive in comparison with the 
food-supply. 

So far as the controlled populations are concerned 
splendid results have been achieved by officers of 
the I.M.S. and R.A.M.C., as can be seen from these 
figures. : 

Death-rales 


British Indian 


= troops. troops. Prisoners. 
1859 69:0 20-0 100-0 
1875 20-0 20-0 — 
1900 13-0 11-0 35:0 
1912 4°62 4-4. — 
1933 2'44 2:39 11-2 


In the uncontrolled population similar results 
have not been possible for obvious reasons. The 
original policy of the Government of India after 
control had been taken over by the Crown about 
1860 was to avoid imposing any restrictions which 
might arouse opposition among the people, but 
instead to popularise modern medicine by opening 
hospitals and medical schools. By this means com- 
bined with the spread of general education it was 
hoped to create a spirit of goodwill towards pre- 
ventive medicine. Besides, the total revenues of 
the Governments of India would have been insufii- 
cient to set up a modern public health machinery. 
Hence attention was concentrated chiefly on vaccina- 
tion, the provision of water-supplies, and drainage 
systems. 


* An abstract of two lectures given under the auspices of 
London University at the London School of Hygiene and Tropical 
Medicine on Dec. 4th and Gth. In a previous lecture some 
of the basic principles of public health had been discussed. 


Medical research has been actively pursued in 
India and has done excellent work ; it was established 
on an organised basis long before the Medical Research 
Council was created in England. If preventive medi- 
cine had been developed on advanced lines and had 
achieved complete success, the population of India 
would probably be 500 millions instead of 370 millions. 
Where would so many people find adequate food if 
the present population is already badly nourished ? 


RESULTS OF A SURVEY 


I carried out a survey about four years ago by 
means of a questionnaire issued to 571 Indian doctors 
in dispensaries situated in typical agricultural villages 
throughout India. An analysis of the replies gave 
the following results. Under 40 per cent. of the 
people were considered to be well nourished, while 
over 40 per cent. were regarded as poorly nourished, 
and 20 per cent. very badly nourished. Few people 
had suffered from actual hunger during the previous 
five years but the evidence pointed to serious defects 
in the quality of the food, especially in the matter 
of high-grade proteins, fats, and vitamins. The 
average quantity of milk consumed daily by each 
person in India was about three and a half ounces. 
Butter in the form of ghee was taken to the extent 
of one-third of an ounce daily. 

The number of cases of the following diseases at 
the time of the survey was :— 


Millions. 


Millions. :: 
Rickets .. eg .- 2$ | Night-blindness .. 33 
Syphilis .. ave .- OF | Gonorrhoaa .. .. Tè 
Leprosy .. Re ae 2 Tuberculosis of the 
Other forms of tubercu- lung . .. 1l} 
losis .. Jt A $ Insanity aes sie + 
Congenital mental defects + ı Blindness By pie A 


In the cases of leprosy and blindness the figures 
are much higher than those shown by the census, 
but are more likely to be accurate. About 15 per 
cent. of the school-children had enlarged spleens. 
The average age at which girls begin to cohabit 
with their husbands is 14, and the average age of 
the mothers at the birth of their first child is 16. 
The maternal mortality-rate works out at about 
30 per mille against about 5 per mille in England. 
Something like ten out of every hundred girl wives 
are doomed to die in childbirth before they cease to 
have babies. 

These data are not claimed to have statistical 
accuracy as they are obtained by the process of 
random sampling and the personal equation enters 
into the replies but they are claimed to give a true 
general impression of the real state of affairs in the 
Indian villages, which of course represent the real 
India. Whether this rough-and-ready survey 1s 
accepted as being reasonably accurate or as being 
unreliable, it follows that there is an urgent need 
for a careful investigation of the situation. 


OTHER EVIDENCE 


The recent official reports show that the birth-rate 
in India remains constantly high, being about 34 per 
mille, while the death-rate shows a tendency to 
decline, being 22 per mille against an average of 
about 34 between 1901 and 1920. These figures 
suggest that a very satisfactory degree of improve- 
ment is taking place in health conditions, but on 
the other hand the population is increasing at the 
rate of 34 millions yearly in British India alone. It 
is estimated by Colonel A. J. H. Russell, public 
health commissioner with the Government of India, 
that the population of the whole of India, including 
Burma, will be about 400 millions by 1941. These 
figures raise the momentous question, will the food- 
supply be enough to nourish so many people ? From 
the survey which has been described above, it appears 
that the people must be living very close to the 
line which separates a bare subsistence from 
starvation. 


62 THE LANCET] 


Prospect 


Prophecy is notoriously unsafe, but a forecast of 
the future is essential if we are to escape from those 
disasters which give warning of their approach. 
Even if the present food-supply were regarded as 
adequate, provision would have to be made for a 
10 per cent. increase during the next ten years. 
If public health were to bring about a further modest 
reduction in the death-rate, this increase in the food- 
supply would have to be about 20 per cent. instead 
of 10 per cent. It is also reasonable to suppose 
that an immediate increase of about 20 to 30 per cent. 
may be found necessary to provide for a proper 
state of nutrition of the existing population, and to 
this would be added the recurring increase of about 
20 per cent. every ten years to feed the increasing 
number of mouths. Here is a stupendous task for 
those who are responsible for the welfare of India. 
The optimists suggest that the one and only thing 
needful is to lower the death-rate; they hold that 
the birth-rate will automatically adjust itself; 
but in India this is not happening, for, while the 
death-rate has fallen from about 34 per mille, which 
was the figure before 1920 to 22 per mille during 
the years 1932 and 1933, the birth-rate has main- 
tained a steady average of about 34 to 35 during 
the past few years and shown only a slight decline 
since the beginning of the present century. Better 
conditions of life can be secured in India by increasing 
the production of food and other commodities, by 
improving the distribution of these, and by diminish- 
ing the appalling waste which goes on; but these 
measures must fail if the increase in the population 
is more rapid than the increase in the available 
supply of commodities. If the growth of population 


continues to occur at the present rate, and the increase 


in the food-supply is not greatly stimulated, the 
available surplus must gradually dwindle away till 
there will be no money to spend on education, medical 
relief, public health, police, railway travel, com- 
merce, &c., and the country must lapse into bar- 
barism. Nature will then resume her sway and once 
more there will be a wildly fluctuating balance 
between population and food-supply. This balance 
will be struck at a much lower average level, probably 
at something like half of the present population. 


Sceptics will ask: ‘‘ Do such things happen ? 
Are these not the predictions of scaremongers ? ” 
The following two examples are given, one to show 
what has happened in the past and another to show 
what is actually happening at present. In Ireland 
the population increased from one and a quarter 
millions in 1700 to 44 millions in 1800, and again 
to more than 8 millions in 1841 when the people 
were living in conditions far worse than those of 
the Indian peasant to-day. Then famine, disease, 
and emigration caused a ruthless reduction in the 
numbers of the people, and now only about 4 millions 
can live in a modest standard of comfort. The 
present low figure is only retained by extensive 
celibacy and by greatly delayed marriage; no less 
than 80 per cent. of the males between 25 and 30 
. remain unmarried. In the case of Japan, where the 
population has doubled itself in the past 50 years, 
and where, despite industrial expansion and strenuous 
efforts in disease prevention, the death-rate is almost 
the same as in 1890, whereas it has fallen in England 
by nearly 50 per cent. during the same period. The 
infant mortality-rate has risen considerably since 
1890 in Japan, while it has fallen in England to a 
good deal Jess than half the figure of 1890. A signi- 
ficant point is that the birth-rate in Japan has risen 
appreciably and is over 30 per mille, whereas in 
England it has fallen from 31°4 in 1890 to less than 
half. These figures seem to show that public health 
actually does fail to achieve success while the popu- 
lation is growing at an excessive rate. If India were 
able to emulate Japan in the thoroughness of her 
measures for disease prevention, she could only 
expect to achieve the same results unless she provided 
a check to the rapid growth of the population. 


NOTES, COMMENTS, AND ABSTRACTS 


[yan. 4, 1936 


WANTED, A PLAN 


My aim has been to demonstrate that there is ` 
reason for grave anxiety about the present condition 
of the people of India, and still greater reason for 
alarm about the future so that a searching inquiry 
is obviously needed. But some people have no 
faith in inquiries. They agree that the people of 
India would resent any suggestion of interference 
with their customs and religions, and it becomes 
necessary to convince them that a useful purpose 
will be served by an investigation such as I have 
suggested. There can be no doubt as to the practi- 
cability of plans for increasing production and for 
preventing disease, these being two of the limbs of 
the tripod on which rests the welfare of India; the 
real doubts are about the third limb, which is the 
regulation of the population. Contrary to the usual 
belief, educated Indians are willing and even eager 
to consider any means of dealing with the evil of 
over-population. The chief prejudice is encountered 
among Europeans who wrongly imagine that Indians 
are antagonistic to any suggestion for reform of 
their ancient customs. Examples migbt be given 
to show the attitude of some western officials and 
even public health workers who refused to believe 
that there was any need for intervention or that 
intervention could serve any useful purpose. On 
the other hand, many British medical officers and 
laymen have called attention to the urgency of the 
situation. The medical research workers, for instance, 
at their annual conferences in 1923, 1924, 1925, and 
1926 unanimously adopted a resolution framed by 
the writer, in collaboration with the late Major- 
General Hutchinson, I.M.S., in which the Govern- 
ment of India was appealed to for the appointment 
of a strong commission, chiefly non-technical, to 
make a thorough inquiry into the wastage of life 
and the economic depression. 

In the report of the Royal Commission on Agri- 
culture published in 1928 it was pointed out that 
“it is the duty of Government to investigate basic 
medical problems and to enunciate and direct sound 
principles of public health administration,” also that 
“the rural problem should be attacked as a whole 
and at all points simultaneously.” In the concluding 
chapter these words appear: ‘‘ the demand for a 
better life can, in our opinion, be stimulated only by 
deliberate and concerted effort to improve the general 
condition of the country side, and we have no hesi- 
tation in affirming that the responsibility for initiating 
the steps required to effect this improvement rests 
with Government.” These weighty words have an 
added significance as representing the views of the 
Viceroy Designate. Views of Sir George Newman, 
Mr. J. H. Hutton, D.Sc.. I.C.S., Lieut.-Colonel A. J. H. 
Russell, Mr. Stanley Baldwin, and Lord Eustace 
Percy might also be quoted, showing that all these 
recognised the great urgency of the combined economic, 
population, and health problem in India. 

In his recent presidential address, Sir Gowland 
Hopkins stressed the need for a comprehensive food 
policy for England. I cordially agree that a food 
policy for England is needed. Much more urgent is 
the need for such a policy in India where it is not 
merely a question of improving unsatisfactory con- 
ditions but of saving the country from a relapse into 
barbarism. Educated Indian opinion is unanimous 
in recognising the need for reform: even the educated 
women are most outspoken in their demand for 
immediate action to lessen the strain on the bodies 
and minds of Indian girls who are compelled to 
endure matrimony at an age when English girls are 
enjoying a happy childhood. 


NATURE OF THE PLAN 


Assuming that the proposed committee of inquiry 
are to find it necessary to prepare a plan, it is 
suggested that the most effective means of dealing 
with the situation will be found to consist in educa- 
tion. There are various methods of conveying 
instruction, but chief reliance will probably be placed 


; ‘ = 
a 


THE LANCET] 


on an India-wide scheme of broadcasting. By this 
means the whole population, including the women, 
can be informed of the hard facts of the situation 
and of the steps which have been taken by other 
countries to secure comfortable standards of life. In 
this way they would come to realise the need for a 
new outlook on life. 

There is no need for pessimism, provided that 
immediate and adequate steps are taken. There are 
vast possibilities of greatly increasing the production 
of food and of eliminating waste, such as the main- 
tenance of 25 million useless cattle. The finances of 
India are in a sound condition, the burden of taxation 
very light, and the country is free from the anxiety 
which rests on nations which are highly industrial 
and therefore dependent on the caprices of world 
commerce. A concerted national effort such as has 
been made recently in England would bring prosperity 
to India, but this would be of short duration unless 
the people acquire a new outlook on life. 


NURSING IN RUSSIA 


WE have published from time to time notes on 
the new Russia from the pens of medical authors. 
Aracy account of the impressions of one of the first 
party of nurses to pay a professional visit to the 
Soviet Union, which originally appeared in the 
Nursing Times and has now been reprinted in pamphlet 
form, records observations from a different angle. 
The party—all members of the College of Nursing— 
seem to have used their ‘‘ nurse’s eyes and ears, to 
note the little significances °’ to good purpose; 
for example, they kept a sharp look-out for rickets 
and impetigo, the total count throughout the trip 
being only some three or four cases of each. Certain 
characteristics of Russian nursing emerged: (1) 
matrons’ posts as understood here, with all their 
responsibilities, are unknown ; (2) nurses are divided 
into two classes, ‘‘ medical sisters,’’ and ‘‘ nurses ”’ 
or orderlies; (3) such refinements as screens and 
sluice rooms, mops, and scrubbing brushes are not 
taken as seriously as in this country. 

The party visited by appointment the Institute 
of First Aid, Leningrad, containing 200 beds and 
specialising in acute abdominal cases. The pre- 
liminary interview with the doctors—the matron, 
if she existed, was not brought forward—revealed 
that the hospital undertakes research work in acute 
abdominal cases and compiles mortality and morbidity 
statistics for general reference. Its findings as to the 
best time to operate on an acute appendix, for example, 
are promulgated all over the Union. It is called a 
“first aid station ’’ because it is open night and day 
and takes in the accidents and emergencies of the 
district it serves. It has no out-patient department 
as such. If a worker in the district falls ill he tele- 
phones to the hospital doctor to come and visit him in 
his home, and if he requires hospital treatment— 
there is not much home nursing in Russia—he is 
brought in the ambulance. All workers are made 
thoroughly aware of the medical facilities in their 
neighbourhood. As working hours are short in 
Russia, and hardly any of the doctors or nurses 
live in, the staff is large. This hospital of 200 beds 
employed 20 doctors, 30 ‘‘ medical sisters,” and 16 
auxiliaries called ‘‘ nurses.” There is no distinguish- 
ing uniform. Everybody ties a starchless overall 
over their outdoor clothes, and a limp white handker- 
chief over their hair, and everybody wears list slippers 
(with or without stockings), the slippers often being 
secured by tape. The medical sisters work six hours 
a day and the nurses eight. There was at one time 
a shortage of nurses, but the position is rapidly 
improving. 

The informality in the wards was the subject of 
comment. The wards in Russian hospitals are 
small—at most ten-bedded, many two- and four- 
bedded—and the beds are much lower and closer 
together than in our hospitals. Visitors are allowed 
twice in every six days. All the patients have ear- 


NOTES, COMMENTS, AND ABSTRACTS 


(san. 4, 1936 63 


phones, and all seemed to be reading something. 
On the stairs between each floor is a sort of letter 
box in which are collected the patients’ personal 
notes to their friends. These boxes are cleared 
twice a day ; friends call for the notes at the entrance 
and leave their own replies. They can ring up 
any time between 10 A.M. and 7 P.M. for news of the 
patients, and there is one hour in the morning during 
which they can interview the doctors. The hospital 
provides nine different diets. 

Not only at the Institute of First Aid but at the 
Lenin Hospital, Leningrad (500 beds, 1000 out- 
patients, ex-patients only, daily) the visiting nurses 
were interested by the complete absence of screens, 
and by the elaborate arrangements for assuring that 
successive batches of nurses were kept informed of 
the patients’ progress and special needs. As there 
is a good deal of changing of duty, particulars of 
really ill patients are written on small squares of 
frosted glass and slipped in front of a viewing screen 
on the sister’s table. There they are lit up like a 
series of X ray plates. Changes of treatment are 
put on cards, a card for each patient, and slipped into 
the slots of an “album ’’—just as if they were a 
collection of picture postcards. 

A “wall newspaper ’’ is to be found in every 
hospital. On it one sees photographs of workers, 
and also articles of general interest, often of self- 
criticism. One whole sheet may be devoted to a 
department which has done poor work, or whose 
staff have grown slack. 

The information sought and gained was not all 
in one direction. The Russian doctors asked pertinent 
questions of the British nurses; for instance :— 


“We understand that, unlike our nurses, very few of 
you are married, and we think it so strange. Speaking 
as doctors we would even go so far as to say that it is a 
physiological crime. We hope you do not think us rude 
to say so.” “ Not at all,” we replied amiably. ‘‘ But we 
work longer hours than you and have little time for marriage 
if it has to be combined with hospital work. Quite a 
lot of our nurses do marry, but they are expected to 
give up nursing then. Anyway, do tell us if you think 
we look ill or strained.” Well, they had to admit that 
we did not, but as we left, with a mutual exchange of 
smiles and bows, the faint murmur of “ physiological crime ”’ 
pursued us to the very gates. 


It had previously been ascertained that besides 
the annual holiday of two or three weeks, ‘‘ medical 
sisters ’’ were allowed four months’ pregnancy leave, 
two months before and two after childbirth. Many 
other interesting differences of custom were observed 
and are here entertainingly recorded. 


HAMLET ANALYSED AGAIN 


THAT artists who concern themselves with character 
study may on occasion be more trustworthy guides 
to problems of psychology than professional psycho- 
logists is a thesis well worth discussing. Inevitably 
Shakespeare, whose intuition provides a veritable 
index to human character, must loom large in such 
an argument. Now that psychology endeavours not 
merely to dissect but to codrdinate character, it cannot 
afford to ignore one whose words appear to stimulate 
each succeeding generation to fresh interpretation. 

Dr. Brock, in a little book recently published,? 
enumerates the theory first that IIamlet’s ‘‘ over- 
growth of some complexion,” of which he was well 
aware, was passion, secondly, that Hamlet constitutes 
Shakespeare’s portrait of himself. The latter is, of 
course, only arguable in a limited sense. At some 
time in his life Shakespeare must have actually 
experienced the pangs that wrung all his great 
creations. If Hamlet was indeed Shakespeare in one 
phase of his life, he passed from that particular 
phase to others in which idealism gave way to 
cynicism, as in Antony, Coriolanus, and Timon, and 


By J. H. E. Brock, 


1The Dramatic Purpose of Hamlet. 
l W. Heffer and 


M.D., B.S., D.P.H., F.R.C.S. Cambridge: 
Sons, Ltd. Pp. 48. 2s. 6d. 


64 THE LANCET] 


gradually thereafter became philosophy as illustrated 
in the last plays. 

Did Hamlet know that his passions would be likely 
to ensnare him? This interpretation certainly has no 
support from Bradley; the picture of the final pre- 
vailing of passion as a resultant of two opposing forces 
—the meaner wish for revenge and the higher restraint 
of idealism—is one well in accord with actual 
experience. When, however, Dr. Brock takes the 
dying words of Hamlet to be a cry of despair, we 
must remember that the excellent Horatio evidently 
did not interpret them thus. As to the ghost, the 
old saying ‘‘ De mortuis nil nisi bonum ” has lost its 
mandatory force among modern commentators. Dr. 
Brock concludes that old Hamlet had probably been 
an egotistical bore in the flesh, and though Hamlet 
naturally idealised his father, other eyes may have 
perceived some excuse for his wretched queen. 


THE HOSPITAL ALMONER .- 


“ Go and ask the lady almoner about that. She will 
be able to help you.” Thisremark may be heard over 
and over again in any out-patient department when 
apparently insuperable obstacles are raised by the 
patient to a line of treatment deemed essential. 
And to the lady almoner they go, poor, harassed 
and worried, mental anxiety contributing its full 
weight to physical illness, and so interwoven with 
it that it is impossible to cope successfully with 
either alone. The new edition! of “The Hospital 
Almoner ”’ shows the variety of ways in which the 
lady almoner is able to solve problems which to the 
uninitiated might appear hopeless, and the agencies, 
State or voluntary, which can be tapped: while 
for intending candidates there has been added a new 
and helpful chapter which contains useful practical 
details of the course of training, of previous quali- 
fications essential and valuable, and of the scope of 
their future work. The book is essentially practical, 
like the almoner’s activities, and it has been com- 
piled with sympathetic insight based on knowledge 
of the psychological as well as the material aspects 
of the fine social service it describes. 


It is of interest to compare with this general survey 
this year’s annual report of the Social Service Depart- 
ment of St. Thomas’s Hospital, whose almoner’s 
department is world-famous. ‘It tells the story of 
the varying aspects of the work at St. Thomas’s, 
from the struggle to get the slums of Lambeth re- 
moved, to the difficult task of finding money for the 
many activities of the department. On the financial 
side, it is interesting to note that patients’ donations 
make up about 10 per cent. of the hospital income, 
and that the average cost of maintaining a patient 
at St. Thomas’s is about 13s. per day. Interesting 
too are the sections on the special departments and 
on the variety and scope of convalescent work under- 
taken. The codperation between the voluntary 
hospitals and the public authorities is a development 
which has grown rapidly of recent years. A helpful 
supplement to the work of both the maternity and 
the children’s department is the ‘ Father’s and 
Mother’s ”’ centre, which has an educative value far 
beyond any centre which caters only for one parent. 


HYGIENE IN THE SCHOOL 


THE movement for the teaching of hygiene as 
well as biology in schools has created a demand for 
elementary text-books which publishers have been 
alert to satisfy. Dr. Gamlin has written a book? 
intended for teachers in training, for student health 
visitors, and as a book of reference for school teachers 
wishing to bring their knowledge of hygiene up to 
date. It covers a wider range than would be antici- 
pated from its title. Such subjects as heredity, 


1 The Hospital Almoner. Second edition. Prepared by the 
Committee of the Hospital Almoners’ Association. London: 
George Allen and Unwin Ltd. 1935. Pp. 168. 5s. 

7 Modern School Hygiene. By R. Gamlin, M.A., M.B., B.C. 
Cantab., M.R.C.S. Lond., M.Hy. and D.P.H. Liverp., Chief 
Assistant School Medical Officer, Liverpool. London: James 
Nisbet and Co., Ltd. 1935. Pp. 388. 7s. Gd. 


NOTES, COMMENTS, AND ABSTRACTS 


[JAN. 4, 1936 


ductless glands, the welfare of infants and young: 
children, air, ventilation, sunlight, personal hygiene, 
food, beverages, alcohol, infection and immunity, 
infectious diseases, tuberculosis, rheumatism, and 
chorea are dealt with as well as school hygiene. 
The exposition is clear, the information accurate, 
and emphasis is properly placed. 

Dr. Lyster’s book ? is intended to be used in con 
nexion with the class instruction of junior pupils in 
hygiene. New features in the second edition include 
a guide to the pronunciation of scientific terms and 
a revised section on artificial respiration. The book 
is written in language appropriate to the age of the 
pupils for whom it is intended. and is freely and, on 
the whole, well illustrated. There is little to cavil 
at in the information which it contains, although 
the relative stress laid on the various aspects of 
hygiene will not meet the views of some teachers. 
The section on ventilation would bear modernisation 
as regards the effects of bad air on health, and it is 
doubtful if children’s memories should be burdened 
with ingenious but little used ventilating apparatus 
described here at some length. Some of the diagrams 
are old fashioned, especially those relating to the 
stomach and intestines. On the whole, however, 
this book is a creditable attempt to deal with the 
difficult subject of hygiene in a way suitable for 
young children. 


BIRTH CONTROL FOR THE LAYMAN 


From a prefatory note to yet another little 
book on birth control it appears that Mr. G. R. 
Scott t has written it for the lay public, in order to 
help married couples to solve their own contraceptive 
problems and select the method or methods best 
suited to themselves. He has succeeded only in 
dishing up a somewhat indigestible hotchpotch. Mixed 
with a certain amount of correct information are 
not a few practical blunders and a good deal of 
material which would have been better omitted. 
The number of methods described, their various 
possible and impossible combinations, and the lists 
of contra-indications and indications for their use 
must surely be confusing and largely unintelligible 
to laymen. The diagrams are poor and in one place 
at least inaccurate. It would be interesting to 
learn whether the author has had any practical 
experience of selecting and teaching methods of 
birth control. 


REGULATION OF PROSTITUTION 


Miss ALISON NEILANS, general secretary of the 
Association for Moral and Social llygiene, writes: 
“ In your issue of Dec. 28th, 1935, Dr. C. Rolleston 
expresses surprise at Dr. White’s statement that the 
examination of prostitutes in regulationist countries. 
is a perfunctory procedure taking one or two minutes. 
Dr. Rolleston appears to think that nowadays in 
Paris and the leading French towns these examina- 
tions are managed in a different way and much more 
thoroughly. I have not seen the periodic examination 
of prostitutes in Paris or in France, but I have seen 
it carried out by French specialists in Syria, under 
the French mandate, where the examinations are 
conducted for the supposed benefit of the French 
troops. The examination is still performed very 
much as described in Flexner’s book. It takes 
rather less than one minute per woman examined, 
and, in addition, at intervals of a few weeks, I believe, 
a specimen is taken to examine for gonorrhoea, 
Also in Turkey at the present time the examination 
only takes from one to two minutes, but I will not 
comment on that as on the occasion when I saw it 


3 A School Course in Hygiene. Second edition. By R. A. 
Lyster, M.D., Ch.B., B.Sc. Lond., D.P.H.. Lecturer in Public 
Health aud in Forensic Medicine at St. Bartholomew's Hospital, 


London. London: University Tutorial Press Ltd. 1935, 
Pp. 266. 3s. 6d. 
t Facts and Fallacies of Practical Birth Control. By George 


Riley Scott, F.R.A.I., F.Pb.S. Eng., F.Z4.8. London: T. Werner 
Laurie Ltd. 1935. Pp. 156. os. 


for a iy eur Oo a 
Se f e ge Bevel ‘a 


THE LANCET] 


NOTES, COMMENTS, AND ABSTRACTS 


Luan. 4, 1936 65 


performed it was only for the purpose of taking 
smears to look for the gonococcus. 

“It is always stated that the prostitute in the 
brothel under medical examination is not usually 
the source of infection. In so far as that is true it 
probably is because women liable to periodic examina- 
tion keep themselves rather cleaner, but they also 
take a great number. of precautions to prevent being 
discovered in an infectious condition. . 

“With regard to the letter from ‘ Traveller’ 
I might point out that the British authorities have 
completely abolished the regulation of prostitution 
throughout the whole of our Crown Colonies and 
dependencies, including Malta and- Gibraltar. In 
Egypt alone this system of tolerated brothels with 
medical examination of women continues and the 
results, judging by the figures for the British Army 
in Egypt, are not altogether satisfactory.” 


MEDICAL VERSES! 


= Mr. Roche has brought together here various 
verses, the majority of which were written over 
15 years ago, many of them having seen light in 
the St. Bartholomew’s Hospital journal, Round the 
Fountain, and the Busy Bees Magazine. About 
‘one-third of the collection follows the usual type of 
rhymed skit on medical subjects, though Mr. Roche 
is both wittier and a better technician than most 
contributors to hospital journals. The remaining 
two-thirds contain superior work, and in one or 
two places display the author as observer and poet. 
But because some of these metrical exercises are 
good—note the verses on Chamonix, and the serio- 
comic obituary note on a blue-bottle—the inclusion 
of others not so good is regrettable. Some pruning 
would have raised the standard of the collection, 
and though great masters of the sonnet have taken 
liberties in rhyming, it is only they who can take 
liberties here. The book closes with translations 
from the Greek and Latin, where several neat render- 
ings of epigrams will be found. 


ARTHRALGIA FROM INJECTIONS OF 
BISMUTH FOR SYPHILIS - 


A STUDY of the records of the dermato-venereo- 
logical department of the Rigshospital in Copenhagen 
has convinced Dr. V. Genner that injections of 
bismuth not infrequently give rise to more or less 
troublesome pains in the joints (Nord. med. tidskr., 
Nov. 2nd, 1935, p. 1753). His study covers the 
period 1913-32 and concerns 5526 cases of syphilis. 
Until 1924—i.e., before the bismuth period, and 
when treatment consisted of injections of mercury 
and salvarsan—arthralgia as a consequence of anti- 
syphilitic treatment was unknown. It was only in 
1924, the year after the replacement of mercury 
by bismuth, that such symptoms began to be noticed. 
Between 1924 and 1932 there were as many as 79 cases 
of what Genner describes as paratherapeutic ailments 
of the joints. During the first few years after 1924, 
the number of cases of arthralgia increased with 
the raising of the dosage of bismuth ; and in the last 
five or six years, during which the bismuth dosage 
has been more or less stabilised, there has been a 
corresponding stability from year to year of the 
number of cases of arthralgia. As there were 2235 
syphilitics treated between 1924 and 1932, these 
79 cases represented an incidence-rate of 3°5 per cent. 
—the same for the two sexes. As a rule, several 
joints were involved, and the pain was reminiscent 
of that of rheumatic arthritis. Though it was most 
exceptional for it to be associated with swelling and 
redness, the pain could be quite troublesome, and 
in several cases it persisted for months after the 
treatment had been discontinued. In two cases its 
severity necessitated the patients’ admission to 
hospital. In 73 per cent. of all the cases the pain 
began in the course of the two first series of injec- 
tions ; and the connexion between pain and injection 


1 Medical and Other Verses. 


By Alex E. Roche. London: 
H. K. Lewis and Co., Ltd. 1935. Gd, 


Pp. 92. 3s. 


was often so intimate that the former followed the 
latter with only a quite short interval. It should be 
noted that the specific treatment given in the Rigs- 
hospital included salvarsan in a goodly proportion 
of the cases, in association with mercury before 
1924, and with bismuth from 1924 to 1932; but it 
is only in a few cases that Genner gives salvarsan 
the credit for arthralgia. Indeed, only 4 per cent. 
of the cases of arthralgia occurred during or after a 
series of salvarsan injections, whereas 54 per cent. 
of them occurred during or after a salvarsan-bismuth 
series, and 42 per cent. of them during or after a 
bismuth series of injections. In several] cases under- 
going a combined course of salvarsan and bismuth 
injections, the arthralgia ceased when the bismuth 
was discontinued and the salvarsan continued ; and 
relapses followed the resumption of bismuth treat- 
ment. Dr. Genner’s attitude towards the pathology 
of bismuth arthralgia is guardedly non-committal. 


DIARIES 


THE HosPITAL DIARY in its third year of issue 
elaborates the useful features with which it started. 
The quality of materials provided for the daily 
record is unexceptionable, and the opening section 
containing tabular information and some signed 
articles on hospital practice and administration are 


as useful as the hospital buyers’ guide which con- 


cludes the volume. The diary, which is edited by 
Lieut.-Colonel Clement Cobbold, secretary of the 
Cancer Hospital, London, and Mr. H. F. Shrimpton, 
house governor of the Children’s Hospital, Birming- 
ham, can be obtained from G. R. C. Brook and Co., 
27, Old Bond-street, London, W.1, for 5s. 6d. 
Warner’s CALENDAR OF MEDICAL History for 
the use of the medical profession gives a page for 
each day’s record of events, and at the foot of each 
page is a useful calendar and some interesting item 
of medical biography or history. Tables of incom- 
patibles, of poisons, of infectious diseases, of 
glandular secretions, and many others, contain 
much useful information attractively arranged. The 
calendar which is printed in the U.S.A. is issued 
by William R. Warner and Co., Ltd., 300, Gray’s 
Inn-road, London, W.C.1. 


THE PREVENTION OF NEUROSIS 


Sir Walter Langdon-Brown has distinguished 
between those ill from unhappiness and those unhappy 
from illness. A large proportion of patients, even in 
favourable circumstances, owe their maladies to 
psychological maladaptation and it is therefore to 
be expected that in industry neurotics are respon- 
sible for much lost efficiency. Statistics have shown 
that in one factory there may be a sickness-rate of 
3 days a year, while in another, where discontent is 
rife, it rises to 16. This difference seems chiefly to 
be due to psychological ill-health and, in a paper 
read before the Society of Medical Officers of Health 
on Dec. 20th, 1935, Dr. Henry Wilson discussed the 
causes of Neurosis and showed how the methods of 
preventive medicine could be applied to the problem. 

Inborn or physical handicaps, environmental 
difficulties, or unsatisfactory psychological habits 
are, he said, the factors which produce absence from 
work or chronic discontent. The neurotic settles 
these problems by evasion, but to classify his con- 
dition with moral defect is to hamper the psycho- 
logist in his already difficult task. Efficient treat- 
ment should be preventive in its aims and it is only 


“by finding the cases in childhood that neurosis in 


the working adult can be excluded. About a tenth 
of all school-children are seriously backward in 
mentality, and this has probably a greater bearing 
upon crime and neurosis than is realised. The 
neurotic child, though overstrung and shy, tends 
to bave an intelligence superior to his fellows, and 
he is at once at a disadvantage if his capabilities are 
either misunderstood or repressed. The attempts 
to assess the discrepancy between mental age and 
‘educational position are in the realm of preventive 


66 THE LANCET] | 


medicine, for there the individual child can be 
studied, his needs discovered, and his emotions 
trained. The psychologist can detect early traits 
even before their importance is seen by the most 
intuitive teacher, and these can be treated before 
they become serious habits of mind. 

Circumstances such as physical disease can be 
improved or the patient’s attitude adjusted by 
satisfactory education and suitable employment. 
Attempts can be made, especially in the young, to 
remedy abnormal outlooks and reactions, but often 
the child’s enemies are those in his own household, 
and the parents are to blame for the bad environ- 
ment. It is here that the psychiatric social worker 
becomes indispensable to the clinician in dealing 
with neurotic manifestations. The object of the 
medical psychologist is to pick his material and to 
aid the children to have their values readjusted, not 
by taboos and social ostracism, but by a real sense 
of self-control. 

Dr. Wilson looks forward to the time when the 
medical psychologist can apply to early cases what 
preventive medicine has offered to those physically 
diseased, when, by means of investigation, early 
notification, suitable environment, and complete 
treatment, he can make the misfit an asset instead 
of a burden to society. 


NEW PREPARATIONS 


DISSOLVED VACCINES G.L.—Under this name the 
Glaxo Laboratories Ltd., Greenford, Middlesex, 
are issuing vaccines ‘in which the bacterial cells 
are in solution and the toxic bacterial products are 
at the same time detoxicated.” With ordinary 
vaccines an antibody response does not develop 
until antigens have been liberated from the bacterial 
cell by tissue lysis at the site of inoculation. Dis- 
solved Vaccines, on the other hand, are said to make 
the antigens immediately available, and their action 
is therefore more rapid and consistent. Both solu- 
tion and detoxication are effected by sodium lauryl 
sulphate which is present in the vaccines at a con- 
centration of not more than 0°025 per cent. Owing 
to the detoxication, which affects endotoxins and 
exotoxins equally, the general level of dosage can, 
it is stated, be considerably higher than that of 
ordinary vaccines; indeed it is often possible to 
give a full dose at the first or second injection, no 
long series of graduated doses being necessary. 
Good clinical results obtained during the past two 
years are described in a booklet which may be had 
on application. The vaccines are put up in rubber- 
capped bottles in the following varieties: acne and 
staphylococcus, anti-typhoid-paratyphoid, cold (pro- 
phylactic), cold (treatment), influenza, staphylo- 
coccus and streptococcus, staphylococcus, strepto- 
coccus, whooping-cough (prophylactic), whooping- 
cough (treatment), gonococcus, and Shiga’s dysentery 
bacillus. Autogenous vaccines can also be prepared. 


CLAUDEN is a preparation of lung tissue recom- 
mended for the control of hemorrhage. In the 
form devised by Fischl in 1916 it is a greyish-brown 
amorphous powder which can be applied as a local 
styptic. Besides this powder the Luitpold-Werk, 
Munich, now prepares a solution in ampoules—for 
intravenous, subcutaneous, and intramuscular injec- 
tion, for irrigation of wounds and tooth-sockets, and 
for instillation into rectum or bladder—and tablets 
for protracted administration by mouth. All three 
forms are obtainable in this country from the Medical 
Laboratories Ltd., 40, Pall Mall, London, S.W. 1. It is 
claimed that the active principle is not impaired by 
alimentary digestion, and that after absorption or 
injection it never causes intravasal coagulation, its 
action being confined to the point where the blood- 
vessel is injured. The use of Clauden is advised 
not only for the prevention and treatment of surgical 
oozing but also for such conditions as hamoptysis, 
nose-bleeding, menorrhagia, and hemorrhage from 
the bladder. The makers issue a pamphlet based on 
over 350 references in medical publications, including 


MEDICAL DIARY 


[JAN. 4, 1936 


an observation by Knosp (1928) that Clauden reduces 
coagulation time by about half. Prolonged adminis- 
tration is reported to have overcome the tendency 
to hemorrhage in hemophilia. 


ESTOFORM.—The chief constituent of this new 
antispasmodic remedy is an ester of formic acid, 
with the formula HC(OC,H;)3;, which is shown to 
be non-toxic to animals in doses as high as 5 grammes 
per kg. of body-weight. Estoform contains 10 per. 
cent. of this ester, together with extracts of Prunus 
virginiana and senega, in a glycerin-spirit base, and 
doses up to 6 teaspoonfuls were given during clinical 
trials. The spasm of chronic and acute bronchitis 
was relieved, patients with miscellaneous coughs 
were mostly benefited, and definite improvement is 
said to have been obtained in a large proportion of 
asthmatics. It should be noted that this preparation 
contains about as much alcohol as ordinary spirits 
and requires to be diluted and taken preferably 
with meals. It is made by the Crookes Laboratories 
(British Colloids Ltd.), Park Royal, London, N.W.10. 


THE OBSTINATE SYRINGE 


Dr. C. S. RYLES writes: Having tried, without 
success, all the usual means for dealing with a valu- 
able glass syringe whose piston was stuck in the 
barrel, I soaked the syringe in a little ‘‘ penetrating 
fluid ”? such as motorists use for spraying the spring 
leaves of cars. After a week the piston came out 
easily. Probably others would be glad to know 
about this. 


` 


Medical Diary 


SOCIETIES 
ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W. ` 


TUESDAY, Jan. 7th. 
Orthopaedics. 5.30 P.M. (Cases at 4.30 P.M.) Mr. Denis 
Browne: Club-feet. Mr. Alan Todd: Pes Cavus. 


THURSDAY, 


Tropical Diseases and Parasitology. 8.15 P.M. Dr. J. C. 
Cruickshank: Modern Methods of Diagnosis by 
Agglutination. 

FRIDAY. 

Ophthalmology. 8.30 P.M. (Cases at 8 P.M.) Mr. J. H. 

Doggart: Eclamptic Detachment of the Retina. 


SOUTH-WEST LONDON MEDICAL SOCIETY. 
WEDNESDAY, Jan. 8th.—9Y P.M. (Bolingbroke Hospital, 
Wandsworth Common, S.W.), Dr. H, Crichton-Miler : 
The Neurotic as the Practitioner’s Bogy. 
WEST KENT MEDICO-CHIRURGICAL SOCIETY. 
FRIDAY, Jan. 10th.—9 P.M. (Miller General Hospital, 
Greenwich, S.E.), Clinical evening. 
WEST LONDON MEDICO-CHIRURGICAL SOCIETY. 
FRIDAY, Jan. 10th.—8.30 P.M. (West London Hospital), 
Dr. Halls Dally, Dr. L. S. T. Burrell, and Dr. Evan 
Bedford : Pain in the Chest. 
LONDON JEWISH HOSPITAL MEDICAL SOCIETY, 
Stepney Green, E. 
THURSDAY, Jan. 9th.—4 P.M., Mr. A. D. Griffiths, Mr. 
Sees Xisch, and Dr. C. C. Worster-Drought : Head- 
aches. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 


FELLOWSHIP OF MEDICINE AND POST-GRADUATE 
MEDICAL ASSOCIATION, 1, Wimpole-street, W. 
Monpay, Jan. 6th, to SATURDAY, Jan. lith.—ST. JOMN’S 
HOSPITAL, 5, Lisle-street, Leicester-square, W.C. 
Afternoon course in dermatology.—WFEsT END Hos- 
PITAL FOR NERVOUS DISEASES, In-patient Depart- 
ment, Gloucester-gate, N.W. Demonstration on 
Fundus Oculi, by Mr. R. Lindsay Rea, at 8.30 P.M., 
on Tuesday, Jan. 7th. 
LONDON SCHOOL OF DERMATOLOGY, 
square, W.C. 
TUESDAY, Jan. 7th.—5 P.M., Dr. H. Corsi: Syphilis through 
Four Centuries. 
THURSDAY.—5 P.M., Dr. J. M. H. MacLeod: Ringworm 
Infections. \ 
ST. JOHN CLINIC, Ranelagh-road, S.W. i 
FRIDAY, Jan. 10th.— 4.30 P.M., Dr. Philip Ellman :| Physical 
Methods in Diseases of Heart and Lungs. 
GENERAL INFIRMARY, Leeds. 
TUESDAY, Jan. 7th.—3.30 P.M., Dr. Veale : 
of Medical Cases. . 
LEEDS PUBLIC DISPENSARY AND HOSPITAL. ! 


49, Leicester- 


Demonstration 


WEDNESDAY, Jan. s8th.—4t P.M., Dr. Hartfall qnd Dr. 
Garland: Diagnosis and Treatment of Rheumatoid 
Arthritis. , 


—— 4 


= # | es ee 
i 
a 


THE LANCET] 


(san. 11, 1936 


ADDRESSES AND ORIGINAL ARTICLES 


CARCINOMA OF THE CGSOPHAGUS 
THE QUESTION OF ITS TREATMENT BY 


SURGERY * 
By G. GREY TURNER, D.Ch., M.S. Durh., 
F.R.C.S. Eng., F.A.C.S. 
PROFESSOR OF SURGERY IN THE UNIVERSITY OF LONDON AT 


THE BRITISH POSTGRADUATE MEDICAL SCHOOL, 
HAMMERSMITH 


“If you have no confidence in success, you can have no 
hope of winning.”—Lord Lovat. 


In the long history of this lectureship extending 
over a period of 52 years, no one appears to have 
thought it worth while to deal with the subject 
which I have chosen. Probably the reason is because 
malignant disease of the cesophagus has always been 
looked upon as so hopeless from every point of view. 
It is recorded of Dr. William Wood Bradshaw, the 
founder of the lectureship, that he was a quiet, 
home-loving, studious man, who diligently cultivated 
his mind both in literature and science. For many 
years he practised at Andover and Reading and 
was for a time vice-president of the Pathological 
Society in the latter town, so that he was: probably 
very familiar with the sad clinical history of these 
cases and of the pathological processes which, if 
unchecked, gnaw steadily at the vitals until death 
comes to the rescue. The attention which is directed 
to this subject from time to time is probably the 
expression of a desire to remove a reproach and to 
conquer a hitherto unassailable peak. So far the 
rewards have been few and bestowed infrequently 
but :— 


“ Delusion sweet thus tempts us on 
Till all the leaves are like to one 
Yet Hope looks back as heretofore 
And smiling seems to say encore.’’ 


J. M. W. Turner. 


The majority of physicians and very many surgeons 
seem to have already decided that, except for 
palliative measures, surgery cannot claim a place 
in the treatment of carcinoma of the cesophagus 
and the earnest student will get nothing but dis- 
couragement from text-books. “Most authorities still 
seem to think that it is along other than surgical 
avenues that legitimate treatment must be directed. 
As a matter of fact although radium and deep X ray 
therapy both hold out great promise, no one can 
claim that at present either method can be expected 
to do more than palliate tlese cases, although there 
are odd instances in which a cure has possibly been 
attained. At the same time these are no more 
frequent than the occasional successes as the result 
of surgical intervention ; so that it comes to this, 
that none of the workers in any field can afford to 
belittle the efforts of others or can legitimately 
crow over their own success. In each of the spheres 
of therapeutic endeavour great ingenuity has been 
displayed and an enormous effort expended. In 
this lecture I only propose to tell you something 
about my own personal experience. It would take 
far too long even briefly to review the vast amount 
of work that has been carried out on this subject 


® Bradshaw lecture delivered before the Royal College of 
Surgeons of England on Dec. 5th, 1935. 


5863 


and as that has been repeatedly done in the immediate 
past, I doubt if it would serve any useful purpose. 


Some Pathological Considerations 
“ First things come first.” 

The prelude to successful treatment must always 
be an understanding of the pathological features and 
this is peculiarly so with a secluded structure like 
the cesophagus, inaccessible and difficult of observa- 
tion. It has been persistently stated that carcinoma 
of this organ is of a particularly virulent type that 
disseminates wide and early, and this teaching has 
had a depressing effect on the outlook with which 
the condition has been viewed by the profession. 
It is only fair to say that those who have paid 
particular and critical attention to the subject, and 
especially with a view to the possibilities of direct 
interference, have from time to time pointed out the 
fallacy of this commonly accepted dictum. In 
what one is pleased to call the old days, there was 
much excuse for this unhappy view of the nature 
of these cesophageal growths because the observa- 
tions made in the post-mortem room were nearly 
always on those subjects who had endured a lingering 
death from malignant disease of this part without 
any means having been taken to stay its progress. 
Anyone who examines the specimens of cancer of the 
esophagus in our museums must be depressed by 
the shockingly advanced condition which they 
represent. What we really most want to know is 
the morbid anatomy at a stage at which the question 
of some form of active treatment arises. We also 
want exact knowledge of the mode of spread of 
malignant disease of the cesophagus and the various 
types which are undoubtedly present together with 
their most prominent features, 

In ten cases in which I removed a portion of the œso- 
phagus for carcinoma, the obvious growth varied in length 
from 1} to 3 in. In three instances the tissues beyond 
the cesophageal wall were invaded and there were obvi- 
ously infiltrated glands in close proximity. The smaller 
growths had the appearance of a constricting type as 
viewed from the outside. All had infiltrated the wall to 
some extent but none were of the massive or fungating 
type so commonly seen in museums, and in only one was 
there proved evidence of distant dissemination—that in 
the form of secondary deposits in the lung. 

In this connexion it is illuminating to review the 
results of the after-death examinations of a series 
of patients which I have recently observed at the 
Hammersmith Hospital. 

There were ten who died under observation without 
any treatment other than palliative gastrostomy. In 
three there were secondary deposits in the liver or spleen, 
the total duration of the illness being 14, 16, and 8 months 
respectively. In one of these cases the growth was situated 
in the lowest part of the cesophagus and had extensively 
invaded the cardia and might properly be considered an 
example of cancer of that part of the stomach which had 
invaded the œsophagus. In the other seven, the disease 
had only extended to the surrounding parts or had : pread 
to the glands in the immediate vicinity but without any 
evidence of distant dissemination. 


ROUTE AND RATE OF DISSEMINATION 


These findings are entirely in keeping with what 
I have previously found from the observation of a 
number of such cases in Newcastle-upon-Tyne. 
But, of course, there are cases in which distant 
dissemination does occur and in what is apparently 
an early stage of the disease, that is to say, as judged 
from the onset of the symptoms. One may safely 
conclude that in the csophagus as in other parts 

B 


68 THE LANCET] 


of the body, malignant disease varies in type and 
in behaviour. The growth may for long remain 
localised and comparatively slow in its spread, at 
other times it may involve a considerable part of the 
wall and rapidly invade surrounding structures, or 
it may early disseminate both by lymphatic channels 
and by the blood stream as shown by the occurrence 
of secondary deposits in distant parts. Very 
occasionally it may rapidly assume such widespread 
extension locally and generally as to bring it under 
the head of general carcinomatosis. In my Bigelow 
oration I expressed the opinion that probably half 
the cases remain local until the time of death; in the 
other half there is spreading to more distant parts. 
Increasing experience and more detailed attention 
to this matter lead me to believe that this proportion 
is probably too high and that one may expect at least 
two-thirds of the cases to belong to the more limited 
and locally spreading group. If we exclude from this 
computation those growths which arise from the 
so-called abdominal portion of the «sophagus, 
then the proportion of those that disseminate will 
be still further and notably reduced. Chevalier 
Jackson, after an experience of nearly half a century, 
states of cancer of the csophagus, “It is not an 
aggressive type of malignancy; on the contrary, it 
is a mild, slow and for a long time purely local 
process.” 1 

In previous writings I have given clinical illustra- 
tions of the general truth of these statements. There 
must be an early stage at which such growths are 
limited to a comparatively small area of the ceso- 
_phageal wall and at which, if there is glandular 
involvement, it is in the immediate vicinity only. 
Such a statement suggests the value of the knowledge 
of the earliest stages of the commencement of the 
disease. What relation has its early features to the 
economy of the body and would it be possible at 
any stage to deal with the condition effectually 
by some endoscopic method? In order to obtain 
information on these points I have asked several of 
my friends who have the opportunity of examining 
large numbers of patients by the cmsophagoscope. 
They all have to admit that the great majority are 
fully developed when they come under observation 
and that the possibility of local radical endoscopic 
treatment practically never occurs. But many 
workers are looking out for such opportunities and 
in the Proceedings of the Mayo Clinic for July, 1935, 
H. J. Moersch tells of a localised carcinoma which 
he was able to remove by endoscopic diathermy, 
the patient being alive and free from recurrence six 
months later. Unless it becomes the routine to 
examine systematically large numbers of patients 
endoscopically without waiting for symptoms, it 
is unlikely that growths in an early stage will be 
found. It is said (Chevalier Jackson) that normal 
swallowing can take place when the diameter of the 
esophagus is only 5mm. and that probably the 
peristaltic wave is not interfered with until the 
growth becomes annular. This knowledge emphasises 
the imperative necessity and importance of skilled 
examination by methods of precision the moment 
there is any complaint of alteration in the act or 
comfort of swallowing. 

The problem, though so much more difficult, is 
very similar to the position with regard to the diagnosis 
of early malignant growths in the rectum. For 
long I had hoped that the almost routine use of the 
sigmoidoscope would lead to the discovery of many 
cases of rectal cancer in which it would be possible 


1 Arch. of Surg., 1926, xii., 236, 


PROF. G. GREY TURNER : CARCINOMA OF THE CESOPHAGUS 


[san. 11, 1936 


to contemplate an early local resection with conserva- 
tion of the sphincter. Unfortunately this hope 
has not so far matured. 


Anatomical Considerations 


The main facts of the anatomy of the csophagus 
are well understood and for the most part adequately 
dealt with in the more ample books on anatomy. 
For those who contemplate direct surgical interference 
I would, however, suggest that the best way to study 
the relationships of the parts concerned is in trans- 
verse sections of the body. In order that the 
impression may be an accurate one, it is essential 
that such sections should be life-size, as it is so easy 
to be misled with regard to depth and distance by 
reduced: pictures of this sort. For the purpose I 
can strongly recommend the ‘‘ Atlas of Topographical 
Anatomy of the Head, Neck, and Trunk ’’ produced 
by the late Prof. Johnson Symington of Belfast. 
The true esophagus itself is really shorter than one 
imagines and a length of from 9-10in. is usual. 
This is about the same as the length of the ureter 
in situ or the distance from the antecubital fossa 
to the front of the wrist. It is quite true that the 
tube may vary to some extent, depending for the 
most part on the size of the subject, and it may be 
elonvated to a remarkable extent when obstruction 
is of long standing, but this does not appertain in 
cases of malignant disease. The normal distance 
from the teeth to the point where the cesophagus 
enters the stomach is 16in. The levels of the various 
parts of the csophagus are best stated in relation 
to the bodies or to the spines of the vertebrx. It 
is convenient to remember that its commencement 
is opposite the sixth cervical spine, its lower extremity 
opposite the ninth dorsal spine, and that the crossing 
of the left bronchus, which is just below the arch 
of the aorta, is opposite the fourth dorsal spine. 
It is important to realise that the oesophagus closely 
follows the conformity of the spine and when, as so 
frequently happens in the elderly, there is a consider- 
able kyphosis, the upper part of the cesophagus 
passes almost directly backwards in the early part 
of its course. There is also some lateral deviation 
of the esophagus so that in the upper part of the 
thorax it inclines more to the right, whereas in the 
lower part it definitely abuts to the left. For the 
exposure of its upper part the right side should 
therefore be selected while for the lower part the 
left is more convenient. This refers not only to the 
transpleural approach but to the approach from the 
posterior mediastinum. Many surgical writers do 
not appear to appreciate the fact that, though the 
whole muscle is extraordinarily distensible, it is not 
extensible to any extent and only a very small portion, 
amounting to not more than 4cm. (a little less than 
2in.) can be excised if the ends are to be brought 
together without tension. It must also be realised 
that the tube is readily friable for the muscular wall 
tears easily, though the submucous coat is tougher, 
The mucous membrane is in excess and tends to 
bulge through any incision in the muscular wall. 
Possibly these conditions are exaggerated when there 
has been obstruction with consequent alteration in 
the wsophageal wall. 


RELATION TO THE PLEURA 


From a surgical point of view, perhaps the most 
important relation is that of the pleura. It is not 
sufliciently realised that this membrane is in contact 
with practically the whole length of the tube on 
both sides. On the right tbe ssutact is intimate 


THE LANCET | 


PROF. G. GREY TURNER: CARCINOMA OF THE GSOPHAGUS 


(JaN. 11, 1936 69 


throughout; on the left there is a middle 
portion in which it is protected from the pleura 
by the prominence of the aorta, but on this side the 
lowest part of the sac goes definitely behind the 
esophagus and is in jeopardy when this part is 
attacked surgically. Opposite the bodies of the 
eighth and ninth dorsal vertebre the two pleure 
sometimes almost meet behind the cesophagus 
providing this part with a sort of mesentery. These 
relations have been very carefully verified by my 
friend, Mr. James Whillis, and the diagram which 
he has made for me is very accurate (Fig. 1). This 
relationship is of great importance, because when 
we attempt to separate the cesophagus from its bed 
the pleura is 
very readily 
torn, especially 
if adherent. 
In transverse 
sections the 
posterior pleu- 
ral sulcus is 
very obvious 
and I have 
noticed that 
this part of 
the serous 
cavity is some- 
times obliter- 
ated by adhe- 
sions. When 
this occurs it 
is a fortunate 
circumstance 
as it protects 
that part of 
the pleura 
which is in 
closest associa- 
tion with the 
esophagus. I 
am contem- 
plating the 
possibility of 
bringing about this obliteration by some previous 
preoperative interference, though it is admittedly 
difficult to ensure that any known method will safely 
produce pleural adhesions as desired. 


FIG. 1.—Anatomical considerations: show- 
ing the relation of the pleura to the 
œŒsop ._ (Dissection and drawing by 
Mr. James Whillis.) 


THE ‘f TUNNEL” 


The next important point is to recognise that while 
for the most part the cesophagus lies more or less 
unattached in its bed of cellular tissue, there are 
certain definite points at which one must expect a 
certain amount of anatomical fixation. The first 
of these is the well-recognised broncho-cesophageal 
muscle attached to the back of the trachea just at 
its bifurcation or to the left bronchus. This may 
also connect to the back of the pericardium. The 
other and less well-recognised points of fixation are 
near the dome of the right pleura, the arch of the 
aorta, the subclavians, and the common carotid 
arteries. The adhesions to the blood-vessels usually 
contain branches of the vessels to which they connect. 
Dr. Vincent Pallares, who is now working with me 
at the postgraduate school, has verified these matters. 
Except at these points the œsophagus is not adherent 
to the very important structures which one finds 
as its fellows. The bed of cellular tissue in which the 
esophagus lies is not so obvious in the developing 
fetus, but it gradually becomes very well marked 
in adult life, although unfortunately it is difficult 
to demonstrate by any pictorial method. Neverthe- 


less anybody who examines the csophagus in situ 
must be struck by this very loose connexion and 
by the way it can be very readily separated from its 
surroundings. The presence of this cellular tissue 
practically amounts to a bursa surrounding the tube, 
providing the freedom which is so necessary for 
its unimpeded movement, not only in the act of 
swallowing, but during the movements of the body. 
The importance of this bursa is well illustrated by 
those occasional cases in which some part of the tube 
gets abnormally attached, in inflammatory conditions 
of the glands for instance, and in consequence a 
traction diverticulum develops. This csophageal 
tunnel can be demonstrated in dissections of the 
fresh cadaver and its surgical importance is at once 
realised when it is entered from the diaphragmatic 
hiatus, for the finger can be readily swept round 
the csophagus which at this site is extraordinarily 
easily separated from the bed in which it les. I 
have attempted to demonstrate this bursa by distend- 
ing the cellular tissue with fluid or with oxygen, 
and I am able to show an X ray in which the latter 
method was used in a young subject. When a 
hollow needle is thrust into the lower part of the 
tunnel and the oxygen turned on, the latter 
immediately passes up by the side of the esophagus 
and reaches the cellular tissue in the root of the 
neck, and this happens on both sides of the tube, but 
it is difficult to distend the cellular tissue in front 
and behind. The arteries which supply the esophagus 
next demand attention, The important point to 
realise is that there are no large branches that pass 
directly to the tube, so that there is fortunately for 
surgical purposes safety in numbers. 


The arteries are all subsidiary branches springing from 
named vessels like the inferior thyroid, the bronchial 
arteries, the intercostals, and the aorta, and they pursue 
a course of some length before they reach the cesophagus 
itself. It is also of some moment that for the most part 
they pass in a downward direction before finally breaking 
up on the wall of the tube. The vessels supplying the 
lower end are in a different category. Here the main 
artery is undoubtedly the special branch from the left 
gastric, but there is another from the left inferior phrenic. 
As can be seen in any well-injected specimen, these 
numerous vessels eventually break up into a very fine 
plexus on the cesophageal wall. 


BLOOD AND LYMPHATIC SUPPLY 


In the early days of my surgical interference with 
the cesophagus, I came to the conclusion on clinical 
grounds that the blood-supply of that part, which 
is about one and a half inches above the diaphragm, 
was, to say the least, precarious. This and other 
matters have been verified by the Japanese worker 
Ohsawa, who has shown by a very interesting series 
of observations the exact area of the csophagus 
which receives its supply from the various vessels. 
The diagram in his recent publication (‘“‘ The Surgery 
of the Gsophagus’’) illustrates this state of affairs 
very clearly and defines the dangerous anzmic spot, 
which is of extreme importance in connexion with 
some of the operative procedures which have been 
suggested and carried out. 

For surgical purposes then we may take it that the 
cesophacus from its commencement to just below the 
bifurcation of the trachea is adequately supplied with 
blood. Below this point the supply becomes less until 
at a spot about 1} to 2 inches above the diaphragm it 
is very poor, in fact dangerously so, for any surgical 
interference. The last part of the cesophagus above 
the diaphragm and the intra-abdominal portion is 
well supplied from the left gastric and from the left 


70 THE LANCET] 


PROF, G. GREY TURNER: CARCINOMA OF THE CESOPHAGUS 


(yan. 11, 1936 


inferior phrenic. The arrangement of the veins is 
fortunate from the surgical point of view. When I 
first began to contemplate direct interference with 
the esophagus I was very fearful of the hemorrhage 
which I expected would come from the azygos veins, 
but, as a matter of fact, these great trunks do not 
receive blood directly from the csophagus and the 
intermediary vessels only open into the azygos after 
considerable interval. There are also large branches, 
' which open into the thyroid veins in the neck and, 
at the lower end, veins, which join the abdominal 
coronary system. Of course, there are many varia- 
tions, and in pathological states the veins may be 
extremely congested as in cesophageal varix, but this 
condition is not likely to occur in carcinoma. 

The relationship of the vagi is also a matter of 
importance and concern but, again fortunately 
for the surgeon, the main trunks are not closely 
adherent and can be separated without much 
trouble and, in point of fact, except when infiltrated 
by growth they seem to look after themselves in 
a wonderful way when the csophagus is isolated 
for any surgical purpose. 

The lymphatic arrangements seem to be well 
understood and in keeping with the usual description, 
but I would like to stress the fact that some of the 
lymphatics from the lowest part of the oesophagus 
drain into the glands along the lesser curvature 
of the stomach, although drainage in the opposite 
direction may also occur. There are several lymphatic 
glands lying directly on the msophageal wall and 
lymphatic vessels also drain to the peribronchial 
lymphatics at the root of the lung. The upper part 
of the cesophagus drains mainly into the lower deep 
carotid glands. The supraclavicular lymphatic 
glands on both sides receive a supply from all parts 
of the esophagus. 

The development of the msophagus has some 
bearing on our surgical outlook. For instance, it 
is well to realise that in the very active changes during 
the second month of fæœtal life it is really pushed 
backwards into the cavity by the development of the 
lungs and pleuræ. When, therefore, the esophagus 
is removed surgically by withdrawing it up into the 
neck after mobilisation, it is but retracing the steps 
which brought it into the secluded position which 
it normally enjoys. 


RESISTANCE TO INFECTION 


When anatomists speak of the abdominal portion 
of the wsophagus they are at considerable difficulty 
to define its exact demarcation ; histology and patho- 
logy are probably more helpful than the ordinary 
landmarks for which they seek. The line of demarca- 
tion between the epithelium of the csophagus and 
that of the stomach is not a very sharp one, and it is 
quite common to find a graduation between cesophagus 
and gastric mucous membrane when the matter 
is looked at histologically rather than by the naked 
eye. Pathologically growths in this lowest portion 
of the cesophagus resemble neoplasms of the stomach 
in their behaviour, for they not only involve the 
lymphatic glands in the lesser curvature, but they 
tend to disseminate, and secondary deposits in the 
liver are a marked feature. The resistance to 
organised invasion of the cellular tissue surrounding 
the cwsophagus is a matter of supreme importance 
when surgical interference is contemplated. It has 
usually been looked upon as of low resisting power, 
and clinically it is well recognised that infection 
of this tissue, known as the clinical entity ‘‘ acute 
mediastinitis,” is extraordinarily rapid in its develop- 


ment, severe in its manifestations, and most lethal 
in its termination. This matter has concerned 
me very much indeed in connexion with the surgery 
of the œsophagus and, because of these known 
characteristics, I have always feared that acute 
infection of the cellular tissue would be almost 
a complete obstacle to surgical interference in this 
neighbourhood. This known tendency to infection 
is an excellent reason for so arranging technical 
procedures that no division of the csophagus and 
no suturing, which might possibly be attended with 
leakage, is made in the midst of the tunnel. In 
the cases in which I have been able to excise the 
cesophagus and in which the patient has completely 
recovered or has lived for a considerable time, I 
have been struck with the almost entire absence 
of any evidence of acute infection, which I so much 
feared. It may be that by removing the esophagus 
the cellular tissue is so freely opened up that drainage 
comes to our aid, but that cannot be the sole explana- 
tion because in my most successful case external 
drainage was not provided and yet the patient 
recovered so well that in three weeks he was able to 
leave the hospital apparently quite well. 


Problems of Diagnosis 


In adults a history of steadily increasing difficulty in 
swallowing without any previous causative factor, such 
as an injury from imbibing noxious fluids, is almost 
pathognomonic of csophageal neoplasm. In the 
other causes of obstruction such as pouches or spasm 
the symptoms are for long intermittent and come on 
in definite attacks which pass off spontaneously. 
As a rule the onset of dysphagia due to malignant 
disease is gradual and takes the form of an increasing 
difliculty with solid foods. More rarely the onset 
may be sudden, and those patients are fortunate in 
whom the blocking of the neoplastic esophagus by 
some hastily swallowed bolus of solid food early 
draws attention to unsuspected narrowing, if indeed 
this warning is promptly followed by the thorough 
investigation which it demands. This event is 
comparable to the patient with the large intestine 
growth, to which attention is first drawn by some 
solid body amongst the fæces. The average length | 
of history is usually short and yet in the majority, 
in fact almost always, we find that the disease is 
well developed at the time that examination is 
first made. These considerations suggest that in 
most cases the disease is already well advanced 
before any symptoms arise. Chevaher Jackson, 
who has had the opportunity of observing many 
cases by repeated csophagoscopy over long periods 
of time, has accumulated data from which he concludes 
that most growths have been present for many months 
before symptoms arise. He is of opinion that when 
the growth has reached the stage of complete obstruc- 
tion the lesion has been present for at least a year 
and probably longer.? Often the discovery of a well- 
developed growth with a short history has been so 
surprising as to stimulate one to make a very searching 
inquiry as to earlier symptoms, but this very rarely 
discloses anything which might have led the patient 
even to suspect that there was something amiss. 
The plain duty of the profession is to realise that any 
interference with the act of swallowing in adults 
usually means that a new growth is present and that 
being so, as soon as a patient exhibits such symptoms 
a full investigation should be carried out, rather than 
those temporising measures which so often delay the 


2 Southern Surgeon, 1935, iv., 1. 


THE LANCET] 


arrival of the patient until the disease has still 
further advanced, often by months. In a series 
of my own cases the average time which elapsed 
between the onset of symptoms and the opportunity 
for dealing with the matter was no less than 15 weeks. 


SIGNIFICANT SYMPTOMS 


Once having been discovered, the symptoms do 
tally with pathology and the variation in the speed 
of the growth is sometimes very remarkable. Some 
clue as to the type may be suggested by the 
symptoms of the patients. Those | 
who harbour rapidly growing -. 
neoplasms complain of weak- l 
ness and loss of general health 
and appetite, rather than of 
the extreme local disability 
as disclosed by dysphagia. Long 
ago my old teacher, Prof. Ruther- 
ford Morison, used to point out | 
that the lack of appetite often 
meant that there were already 
secondary deposits and that 
the patient was not likely to 
live long. There can be no `Ñ; 
doubt that the outlook in ! © 
patients who complain only or 
mainly of mechanical difficulty 
is much more hopeful than 
where general weakness and | 
impaired condition is out of | 
proportion to the inability to ` 
take food. Anæmia and rapid 
loss of weight are ominous 
symptoms. Persistent cough, or 
cough made worse whenever 
the patient takes food, is also 
a very bad sign and often 
means that a communication 
between the respiratory 
passages is already established. 
But it is incorrect to assume 
that such a communication 
will immediately be followed 
by some type of septic pneu- 
monia although that is so 
frequent a sequel. I have 
recently observed a patient 
on whom gastrostomy had been 
performed seven months pre- 
viously for a malignant growth 
in the œsophagus. The condi- 
tion was investigated by an 
opaque drink, and to our 
surprise we secured a beautiful 
bronchogram of the left lung. 
The presence of the opaque 
material in the bronchial tree did not appear to 
give rise to any disturbance whatever, and with- 
out any special treatment of any sort this man 
lived for a further period of eight weeks and then 
slowly died from a general process of inanition. 
At the same time, if there is any suggestion of such 
a communication it is most important that such 
interference as may be necessary should be conducted 
under local anæsthesia. 

Sometimes there is long-standing history of either 
persistent difficulty in swallowing or an exacerbation 
of a degree of difliculty which has existed for many 
years. I have come across this combination in two 
striking cases. While this sort of history is usually 
suggestive of some condition that is non-malignant, 
it must be borne in mind that some of these patients 


hiatus. 


, ( 
PROF. G. GREY TURNER: CARCINOMA OF THE CGSOPHAGUS 


FIG. 2.—Large growth in lower msophagus 
almost completely separated froin its bed as 
a result of exploration from the abdominal 


[san. 11, 1936 71 


do ultimately develop malignant disease and J think 
that is especially so in women. The comparative 
frequency of an upper cesophageal spasm in the 
female sex has often been noted and has been followed 
by the development of malignant disease in quite a 
proportion of cases. Prof. Lambert Rogers, who has 
drawn attention to this association,® is inclined to 
think that the treatment he advocates may be in some 
degree prophylactic against the development of 
malignant disease. 
When a patient is examined as soon as difficulty 
in swallowing declares itself, 
. it is unlikely that there will 
| be any physical signs that can 
. be discovered by ordinary 
methods. We must urge the 
complete examination at this 
: stage by the X ray and the 
|  œsophagoscope wherein seems 
| to lie the only hope of discover- 
ing the growth at a stage at 
which treatment has a chance 
to be effective. But, at what- 
ever stage the patient is seen, 
' it is essential that an ordinary 
examination should be made 
in the first instance, if for no 
_ other purpose than to eliminate 
, conditions suggestive of dis- 
© semination. Such an examina- 
tion involves the palpation of 
such part of the œsophagus 
as can be reached in the root 
of the neck. Sometimes the 
growth can actually be felt ; 
it may even then be stony- 
' hard and fixed, or it may be 
| moved from side to side and 
| moves up and down on swallow- 
ing. Though the actual growth 
is rarely felt, there may be 
some enlargement of the glands 
which is suggestive, and in this 
+ disease the glands at the root 
' of the neck are commonly 
affected on both sides. In 
the same way the lower end 
of the cesophagus is some- 
times suspected to be the 
seat of a growth, when, as 
a matter of fact, the neoplasm 
is really in the cardiac end 
of the stomach. In these 
circumstances the growth may 
occasionally be felt in the 
latter situation and there is 
no excuse for not making such 
an examination as might detect it. For the same 
reason and in order to eliminate advanced cases 
examination of the liver and peritoneal cavity for 
secondary deposits is important. 


USE OF X RAYS AND QOSOPHAGOSCOPE 


The detection of growths in the middle part of the 
tube by ordinary examination is wellnigh impossible, 
but it should never be omitted because sometimes 
the signs point to an extra-cesophageal growth, which 
will explain all the symptoms. The confirmation 
of the diagnosis in the absence of physical signs is 
of course most conveniently made by X ray examina- 
tion, and this may tell us a great deal more than 


3 Brit. Jour. cf Surg., 1935, xxii., 829. 


(2 THE LANCET] 


merely the situation and the nature of the obstruction, 
In fact, if we are to contemplate direct interference, 
we must ask of it information, not only as to the 
nature and site, but with regard to the size, the shape, 
and especially the length of the growth, as well as 
the question of the condition of the msophagus 
above it. It is also by this plan that I think we 
may get the most valuable help as to the question 
of fixation of the growth by local infiltration. This 
may be demonstrated by the absence of the swallowing 
movements conveyed to the growth and possibly 
by movement in response to change of position. It 
has been suggested that the relationship of the 
neighbouring organs, for instance the aorta and the 
heart, may similarly give such information. 


After the X ray examination, the use of the cso- 
phagoscope is by far the most important method. 
By its means the presence and nature of a suspected 
lesion can usually be determined and in doubtful 
cases a fragment may be removed for histological 
examination, while the presence of outlying nodules 
and multiple growths may also be established. I 
have been a little disappointed at the small amount 
of other information which this method furnishes ; 
one cannot get much help with regard to the 
extension of the growth beyond the wall of the 
esophagus. If there is any question of the involve- 
ment of the lung root, bronchoscopy should certainly 
be carried out and has occasionally given valuable 
information. The method of retrograde csophago- 
scopy is now on trial and may have possibilities that 
make it worth while, in spite of the fact that it 
demands an abdominal operation in itself. Gross 
extension to other parts and the involvement of 
nerves, such as the recurrent laryngeal and 
sympathetic, are an evidence of the utter futility 
of any but the simplest palliative measures. As 
yet most patients suffering from cesophageal growths 
are in a state of serious subnutrition when they come 


under the notice of the surgeon, and gastrostomy. 


or jejunostomy is imperative. In these circum- 
stances I think it is much better to make the 
gastrostomy first and to carry out detailed investiga- 
tion as soon as their condition will allow. Whenever 
the patient’s condition permits the upper abdomen 
should be explored at the time that the gastrostomy 
is made. When the growth is at the lower end, any 
extension to the stomach can be noted and whether 
or not there are secondary deposits in the liver. The 
condition of the glands along the lesser curve of the 
stomach is most important, for when they are 
infiltrated in esophageal cases it almost invariably 
means that the growth is entirely beyond the 
possibility of direct interference. But having dis- 
covered the presence of a growth and eliminated 
such ordinary signs of dissemination as can be made 
out on clinical examination, what more can we do 
in order to determine whether or not there are such 
hidden extensions of the neoplasm as to render ,an 
attempt at its removal inadvisable ? 


I would like to emphasise the importance of 
re-examining these patients after such relief as may 
have been provided by gastrostomy. An extension 
to the bronchus may be entirely unsuspected one 
day, while by the next perforation may have occurred 
and aspiration pneumonia be developing. General well- 
being as expressed by the patient, appetite and relish 
for food, and gain in weight are the best indications 
of improvement. Despite what has been said by the 
‘ardent endoscopists about the futility of surgical 
exploration there are ways in which useful information 
may be gained without unjustifiable risk, 


PROF. G. GREY TURNER: CARCINOMA OF THE GSOPHAGUS 


exploration had inflicted. 


[san. 11, 1936 


THREE AVENUES OF EXPLORATION 


Growths in the upper third may be explored by 
exposing the csophagus in the root of the neck and 
sounding the cesophageal tunnel with the finger. 
If the growth is found to have infiltrated the peri- 
esophageal tissues or neighbouring structures like 
the trachea or aortic arch the exploration may be 
abandoned without the patient coming to any harm. 
With growths in the lower third the same sort of 
exploration may be conducted from the abdomen. 
The left lobe of the liver should be mobilised and the 
tunnel sounded with the finger introduced through 
the diaphragmatic hiatus (Fig. 2). For growths in 
the intervening portion, the transpleural approach 
is both feasible and practicable and is not necessarily 
attended with any great risk. 


By whatever route the exploration is conducted, 
it should be the rule that unless the csophagus with 
the growth can be easily separated from its bed by 
the insinuating finger it is best not to attempt removal. 
I have conducted each of these methods of explora- 
tion without any harm coming to the patient. When 
it has been otherwise the fatality has nearly always 
resulted from opening up an infected focus outside 
the growth or actually tearing into the growth itself. 
In either case a rapid form of infective mediastinitis 
has carried off the patient. Whenever the surgeon 
makes such an exploration, he ought to be prepared 
to carry straight on with the operation of excision 
if found to be feasible. In some cases a growth of the 
lower cesophagus has been explored by sounding the 
tunnel at the time of making the gastrostomy. Having 
found the conditions favourable for an attempt 
at removal, I have returned to the problem in three 
or four weeks’ time when the patient’s general condi- 
tion had sufficiently improved to warrant the attempt 
at excision. To my dismay the growth was.by then 
densely fixed and _ irremovable, presumably a 
consequence of the previous traumatism which the 
So that Iam prepared to 
advise that if the patient is well enough when the 
gastrostomy is required, the condition of the liver 
and the glands along the lesser curvature may be 
investigated, but that any further exploration should 
be deferred until the patient has obtained the 
optimum improvement from preliminary measures 
and the surgeon is prepared directly to follow up 
exploration by excision should it appear feasible. 
For my own part I am not depressed by the 12 cases 
in which exploration has shown that the disease 
was too far advanced, but am greatly impressed by 
the fact that in no less than 19 cases it was possible to 
remove the growth, and in 13 with great promise of 
success, if technical preparation and achievement 
had been equal to the opportunity. 


(To be concluded) 


BRISTOL ROYAL INFIRMARY.—The number of 
patients received during the year at this hospital again 
reached a record, the casualty department dealing with 
42,000 cases (115 a day). The annual expenditure 
exceeds the annual income by £30 a day. 


HOME FOR RUEUMATIC CHILDREN AT SMETHWICK.— 
Dr. Clyde McKenzie, chairman of the health committee, 
announced at a meeting of the Smethwick town council 
on Jan. Ist that the Ministry of Health had approved the 
scheme for the provision of a home for rheumatic and 
marasmie children. The building will accommodate some 
30 childron, and will adjoin the Firs Open-Air School, 
which those children will be able to attend. 


THE LANCET] | 


INTERMITTENT CLAUDICATION AND 
ITS QUANTITATIVE MEASUREMENT 


By H. T. Simmons, Ch.M. Manch., F.R.C.S. Eng. 


ASSISTANT SURGEON TO THE CHRISTIE HOSPITAL AND HOLT 
RADIUM INSTITUTE, MANCHESTER; OHIEF ASSISTANT, 
MANCHESTER ROYAL INFIRMARY 


(From the Department of Surgery, University 
of Manchester) 


INTERMITTENT attacks of limping in horses have 
been recognised by veterinary surgeons for well over 
a century and in 1831 Boullay! demonstrated that 
they were associated with an ischemic condition of 
the hind limbs. In 1858 Charcot ? described a similar 
condition occurring in a man and introduced the 
name intermittent claudication. His patient had a 
traumatic aneurysm of the proximal part of the right 
common iliac artery, with obliteration of the lumen 
of the distal portion, and Charcot pointed out the 
similarities between the intermittent limping of this 
man and that observed in horses. Erb,’ and the 
German writers immediately following him, gave 
excellent descriptions of the claudication and asso- 
ciated symptoms, but wrote as though it constituted 
a morbid entity, inventing at the same time a number 
of different descriptive names which only served to 
confuse the issue. Buerger * vigorously attacked the 
suggestion that this condition constitutes a disease ; 
he ‘pointed. out that intermittent claudication is a 
very striking symptom of muscular ischemia due to 
varying pathological conditions. 

A small proportion of cases of intermittent claudi- 
cation are due to pure spasm of the arteries in neuro- 
pathic individuals and no structural disease of the 
vessels is demonstrable either at the time or in later 
years. Apart from this relatively rare ‘functional 
vasomotor ’’ type, the presence of this symptom is 
evidence of organic vascular disease which has 
produced some degree of occlusion in the vessel. 
Arterio-sclerosis, thrombo-angiitis obliterans, and 
syphilitic endarteritis are the usual causes of the 
vascular disease. The symptom of intermittent 
claudication is, however, most often present and best 
studied in thrombo-angiitis obliterans. 

The patient complains that shortly after beginning 
to walk he notices 
paresthesiz, ten- 
sion, and weakness 
in the calf muscles 
which become 
painful. These 
symptoms steadily 
increase in sever- 
ity so that walking 
is embarrassed 
and finally be- 
comes impossible. 
The symptoms 
fade after a rest of 
a few minutes and 
a further period of 
walking is then 
possible. 

The pain is 
cramplike and 
arresting, usually 
in the calf, but 
sometimes in the 
sole of the foot. 
A few patients - 


MR. H. T. SIMMONS : INTERMITTENT CLAUDICATION 


The apparatus in use. = .’>3 , 


(san. 11, 1936 73 


have likened it to “a clod of clay under the 
foot,” and others to a “tight string tied round 
the calf, just below the knee.” The trouble begins 
earlier if the patient walks rapidly, or uphill, an 
observation which he quickly makes and allows for 
in his walking. The muscles of the thigh and buttock 
may be affected, indicating involvement of the iliac 
vessels and a graver prognosis. 

This typical sequence of embarrassment of muscular 
action after a short period of work, followed by 
recovery on resting, occurs in other muscle groups, 
and the term intermittent claudication is applied 
to the syndrome when observed in any part of the 
body, though it is usually restricted to its occurrence 
in the lower limbs. The arms are occasionally 
affected in arterio-sclerosis, and in thrombo-angiitis 
the presence of claudication in the arms is of grave 
omen because the legs will be found to be extensively 
involved, if, indeed, they have not already been 
amputated. Determan® reported the case of a 
young Russian whose tongue was affected so that 
after 5-8 minutes, speech became impossible and the > 
motility returned only after a period of rest. 

Charcot believed that the pain was due to the 
ischemia and resulting anoxia of the muscles and 
nerves of the limb, but Lewis* with his recent 
experiments suggests that the muscles elaborate a 
pain-producing factor (P). This passes out into the 
tissue spaces and is normally removed by the blood 
stream. The development of pain is dependent on 
the accumulation of a certain concentration of this 
substance in the tissue spaces, and so long as the 
circulation is adequate pain is avoided. Should the 
circulation be inadequate, pain is produced when the 
requisite concentration of P is attained, and dis- 
appears only after a period of rest long enough to 
enable the blood stream to wash away the P factor 
and lower its concentration below the pain threshold. 


A METHOD OF ESTIMATING CIRCULATORY EFFICIENCY 
IN THE LEGS 


The condition is always bilateral in thrombo- 
angiitis obliterans, but the leg more severely affected 
always halts the patient, so that he is not aware of the 
condition of the other leg. It is a peculiar and 
constant observation that when the second leg does 
give symptoms, the arterial occlusion progresses 
much more rapidly than on the side first affected. 
It is important, 
therefore, to esti- 
mate the condition 
of the circulation 
in both legs, and 
especially when 
considering sym- 
pathectomy opera- 
tions for thrombo- 
angiitis obliterans. 
The chief anxiety 
of the surgeon who 
is called upon to 
advise for or 
against sympa- 
thectomy in a 
case of thrombo- 
angiitis obliterans, 
lies in the difħ- 
culty he has in 
estimating just 
how far the 
circulation of the 
limb is depre- 
ciated. 


[4 THE LANCET] 


MR. H. T. SIMMONS : INTERMITTENT CLAUDICATION 


[sax. 11, 1936 


The rate of appearance of rubor in the dependent 
and of blanching in the elevated position will afford 
some guide; the more rapidly these things happen, 
the worse is the circulation. Such a guide is, however, 
at best a rough one. The effect of a spinal anesthetic 
in raising the surface temperature of the limb is 
apt to be misleading since a rise of skin temperature 
bears no necessary relation to the amount of blood 
which may be entering the muscle bellies. The 
patient’s own account of his symptoms is of small 
value, vitiated as it is by differences of level and of 
speed. Prof. E. D. Telford suggested that some 
simple form of ergometer might supply the informa- 
tion required and in a numerical form. Accordingly 
the apparatus here illustrated has been erected and 
used in several cases. It consists of a simple ergo- 
meter made out of a single inclined plane foot-splint 
with a hinged foot-piece. 

In our experiments we have used a weight of 51b. 
and governed the rate of the exercise by a metronome 
working at 60 beats per minute. The foot is fully 
elevated at one beat and depressed at the next so 
that the weight is raised 30 times per minute. 
Difficulty in counting the beats is avoided by timing, 
and half the time, expressed in seconds, gives the 
number of elevations of the weight. This is the 
figure that we have used to express the results. We 
incline the leg piece at an angle of 20° with the idea 
of ensuring an adequate venous return so that our 
estimation is directly concerned with arterial flow. 
It is necessary to prevent the patient raising the 
thigh from the splint. Flexion at the knee and the 
use of the thigh muscles must not be allowed. This 
is secured by the use of an adjustable arch of 
Duralumin, so arranged that no constriction falls 
on the thigh. It is also advantageous to give the 
patient a loop of bandage to hold on to the apparatus 
so that he keeps his foot squarely planted against 
the foot-piece. Reviewing the results we find that 
a normal man can elevate the weight easily 150 times 
without discomfort. He then notices a dull ache 
about the instep and calf which does not progress 
in severity and which does not prevenc him from 
carrying on for 250 times, or more. 


THE TEST IN ACTION 


The cases of intermittent claudication studied 
have been due to thrombo-angiitis obliterans and here 
the result is quite different. In some cases, shortly 
after commencing the exercise, a sudden pallor of the 
foot has been noticed, followed by pain in the instep 
and lower third of the calf. A rapid increase in the 
severity of the pain occurs with short, rapid, irregular 
excursions of the foot, until the movement ceases, 
the patient stating that the pain prevents continua- 
tion of the exercise. The pain is exactly similar to 
that which he experiences on walking. We have 
always tested the more affected limb first, unless there 
has been any contra-indication such as gangrene, or 
ulceration extending on to the plantar surface. The 
patient has been surprised to find that testing of his 
supposedly good leg has produced very little better 
results than those shown on the side of which he was 
complaining. A typical case is as follows :— 

A blacksmith’s striker, 45 years of age, well built and 
six feet in height, developed phlebitis in the superficial 
veins of the calf of his left leg during August, 1934. He 
was confined to bed for a month and, during his con- 
valescence, noticed that cramplike pains appeared 
in the calf of his left leg if he walked some fifty yards. 
After a rest of 5-10 minutes he could resume walking, only 
to be stopped again by the cramp, after continuing a 
further fifty yards. For about a year before the attack 


of phlebitis he had noticed a similar pain in the left 
leg, but only following a long walk, or towards the end of 
a busy day. The right leg never troubled him and he had 
no rest pain. 

He came for examination in January, 1935, and then 
could only walk about ten yards before the pain appeared 
in the left calf. Both feet showed a moderate degree of 
rubor, particularly the left. Raising the legs to 45° 
caused blanching of both feet in thirty seconds and again 
the blanching was more severe in the left foot. No pulses 
were palpable in either leg, but the thighs showed weak 
popliteal and superficial femoral pulses on either side. 
On both sides there was present a good, strong common 
femoral pulse. The blood pressure was 124/85, the 
Wassermann reaction was negative, and general examina- 
tion revealed no other abnormality. The result of the 
claudication test was as follows :— 


Plantar 
flexions. 


{ 25. a 
37 " 

{ ST. 48 
ae 

This case may be taken as one of typical thrombo- 
angiitis obliterans of moderate severity, likely to 
give a satisfactory result after lumbar cord 
ganglionectomy. This satisfactory result was indeed 


obtained as is shown by the readings given by the 
claudicometer ten months after operation. 


Remarks. 
Pain commencing. 
Unable to continue. 
Pain commencing. 
Unable to continue. 


Left leg 
Right leg aon 


Plantar 
flexions. Remarks. 
130 Pain commencing. 
Leg leg { 150 Continuing, but some diffi- 
culty. 
Right leg .. 150 he No discomfort of any kind. 


The method appears capable of expressing as a 
definite figure what one may call the circulatory 
value of a limb, and particularly is it valuable in 
assessing the condition of the leg less affected and 
of which the patient is not complaining. It is likely, 
as cases accumulate, that this simple method will 
afford a means of recording results much more 
accurately than is now done. It is obvious that 
terms such as “good,” ‘fair,’ “improved” depend 
too much on the personal equation of both patient 
and surgeon to be of much value as clinical records. 


SUMMARY 


The symptoms of intermittent claudication are 
briefly reviewed and a simple ergometric method is 
described by which the severity of this symptom, 
and its progress after sympathectomy, can be 
conveniently estimated. 


REFERENCES 


1. Boullay: Arch. gén. de méd., 1831, xxvii., 425. 

2. Charcot, J.M. : Compt. rend. Soc. de biol., 1858, v., 225. 

3. Erb, W. H. : Deut. Zeits. f. Nervenheilk., 1898, xiii., 76. 

4. Buerger, L.: Circulatory Diseases of Extremities, Phil- 
adelphia and London, 1924. 


5. Determann, H.: Deut. Zeits. f. Nervenheilk., 1905, xxix., 
152. 


6. Lewis, T.: Arch. Internal Med., 1932, xlix., 713. 


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THE LANCET] ~ 


| LUMBOSACRAL STRAIN | 
By Q. A. Œ. Mitcnett, M.B., Ch.M. Aberd. 


SURGICAL SPECIALIST FOR THE COUNTY OF CAITHNESS 


Few nowadays deny the possibility of such an 
entity as lumbosacral strain. The pendulum indeed 
has swung too far in the opposite direction, and the 
condition is diagnosed too often. Only a greater 
knowledge of its etiology and clinical features will 
enable us to give strain its true significance. 


THE CAUSES OF STRAIN 


To understand how lumbosacral strain is produced, 
a knowledge of the anatomy and mechanics of the 
lower spine is essential. As these have already been 
described in several papers,?° 21 28 27 46 55: 68 this aspect 
of the problem will not be considered here. 

Acute lumbosacral strain may be -caused by a 
sudden blow forcing the junction into positions 
beyond the normal limits of its mobility, by an 
effort to prevent some heavy article from falling, or 
by a sudden movement of the body in attempting to 
regain lost balance; the spinal muscles are caught 
off their guard and the ligaments sustain the full 
force of the injury. The ligaments and the surround- 
ing muscles are stretched or torn, the synovial 
membrane and articular cartilages of the lumbosacral 
interarticular joints are bruised, and the corresponding 
intervertebral disc suffers. One or other. of these 
structures may be predominantly affected, and all 
gradations of severity are encountered. Acute strains 
may also be caused by lifting a heavy weight with the 
body in aslightly bent position, the stoop accentuating 
the sacral obliquity and increasing the shearing stress 
at the lumbosacral junction. Another cause is the 
failure to provide support for the lumbar spine during 
an operation under a general or spinal anesthetic or 
during a debilitating illness, when muscle relaxation 
and weakness throw additional strain on the ligaments. 

After a heavy fall on the buttocks or feet, complaint 
is often made of low back pain which is sometimes 
due to lumbosacral strain, although this diagnosis 
cannot be confirmed until enough time has elapsed 
to exclude a possible vertebral crush-fracture. The 
momentum of the falling body,when suddenly arrested, 
produces a strong downward thrust at the lumbo- 
sacral junction, and the patient will be fortunate if 
he sustains no more serious injury than a strain. 
Sometimes the lumbosacral angulation is found to be 
increased after such falls, and nerve features suggestive 
of irritation or injury may be discovered. It has been 
suggested that the increased prominence of the 
junction causes tension on the fourth or fifth lumbar 
nerves as they pass downwards in the lumbosacral 
cord to join the sacral plexus, but it is more probable 
that they are involved in peri-articular exudate. 

Diseases or deformities of the lower extremities 
interfere with the gait, posture, and body balance, 
and occasionally give rise to lumbosacral or inter- 
vertebral strains. Employment necessitating a con- 
tinual stooping or semi-stooping posture increases 
lumbosacral shearing stresses and throws great strain 
on-the back muscles, which become fatigued and 
leave the ligaments to bear most of the load. Working 
with one foot higher than the other for a long time is 
said to be the chief «xtiological factor in many cases 
of strain in surgeons and dentists, but this danger 
may be averted if the foot is kept in the elevated 
position only for short periods, or if the feet are 
elevated alternately. It is doubtful if the wearing of 


MR. G. A. G. MITCHELL: 


LUMBOSACRAL STRAIN [yan. 11; 1936 75 
high-heeled shoes is a common cause of low back 
strain. The tilt produced is mainly compensated for 
by extension at the ankle-joints and to a lesser degree 
at the hips, and there is little evidence that. a lumbar 
lordosis of sufficient degree to cause ligamentous 
strain is produced; the mechanism of the foot is 
more liable to suffer than the lower spine. Postural 
and static derangements produce their evil effects 
by necessitating the prolonged use of the various 
spinal articulations in abnormal positions, and, just 
as an unevenly fitted hinge suffers from excessive 
friction, so do joints suffer from repeated minor 
injuries caused by working in unusual or extreme 
positions. 

An increase in the weight of the abdominal contents 
interferes with the body balance, and throws increased 
strain on the lower spine, the additional weight pulling 
the trunk downwards and forwards and. displacing 
the centre of gravity anteriorly. To bring the centre 
of gravity back to a more normal position, the 
lumbar spine assumes varying degrees of lordosis, 
while the back' muscles contract more powerfully to 
sustain the additional weight and to maintain the 
lumbar lordosis necessary for equilibrium. When tha 
body is erect, these muscles are in a state of. postural 
tonus. Normally this can be maintained almost 
indefinitely and without voluntary effort, for the 
muscle-fibres act in relays, and when one set is in 
action the others are quiescent or recovering. A great 
increase in the load borne by the back muscles upsets 
the posturing mechanism by throwing an abnormal 
strain on the muscles, and the lumbar lordosis present 
in such cases shortens the muscle-fibres so that 
their power of contraction is decreased according to 
the well-known physiological law. Neurasthenia, 
excessive mental work, and worry have also been 
blamed for upsetting the delicate proprioceptive 
reflexes which govern the maintenance of posture. 
In whatever manner the mechanism is upset, the end- 
result is the same—a certain amount of voluntary 
muscular effort becomes necessary, and this, in 
contradistinction to postural contraction, rapidly 
leads to muscle exhaustion and relaxation so that the 
ligaments have to bear more strain than usual. 
Should the muscles be weak or atonic for any reason, 
fatigue and strain are even more readily induced. 

Goldthwait,?* 27 who did much pioneer work on the 
genesis of back strains, distinguished two types of 
persons who are particularly liable to suffer from low 
backache. 

(1) The visceroptotic, with poor muscular development, 
a long narrow back, a flexible spine often showing lumbar 
lordosis, and a sharp lumbosacral angle. This type seems 
to be specially subject to sacro-iliac strain. 

(2) The exact opposite—a heavy individual, with a 
short thick-set body, limited mobility of the lumbar 
spine, and a varying degree of lumbar lordosis. 


In this second type lateral bending in particular 
is limited, but all spinal movements are restricted. 
The vertebral bodies and articular processes are 
large, the latter having crescentic facets, whereas in 
the first type the vertebral bodies and articular 
processes are smaller and the articular facets are 
flattened. These bony differences explain the varia- 
tions in the spinal mobility in the two types. 
Goldthwait’s second type is supposed to be specially 


liable to lumbosacral strain. | 


SYMPTOMS 


The chief symptom in lumbosacral strain is low 
back pain and the onset may be sudden and acute or 
chronic and insidious. In acute strains the patient 

B2 


/ 
76 THE LANCET] 


often volunteers the information that, while he was 
lifting a heavy weight or making a sudden movement, 
he felt something snap and immediately experienced 
pain in the fower back. The pain may be intense 
and localised at first, but later it becomes less severe 
and persists in a milder form for a variable period. 
Movement of the back increases the pain. Deep 
breathing and expulsive efforts produce the same 
effect, and Heald 2° suggests that this is due to tearing 
of the quadratus lumborum and its anterior fascial 
covering near their attachment to the iliolumbar 
ligament as a result of a sudden contraction in an 
asymmetrical position. This may occur alone, or 
in association with lumbosacral articular injury, 
and is likely to be unilateral. The pain is explained 
by the fact that the quadratus lumborum muscles 
contract during expulsive efforts in order to steady the 
lower ribs, and the diaphragm arises partly from the 
external arcuate ligaments, which are thickened 
parts of the anterior fascial coverings of the quadratus 
lumborum muscles. 

Sometimes the pain is completely confined to one 
side, and radiates along the branches of the great 
sciatic nerve. The lumbosacral articular structures 


are supplied by. 


the fourth and 
fifth lumbar 
nerves, and the 
anterior and 
posterior divi- 
sions of the 
fifth lumbar 
nerves are in 
close anatomi- 
cal relationship 
to the articu- 
lations. There- 
fore pain may 
be either of 
the referred 
variety due to 
irritation of 
the articular 
nerve-endings, 
or may he caused by direct compression of the 
fifth lumbar nerve by peniarticular oedema or 
hemorrhage ; at a later date the same effect may be 
produced by adhesions, ecchondroses, or osteophytes. 
The distribution of the pain corresponds with the 
cutaneous areas supplied by the fourth and fifth 
lumbar nerves, the fifth nerve areas being more often 
involved than the fourth. (See Figure.) 

Effective treatment quickly relieves the pain but, 
if it is inadequate, the condition passes into a sub- 
acute or chronic stage with intractable backache 
which is aggravated by hard work, trauma, or climatic 
changes. In chronic cases the pain is more diffuse 
than in acute cases, and all have varying degrees of 
disability. Patients with increase or decrease in 
the normal lumbar curvature often have severe pain 
in the early stages of their deformity when the liga- 
ments are stretching, but as the deformity becomes 
more pronounced the pain becomes progressivoly less, 
till in advanced cases it may be absent. The patient 
then describes his condition as a weak back because, 
although the pain goes, a feeling of weakness persists. 
Others lose all their symptoms and imagine they are 
cured. This type of case has been compared to the 
early and late stages of flat-feet. In the early stages 
pain is often severe, but as the ligaments stretch 
further the pain gradually decreases, till in the late 
stage with complete flattening it may be entirely 
absent. 


The commonest sites of referred pain and 
of hyperesthesia in lumbosacral strain. 


MR. G. A. G. MITCHELL: LUMBOSACRAL STRAIN 


fsan. 11, 1936 


The symptoms may be out of all proportion 
to the injury sustained, especially in middle-aged and 
elderly persons who already have a pathological 
condition, such as osteo-arthritis, affecting the lower 
spine. Until the time of the injury the disease 
may have been entirely latent, and there may be 
difficulty in deciding whether the symptoms and 
signs are due to the osteo-arthritis, or whether the 
clinical features are due to the combined effects 
of strain and osteo-arthritis. In many cases, even 
with the most complete examination, no definite 
decision can be given. In younger persons a 
congenital abnormality may account for dis- 
proportionately severe symptoms, while in others 
a functional element may be present. .In a few 
malingering may be suspected, but the consensus 
of expert opinion appears to be that this is 
comparatively rare. 


SIGNS 


The patient may conform to one or other of 
Goldthwait’s types. A pendulous abdomen is a 
common finding, and distension due to cyesis, cysts, 
or tumours may be discovered. Owing to the depth 
of the lesions, swelling and discoloration in the 
lumbosacral region are rare even in acute cases. 
Deformities of the lower limbs or spine and faulty 
posture should be noted. The spine may show a 
lumbar lordosis, and, in cases with unilateral pain, 
there is often a slight scoliosis to the unaffected 
side which relieves pressure on the injured joints 
and widens the intervertebral canals on the affected 
side, thus diminishing the possibility of pressure 
on nerves. 

Palpation of the lower spine yields valuable informa- 
tion in all cases. Pressure over the spinous processes 
of the last lumbar or first sacral vertebræ, or in the 
space between may elicit tenderness, but more 
commonly deep pressure over the regions of the last 
lumbar transverse processes is necessary before 
pain is produced. The tenderness is usually greater 
on one side and occasionally is completely unilateral. 
In thin persons, deep abdominal palpation may 
elicit tenderness over the anterior aspect of the 
lumbosacral junction. A functional element or 
malingering should be suspected if the patient is 
inaccurate in the location of points of tenderness, 
and if he contradicts himself during the same or 
subsequent examinations. If one is in-doubt, the 
following manouvre is often valuable. The hand 
is placed on the tender region and the patient is asked 
to lean backwards. As he does so, the hand exerts 
increasing pressure and in a genuine case the patient 
soon recognises this, but a malingerer may be so 
concerned in retaining his balance that he fails to 
realise that he is now withstanding considerable 
pressure On a region which a short time before was 
sensitive to the slightest touch. This test loses 
much of its value if a neurasthenic element is present, 
for in traumatic spinal neurasthenia a paradoxical 
response to light and deep pressure is well known. 

In chronic cases pressure over the various points 
mentioned may cause discomfort rather than actual 
pain, and this discomfort is usually greater if the 
pressure is applied when the patient is stooping. 
Spasm and tenderness of the lower back muscles are 
common in acute cases. The former is of a reflex 
protective nature, while the latter is due partly to 
muscular hyperalgesia and partly to tearing of 
muscle and aponcurotic fibres. 

Neurological examination may reveal tenderness 
over the course of the great sciatic nerve, and 
hyperesthesia along the antero- and posterolateral 


THE LANCET] 


aspects of the leg or ankle, or about the sole 
of the foot. If it is bilateral, one leg is commonly 
more affected than the other. Muscle wasting, 
hypertonicity, or atonicity are slight or absent, and 
the tendon reflexes are normal; if they are abnormal, 
itis probable that lumbosacral strain is not the only 
lesion present. I cannot agree with those writers 
who claim that the first sacral nerves supply branches 
to the lumbosacral articulations, and who therefore 
assume that changes in the tendo-Achillis reflexes, 
and referred pains in the area of cutaneous distribution 
of one or both first sacral nerves, are possibilities in 
uncomplicated lumbosacral strain. Attention might 
be drawn to another common mistake, that the 
posterior divisions of the fifth lumbar nerves supply 
the skin over the lumbosacral region posteriorly, so 
that referred pain and hyperesthesia are present in 
this area in cases of lumbosacral strain. The posterior 
divisions of the last two lumbar nerves end in the 
muscles and. never reach the skin, and it is muscular 
hyperalgesia and not cutaneous hyperesthesia which 
is present. 

An investigation of the lower spinal movements 
reveals interesting changes, though it is necessary 
to recollect that the degree of spinal mobility varies 
greatly even in normal individuals. In acute cases 
muscle spasm interferes with both flexion and 
extension, whether the patient is standing, sitting, 
or lying, and whether the movements are actively 
or passively produced. Likewise lateral bending of 
the lower spine is impaired, but it is often freer 
towards one side than the other. In these cases the 
symptoms and signs are mainly or completely unilateral, 
and the freer movement occurs away from the affected 
side. If the patient is asked to bend in various 
directions, he usually holds his lower spine immobile 
and assumes the desired position by movements at 
other joints. Heald ?* states that when one quadratus 
lumborum muscle is torn the patient, when lying 
supine, cannot raise both legs simultaneously if the 
feet are placed six inches apart. 

Rectal examination is negative in uncomplicated 
cases of lumbosacral strain, unless the sacral pro- 
montory can be reached, when slight pain may be 
produced. 


RADIOGRAPHIC APPEARANCES 


In acute uncomplicated lumbosacral strain radio- 
graphy shows nothing abnormal, but in chronic 
cases partial ossification of one or both iliolumbar 
ligaments is occasionally seen and osteo-arthritic 
changes are not uncommon. Lateral views show 
the type of lumbar curve, and, if there is much 
lordosis, the spinous processes may be seen impinging 
on each other. Congenital anomalies about the 
sacrovertebral junction should be looked for and the 
size of the lumbosacral angle estimated. Since the 
arrangement of the lumbosacral articular processes 
is very important, Berry ê has devised a special 
radiological technique to determine the angles at 
which these processes are set so that any asymmetry 
can be detected. 


DIFFERENTIAL DIAGNOSIS 


Fractures or dislocations in the lumbosacral 
region must be excluded, and, as radiographic evidence 
of a vertebral compression fracture is often delayed, 
several examinations may be necessary before a 
positive opinion can be given. Good lateral radio- 
grams are essential to differentiate between lumbo- 
sacral strain and early cases of spondylolisthesis.* 45 
In a case of suspected strain X rays may reveal other 


MR. G. A. G. MITCHELL: 


LUMBOSACRAL STRAIN [yan. 11, 1936 77 
pathological changes, such as osteo-arthritis, tuber- 
culosis, primary or secondary neoplasms, or gono- 
coccal spondylitis, the symptoms being due to a 
flare up of the previously quiescent disease. Rarer 
conditions, such as acute osteomyelitis, ‘ typhoid 
spine,” gummatous osteitis, osteomalacia, osteitis 
fibrosa, osteitis deformans, and tumours of the 
cauda equina and meninges are less likely to cause 
difficulties in differential diagnosis. Low back pain 
is occasionally the earliest symptom in disseminated 
sclerosis and tabes dorsalis, and the referred pain 
in the legs and feet in cases of strain may be mistaken 
for sciatica, while the hyperalgesia of the lower 
spinal muscles may be suggestive of fibromyositis, 
the true underlying lesion being missed. Some- 
times lumbosacral strain may simulate diseases of 
the kidney, appendix, uterus, or other viscera. 


Congenital anomalies such as spina bifida occulta, 
interarticular neural arch defects, sacralisation or 
lumbarisation, may predispose to strain or cause 
similar symptoms. Incomplete  sacralisation or 
lumbarisation gives rise to most difficulty in diagnosis 
and unilateral symptoms and signs in such a case 
suggest that the congenital abnormality may be 
the cause of the trouble. Spina bifida occulta may 
cause characteristic nerve features, but local signs 
are slight and spinal mobility is scarcely affected. 
Interarticular arch defects of the fifth lumbar vertebra 
undoubtedly predispose to strain, and it is impossible 
to separate the symptoms of the former from the 
latter. 

Finally there is the problem of differentiating 
lumbosacral from sacro-iliac strain. In a certain 
proportion of cases, variously estimated. at from 
8-33 per cent., a condition of combined pelvic joint 
strain exists. In the others the history, physical 
examination, and radiographic findings must be 
considered in every detail, as the diagnosis can be 
made only by piecing together scraps of evidence 
which by themselves would be inconclusive, but which, 
when taken together, make a complete case incriminat- 
ing one or other joint. 

Exact information should be obtained regarding 
the onset of symptoms. The occurrence of a snap 
or “giving-way’’ sensation is important, and one 
should discover the exact site of the initial pain and 
whether it radiated. The attitude of the patient 
at the onset, and the position of maximum comfort 
should be ascertained; a patient with sacro-iliac 
strain is usually most comfortable when lying in 
bed on his unaffected side; a patient with lumbo- 
sacral strain when lying on his back with a support 
under the lumbar spine. Valuable information is 
obtained by watching the patient walking, standing, 
or attempting to climb stairs. The short deliberate 
steps to avoid any jolt or jar, the tendency to climb 
stairs like a man with an artificial limb, and the habit 
of standing with one leg bearing most of the weight 
and with the other leg slightly flexed at the knee 
are very characteristic of a sacro-iliac condition, 
but do not absolutely rule out lumbosacral disease. 
Great stress cannot be laid on alterations in the spinal 
curvature, but a lordosis is more common in lumbo- 
sacral and a scoliosis in sacro-iliac conditions. 


Pain and tenderness confined to the lumbosacral 
or sacro-iliac regions are of the utmost significance, 
but the proximity of the two areas, and inaccurate 
localisation on the part of the patient, may cause 
errors in diagnosis. Radiating pains or paresthesia 
are commoner and more extensive in sacro-iliac 
cases and are felt along the posterior aspects of the 
thigh and leg, the outer side of the leg, ankle, and foot, 


78 THE LANCET] © 


MR. G. A. G. MITCHELL : LUMBOSACRAL STRAIN 


[yan. 11, 1936 


and the posterior third of the sole of the foot. In 


lumbosacral derangements posterior thigh pains 
seldom occur, but the distribution of the leg pains 
closely resembles that. found in sacro-iliac cases. 
Referred pains confined to the outer border of the 
foot and the heel are more often secondary to sacro- 
iliac conditions, but, if they are confined to the toes, 
anterior part of the sole, and inner half of the foot, 
they are more often due to lumbosacral disease. 
Posterior thigh pain, if present alone, usually indicates 
a sacro-iliac condition, while pain referred entirely 
below the knee suggests lumbosacral strain. Other 
causes of radiating pain must be excluded. Wasting 
of the gluteal, hamstring, or calf muscles, or inter- 
ference .with the tendo-Achillis reflex, are rare in 
lumbosacral but common in sacro-iliac disease, and 
in the latter Gratz’s bimanual method of examination 2° 
may elicit tenderness about one or other sacro- 
iliac joint. X rays are not of much diagnostic 
value in acute cases, but in chronic cases they may 
show partial ossification of the iliolumbar ligaments 
or arthritic changes affecting either the sacro-iliac 
or lumbosacral regions. 


Forcible lateral pressure over the iliac crests causes 

pain in all cases of acute sacro-iliac strain and in many 
chronic cases, but seldom produces pain in lumbo- 
sacral strain. Pressure backwards over the symphysis 
pubis usually aggravates the pain in sacro-iliac 
but not in lumbosacral strains. Forced flexion, 
abduction, and external rotation at one hip-joint 
separate the innominate bones, cause movement at 
the sacro-iliac joints, and produce pain in cases of 
sacro-iliac strain (Smith-Petersen’s © “ cross-leg ” 
test.) Hyperextension at the hip-joint rotates the 
innominate bone on the same side and accentuates 
the pain of sacro-iliac strain. 
In Gaenslen’s ? test, the patient lies supine near one 
edge of a bed or couch. The leg further away from the 
edge is acutely flexed at the knee and hip till the thigh 
touches the abdomen, and the patient then holds the 
limb firmly in this position with both his arms, thus 
immobilising the lower spine. The other leg is allowed 
to hang down over the edge of the bed and it is pressed 
down till the tension on the ilio-femoral ligament and the 
muscles attached to the anterior superior and inferior 
iliac spines causes the innominate bone to rotate on the 
sacrum. In sacro-iliac strain both local and referred 
pains are produced, and, by performing the test on both 
sides, it is possible to tell which joint is affected. 


It has been claimed for all these tests that they will 
differentiate between lumbosacral and sacro-iliac 
conditions, but this is doubtful. The movements 
of the innominate bones may irritate a strained 
iliolumbar ligament or a torn quadratus lumborum 
muscle, which are occasional complications of lumbo- 
sacral strain, and low back pain may be produced 
in this way. Moreover, in Gaenslen’s test, the acute 
leg flexion straightens out the lumbar spine, and this 
in itself may cause pain in a case of lumbosacral 
strain. Thus none of these tests is absolutely 
diagnostic, though the evidence they supply is very 
valuable when studied in conjunction with other 
findings. 

The ‘‘straight-leg-raising °” test is performed with 
the patient supine. 

One hand is placed under the lumbar spine, and with 
the other hand first one leg and then the other is raised, 
keeping the knee extended; the hamstrings tighten and 
exert an ever-increasing pull on the tuber ischii, first 
causing rotation of the innominate bone on the same side, 
then tilting the whole pelvis backwards, and finally 
straightening out the lumbar curve. 

Movement is first produced at the sacro-iliac joint on the 
same side, soon followed by movement on the opposite 


side, and finally by movements at the lumbosacral and 
lumbar joints. Thus in unilateral sacro-iliac strain, the 
leg on the same side cannot be raised as high as the leg 
on the opposite side before pain is produced; while, 
if lumbosacral strain is present alone both legs can be 
raised higher, because pain is absent until movements 
occur at the lumbosacral junction. The commencement 
of movement in the lower spine can be felt by the hand 
placed under it, and it is easy to tell if pain occurs before 
or after spinal movements begin. If pain is caused before 
spinal movements begin it suggests involvement of the 
sacro-iliac and not the lumbosacral region, although even 
at this stage movement of the innominate bones might 
irritate a damaged iliolumbar ligament or quadratus 
lumborum muscle. Pain coming on after the lumbar 
spine begins to move is more likely to be due to lumbo- 
sacral strain. The exact site of the pain affords valuable 
additional help in locating the affected joint. 


Active and passive spinal and hip movements are 
examined when the patient is standing, sitting, and 
lying, and they may be altered in such a character- 
istic way that they provide valuable diagnostic 
data. As for the others, the degree of mobility in 
different people, in the two sexes, and at different 
ages, is so variable that there is no standard by which 
one can judge whether the range of spinal and hip 
movements is diminished. In the erect position, 
forward bending of the trunk is limited and causes 
pain in both forms of strain. If the patient sits 
down, forward bending becomes comparatively free 
and painless in sacro-iliac strain, but this is not so 
in lumbosacral cases. A sufferer from  sacro-iliac 
strain stoops by combined flexion of the spine and 
hips until the hamstrings become taut. The move- 
ment is then arrested because of pain in the affected 
joint and can be continued only by flexing the knee 
on the affected side to relax the hamstring tension. 
A patient with lumbosacral strain stoops forward 
by flexing the hips and knees, and the lower spine 
is held as rigid as possible. Lateral flexion of the 
spine is less restricted in sacro-iliac than in lumbo- 
sacralstrain. Smith-Petersen ® has found that passive 
flexion of the lumbar spine, produced by the examiner 
flexing the knees and hips while the patient is in the 


supine position, is much more likely to cause pain in 


lumbosacral than in sacro-iliac cases because the 
pelvis tends to move as a whole, thus eliminating 
movement at the sacro-iliac joints. All these signs 
and tests considered individually are inconclusive, 
but they may fit in with others just as pieces fit into 
a jig-saw puzzle, until a clear picture is evolved from 
the scattered fragments. 


TREATMENT 


During the acute stage rest in bed for 2-6 weeks 
is essential. In the early stages sedatives may be 
necessary to relieve the pain, and hot fomentations 
or cold compresses are soothing. The patient should 
lie on a firm bed, but soft pillows placed under the 
knees and the lumbar region often give relief. If the 
pain persists, the back should be strapped with 
3-in. wide adhesive plaster, one layer being applied 
obliquely and another vertically, from the level of 
the lower dorsal spine to the trochanters ; anteriorly 
the strapping should not extend further than the 
lateral abdominal lines. In a severe case the patient 
should be nursed on a posterior plaster shell. 


When the acute. symptoms have subsided, local 
massage should be commenced and physio- 
therapeutic measures instituted. These aid in the 
absorption of effusion, relieve discomfort and stiffness, 
and expedite repair. Ultra-violet radiation, radiant 
heat, radiotherapy, jonisation, or diathermy may be 


THE LANCET] 


employed either alone or in combination, and seldom 
fail to produce a beneficial effect. Graduated passive 
and active. movements should be commenced in 
six or seven days, or earlier, and should be continued 
until full movements are allowed in the- sitting or 
recumbent position by the end of 10-20 days, accord- 
ing to the acuteness of the symptoms. These move- 
ments prevent the formation of periarticular adhesions 
which are so often the cause of persistent pain and 
disability. Deep-breathing exercises. in bed are 
advocated by one or two writers. In the severer 
cases the patient should be provided with a plaster 
jacket, or a properly fitted back brace, when he is 
alowed up; women prefer strong, specially made 
corsets. The corsets or back brace should be worn 
during the day for three months to allow of complete 
healing of ligaments, but the prolonged use of a 
brace is necessary only in exceptional cases. A 
course of remedial exercises to strengthen the back 
and abdominal muscles and to correct postural 
defects should be prescribed, and these have been 
advocated as a prophylactic measure after child- 
birth, Women should be advised to avoid preg- 
nancy for at least a year after an acute lumbosacral 
strain. ; 
_ In chronic strain, rest in bed for a short period at 
the commencement of treatment is beneficial, and 
physiotherapeutic measures are as important as in 
acute strain. The-patient’s general health should 
receive attention, constipation is treated, and septic 
foci are eradicated. Large abdominal neoplasms 
or cysts are removed, and obese patients or those 
with pendulous abdomens should be put on a suitable 
diet and fitted with an abdominal support. A back 
brace is not always necessary or advisable as it 
focuses the patient’s attention too much on his weak 
back, but, if the pain and disability are considerable, 
and especially if the patient’s work is arduous, there 
should be no hesitation in prescribing one. Faulty 
posture should be corrected, and if it is due to any 
remediable cause, such as a deformity of a lower 
limb, this must be treated by operation, or by a 
suitable orthopedic appliance. The patient should 
be warned against heavy lifting and against working 
in awkward positions for prolonged periods. 
Persistent pain and stiffness often point to adhesions 
interfering with the joint action or pressing on nerves 
or nerve-endings and no amount of heat, diathermy, 
or ionisation will affect them. Manipulation to 
break down the adhesions, followed by careful after- 
treatment to prevent their recurrence, is the logical 
remedy. The recognised treatment for persistent 
stiffness in a knee or shoulder after an injury is 
manipulation, but the application of similar measures 
to a stiff spine following trauma has not received the 
same wide recognition. Riches,°* working under 
Bankart at the Middlesex Hospital, claims that 
manipulation is successful in 90 per cent. of cases 
with chronic back strains, and “‘ where there is evidence 
of definite exciting trauma, success may be anticipated 
in almost all cases.” He adds, however, that the 
improvement in cases of lumbosacral strain is not 
always permanent, although the permanency or 
otherwise of the relief is largely dependent on the 
efliciency of the after-treatment. The method of 
spinal manipulation described by Jones and Lovett 3? 
in their treatise on ‘“‘ Orthopedic Surgery ” is the 
best. A general anesthetic is given, the knees and 
hips are acutely flexed in order to control the pelvis, 
an assistant steadies the shoulders, and the pelvis 
is moved in various directions until complete flexion, 
extension, lateral flexion, and rotation of the spine 
are produced. Before manipulation is performed 


MR. G. A. G. MITCHELL : LUMBOSACRAL STRAIN 


[yan. 11, 1936 79 


recent radiograms of the lower spine must be examined 


to exclude other pathological conditions. 

Finally we have to consider the type of case where 
efficient conservative treatment and even manipula- 
tion fail to give relief. .This may be due to neurosis 


or to mechanical imperfections at the lumbosacral 


junction, such as articular processes arranged in the 


‘sagittal plane, interarticular neural arch defects, or 


an almost horizontal sacrum; in other cases the 
intractable symptoms are caused by superadded 
disease, and this must be treated. The patient 
may be so miserable and disabled that operative 
treatment becomes a necessity, but this should not 
be undertaken until conservative treatment has 
had a fair trial, and gross arthritic or other patho- 
logical changes negative operation in the opinion 
of most surgeons. In selected cases stabilisation of 
the lumbosacral region by Hibbs’, Albee’s, and other 
operations has given good results. A successful 
fusion operation effectually prevents lumbosacral 
strain by ankylosing the junction, and by shifting the 
point of weight transmission to a higher spinal level, 


which is mechanically more stable and less liable to 


strain. Chandler 1? has devised a method of “ tri- 
sacral fusion” suitable for cases with combined 
pelvic joint strains, and Rich’s 53 operation for 
stabilising the lower spine is designed for a similar 
purpose. | 


BIBLIOGRAPHY 
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.: Backache from Standpoint of Orthopedist, 

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6 


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16. Carnett, J. B.: Chronic Strain of Lumbar opne and Sacro- 
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Backache from Orthopmdic Viewpoint, 

1927, n.s., xxxiv., 61 (Trans. Med.- 

Chir. Soc.). 


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: Bone and Joint Surg., 1925, vii., 109. 

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Amer. Jour. Orthop. Surg., 1917, xv., 803. 


19. Same author : 
- Edin. Med. Jour., 


22. Doub, H. P.: The Rôle of Ligamentous Calcification in 
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Author’s Technic, and End Results, Jour. Amer. Med. 
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24. Ghormley, R. K.: Operative Treatment of Painful Condi- 

: tions of Lower Part of Back, Proc. Staff Meet., Mayo 
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25. Same author : Backache from the Orthopedic Viewpoint 
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Mayo Foundation, 1930, oo » 670. 

B 


80 THE LANCET] 


MR. A. A. DAVIS: DYSMENORRHGA AND ALCOHOL INJECTION 


[san. 11, 1936 


26. Goldthwait, J. E.: The Pelvic Articulations ; a Considera- 
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1907, xlix., 768. 

27. Same author : The Variations in the Anatomic Structure 

: of the Lumbar Spine, Jour. Orthop, Surg., 1920, ii., 416. 

28. Gratz, C. M.: Bimanual Examination of the Sacro-lIliac 

Joints : its Importance in the Karly Differential Diagnosis 
of Sacro-Iliac Disease, Jour. Amer. Med. Assoc., 1928, 
xci., 397. 

29. Heald, C. B.: 

1928, ii., 66. 

30. Herndon, R. F.: Back Injuries in Industrial Employees, 
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31. Hibbs, R. A., and Swift, W. E.: "Developmental 
Abnormalities at the Lumbosacral Junction causing 
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by the Spine Fusion Operation, Surg., Gyn., and Obst., 
1929, xlviii., 604. 

32. Jones, R., and Lovett, R. W.: 
London, 1923. 

33. Key, J. A.: Low Back Pain as seen in aj Orthopedic, 
Clinic, Amer. Jour. Med. Sci., 1924, clxviii., A 

34. Kleinberg, S.: Backache, its Ætiology ad Pathology, 
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35. Same author: The Causes and Treatment of Low Back 
Pain, bet 1929, cxxx., 133. 


The Sacro-Iliac Problem, THE LANCET, 


Orthopeedic Surgery, 


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Australasia, 1940. iii., 201. 

38. Lovett, R. W.: The Causes and Treatment of Chronic 
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39. McKendrick, A.: Back Injuries, Edinburgh, 1916. 

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41. Martyn, G.: The Significance of Lumbosacral Poin “Peck 
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1932, liv., 371. 

44. Miltner, L. J., and Lowendorf, C. S.: Low Back Pain; 
Study of 525 Cases of Sacro-lliac and Sacrolumbar Sprain, 
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45. Mitchell, G. A. G.: The Radiographic Appearances in 
Spondylolisthesis, Brit. Jour. Radiol., 1933, vi., 513. 

Same author: The Lumbosacral J unction, Jour. Bone and 

Joint Surg., 1934, xvi., 
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Origin, Canad. Med. Assoc. Jour., 1925, xv., 1055. 
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50. Same author: The Lumbosacral Region, Jour. Amer. Med. 
Assoc., 1921, lxxvii., 1394. 

51. Osgood, ’R. B.: Bone and Joint Causes of Low Back Pain, 
Boston Med. and Surg. Jour., 1923, clxxxix, 1059. 

52. Same author : Etiologic Factors in Certain Cases of So- called 


ie ear Scoliosis, Jour. Bone and Joint Surg., 1927, 
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54. Riches, E. W.: End-Results of Manipulation of the Back, 
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55. Robinson, W. H., and ’Grimm, H. W.: The Sacrovertebral 
Angle, its Measurement and the Clinical Significance 

: of its Variations, Arch. of Surg., 1925, xi., 911. 

56. Rueth, J. B.: Physical Therapy in Chronic Lumbar Pain, 
Arch., Physical Therapy, 1927, viii., 242. 

57. Rugh, J. T.: Concerning the Diagnosis of Lesions of the 
Lateral Process of the Fifth Lumbar Vertebra and of 
its Removal, Jour. Bone and Joint Surg., 1923, v., 235. 

58. Ryerson, E. W.: Surgical Treatment of Low Back Disabilities, 


ibid., 1932, xiv., 154. 
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and Treatment, Jour. Amer. Med. Assoc., 


Diagnosis 

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exxvii., 532. 

62. Skinner, E. H.: Anatomical and Postural Variations of 
the Lumbosacral Spine, Radiology, 1927, ix., 451. - 

63. Smith-Petersen, M. N.: Routine Examination of Low Back 
Cases with particular reference to Differential Points 
between Lumbosacral and Sacro-Iliac Regions, Jour. 
Bone and Joint Surg., 1924, vi., 819. 


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Buttocks, Med. Jour. Australia, 1925, ii., 
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Bone ‘and Joint Surg., 1925, vii. ., 763. 
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i 
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i 


TREATMENT OF DYSMENORRHŒA BY 
ALCOHOL INJECTION 


By ALBERT A. DAVIS , M.D., Ch.M. Vict., 
F.R.C.S. Eng. 


IN spite of the research, more or less scientific, 
of centuries, dysmenorrhea still remains one of the 
most important and interesting problems of gynæco- 
logical practice. It is responsible for an appalling 
amount of physical and mental distress, and is 
economically a most costly disability, both nationally 
and individually. There is, of course, no doubt that 


the majority of the milder cases are amenable to 


medicinal treatment, and that a considerable propor- 
tion of the severer type react favourably to cervical 
dilatation; but there remains a large percentage 
of the latter who are unrelieved by any procedure 
short of sympathectomy, and it is for these that the 
technique described below has been devised. 


RATIONALE 


The object of the operation is to block the nerve 
pathway to the uterus at its nearest accessible point. 
The portion of this pathway which most conveniently 
lends itself to external intervention is the pelvic 
plexus of Lee-Frankenhauser, which concentrates 
most of the uterine nerve-supply in a comparatively 
small area. I have elsewhere? described this plexus 
in detail, but its relations are so important in the 
present connexion that it will be useful here to 
summarise their more salient features. 


The plexus is a bilateral quadrilateral sheet of 
neurofibrous tissue lying on either side and in front 
of the ampulla of the rectum. It stretches forward 
to a point just short of the posterolateral border 
of the uterus immediately above the cervix, inclining 
in a plane parallel with the lateral pelvic wall at this 
level. In other words, the plexus lies obliquely 
upon the posterolateral part of the floor of the pouch 
of Douglas just above the corresponding vaginal 
fornix, its deeper portion, consisting mainly of para- 
sympathetic (nervi erigentes) fibres, being contained 
within the uterosacral folds. 

The internal iliac artery and vein lie somewhat 
behind and below the plexus, but the uterine vessels are 
fairly closely related to its lateral surface. This 
apparently alarming relationship is in reality of 
negligible importance, for the extreme mobility of the 
artery allows of its being pushed aside by the injecting 
needle without injury. In addition, actual puncture 
of the vessel appears to be relatively harmless (see 
below). 

Medially is the lateral aspect of the rectal ampulla, 
to which the plexus is closely adapted. The ureter 
crosses its superior border from without inwards, to 
be related to its medial border for a short distance. 


The pelvic plexus is the junction at which almost 
all the nerves supplying the uterus converge. From 
above it receives abdominal sympathetic fibres via 
the solar plexus, presacral nerve, and hypogastric 
plexuses, and the sacral parasympathetics (nervi 
erigentes) enter it from behind. The nerves to the 
uterus are distributed from its anterior border in the 
form of several strands. 

The nerve-fibres in the pelvic plexus are inextric- 
ably mixed and interlaced, though it is true that 
the two main constituents—sym pathetic and para- 
sym pathetic—lie in separate dissectable planes. This 
latter fact, however, is of anatomical interest only, 


THE LANCET] | 


MR. A. A, DAVIS: DYSMENORRHGA AND ALCOHOL INJECTION — 


(JAN. 11, 1936 81. 


for practically it is impossible to differentiate the 
various motor and sensory fibres contained, and in 
any case the thickness of the plexus allows of very 
little discrimination by the. exploring needle. . 


TECHNIQUE 


With the patient in the lithotomy position, and 
under Evipan anæsthesia, the cervix is seized with 
vulsella and retracted towards the left. The right 
fornix is further exposed with the aid of a flat lateral 
retractor. A long graduated Gasserian needle is 
then passed horizontally through the vaginal mucosa 
at the side of the cervix for a distance of 0-5 cm., 
and the retractor removed, The needle is now passed 
backwards and outwards for approximately 1:5 cm. 
at an angle of 45° to both the sagittal and coronal 
planes, and guided by a finger in the rectum to a 
point 0:5 cm. from the side of the rectal ampulla. 
The needle is then withdrawn for 0-5 cm., and 1 c.cm. 
of 85 per cent. alcohol injected, the needle point 
being kept slightly but continually moving. .The 
same procedure is then repeated on the other side. 


DIFFICULTIES AND DANGERS 


Perforation of the rectum with consequent cellular 
infection is avoided by making the injection 1 cm. 
away from that organ, as calculated from the internal 
finger. Injury to the ureter is prevented by adherence 
to the technique described, which keeps the needle 
point lateral to it. The uterine artery, if touched, 
usually slips away from the needle, but constant 
movement of the latter is a further safeguard. 

Hofstetter ? has suggested that the injection of a 
destructive substance like alcohol into the loose 
pelvic cellular tissue might cause a local aseptic 
necrosis. I have not encountered this complication, 
and experience with alcohol injection elsewhere leads 
one to regard it as only a very remote possibility. 

It is unnecessary to use more than 1 c.cm. of 
alcohol] on each side, for only a partial destruction 
of the plexus is aimed at. It must be remembered 
that the upper part’ of the plexus contains the motor 
nerves to the bladder, which have been shown by 
Learmonth 3 to be indispensable to the proper func- 
tion of that organ. With the quantity of alcohol 
suggested, these fibres escape injury, but it is con- 
ceivable that larger amounts might damage them, 
with consequent urinary disorder. 


RESULTS 


Only 6 cases have been treated over a sufficiently 
long period to be worth recording, and in 3 of these 
the success of the method has been vitiated by the 
fact that a cervical dilatation was performed at the 
same time. But the ultimate result in all was com- 
plete and apparently permanent relief, an effect 
which appears to indicate the superiority of this 
operation over the ordinary dilatation, in spite of 
the small number of cases observed. 

The latter procedure, as I have suggested else- 
where,‘ is really a form of sympathectomy, and owes 
its effect to the disruption of the sympathetic fibres 
in the cervix. The amount of this destruction is 
necessarily variable, depending as it does on the 
type of cervix, the extent and duration of the dilata- 
tion, &c., with the result that it relieves only about 
40 per cent. of cases so treated. It therefore seems 
reasonable to attempt to improve this figure by a 
less crude and more complete denervation of the 
whole uterus by alcoholisation of the more centrally 
placed pelvic plexus, an. assumption which is appa- 
rently justified in the results recorded. 


MODE OF ACTION 


The relief of dysmenorrhea which follows the. 
operation described above may be explained in 
three ways, viz.: . : i 

Interruption of sensory pathways. 


js motor $ 
=i irregular ovarian influence. 


Interruption of sensory pathways.—The results of 
sympathectomy suggest, though they do not prove, 
that the autonomic nervous system is capable of 
conveying afferent pain-sensory impulses. ` Normally 
the contractions of the menstruating uterus are not 
appreciated by the subject, but when they are exag- 
gerated impulses are transmitted to the sensory 
cortex, which contains, as Sheehan ê has recently 
shown, the highest central sympathetic representa- 
tion. It is reasonable, therefore, to suggest the 
interruption of this sensory pathway as the reason 
for at least part of the relief following the operation. 

Interruption of motor pathways.—It has for a long 
time been assumed, and Moir 6 has recently proved, 
that spasmodic dysmenorrhea is accompanied by 
a hypercontraction of the myometrium. The exact 
mechanism of the pain production is disputed, but 
the muscle spasm appears to be the main contri- 
butory cause. Now almost all the motor nerve- 
supply to the uterus passes through the pelvic plexus, 


and it is possible that destruction by alcohol. of at 


least part of this supply might have the effect of 
abolishing the nerve impulses conveying the impulses 
to abnormal contraction. 

Interruption of irregular ovarian influence.—The 
work of Blotevogel? and of Kennedy ê has shown 
how completely the pelvic plexus is under the con- 
trol of the ovarian autocoids; apparently it serves 
as the vehicle for the transmission of at least part 
of the ovarian influence on the uterus. Disorder of 
this influence is probably of primary importance in 
the causation of spasmodic dysmenorrhea, and as 
it acts at least partly through the peripheral auto- 
nomic nerves, some of the beneficial effects of inter- 
vention on the pelvic plexus may be ascribed to this 
intervention. 

It would appear, therefore, that the relief of pain 
is the result of interruption of the pathway of three 
separate and distinct impulses. It is difficult to 
assess the relative importance of these factors, but 
it is probable that destruction of the sensory nerves 
is the predominant one. The reason for this assump- 
tion is that unilateral alcoholisation of the para- 


metrium relieves pain on that side only (Blos °). 


COMMENT 


The injection of alcohol for the relief of dysmenor 
rhea was first introduced by Blos, of Karlsruhe, in 
1929, and has since been practised by him on a good 
many cases. His technique, however, is quite dif- 
ferent from the one advocated above, and consists 
in the infiltration of the parametrium with 8 c.cm. 
of 75 per cent. alcohol on each side. This method 
owes its success to the extensive destruction of the 
most peripheral uterine nerves, rather than of the 
pelvic plexus itself, and it seems more reasonable to 
alcoholise that structure directly in the manner 
described above. To Blos, however, must be given 
the credit for the invention of a procedure at once 
ingenious and practical, and one that is likely to be 
of permanent therapeutic value. 

A modification of Blos’s infiltration method has 


also been used by Young,!° in the treatment of the 


syndrome named by him ‘‘ broad ligament neuritis,” 


82 THE LANCET]. 


DRS. BEGG & COVENEBY : SPECIFIC VACCINE IN WHOOPING-COUGH 


[yan. 11, 1936 


with excellent results. What is, however, of more 
importance in the present connexion is the fact that 
those cases complaining of a coincident dysmenor- 
rheea were relieved of this symptom by the injection. 
I have since had the opportunity of demonstrating 
my technique to Prof. Young, and he agrees that, 
theoretically at least, it is preferable to Blos’s s original 
method. 
REFERENCES 


1. Ka i A.: Jour. Obst. and Gyn. Brit. Emp., 1933, 
2; Hofstetter, R. : Monats. f. Geburtsh. u. Gyn., 1931, Ixxxix., 
3. Ponsnth: J. R., and Braasch, W. F.: Surg., Gyn., and 
Obst., 1930, li., 494. 

- Davis, "A. A. : Proc. Roy. Soc. Med., 1934, xxvii., 4. 
. Sheehan, D.: Jour. of Physiol., 1934, Ixxxiii., 177. 
. Moir, J. ’C.: Proc. Roy. Soc. Med., 1935, xxviii., 1654. 
. Blotevogel, W.: Zeits. f. mikr. Anat., 1927, X., 149. 
Kennedy, W. P.: Brit. Med. Jour., 1932, ii., 746. 
Blos, D.: Münch. med. Woch., 1929, Ixxvi., 1173. 


10. Young, J.: Trans. Edin. Obst. Soc., June 14th, 1933, in 
Edin. Med. Jour., December, 1933. 


London. 


6D 00 1 2 Or he 


WHOOPING-COUGH 


VALUE OF A SPECIFIC VACCINE IN TREATMENT 
By Norman D. Beco, M.D. Aberd., D.P.H. 


MEDICAL SUPERINTENDENT, BOROUGH INFECTIOUS HOSPITALS, 
SOUTHEND-ON-SEA 5; LATE SENIOR ASSISTANT MEDICAL 
OFFICER, NORTH-EASTERN HOSPITAL, LONDON 

COUNTY COUNCIL; AND i 


MARGARET. F. COVENEY, M.B. Sheff., B.Sc. 


ASSISTANT MEDICAL OFFICER, NORTH-EASTERN HOSPITAL 


FEW therapeutic measures can have given rise 
to more conflicting reports than the vaccine treat- 
ment of whooping-cough. Widely varying doses 
of whooping-cough bacilli, alone or in combination 
with other organisms, were used by the early 
investigators and the results, as might be expected, 
were equally varied. 

In prophylaxis the reported results are excellent 
and the preventive value of a pertussis vaccine would 
seem proven. A protective vaccine to have any 
success must be prepared from the hæmolytic smooth 
form of the bacillus. Madsen,! using a vaccine of 
this nature, has obtained either protection or attenua- 
tion in recent epidemics of whooping-cough on the 
Faroe Islands. On the other hand, Krueger ? believes 
that mechanical disruption of the bacillary body is 
necessary in order to avoid possible denaturation. 
In this way an endo-antigen is obtained and has 
been successfully used by Munns and Aldrich? 
in prophylaxis. It is doubtful whether the results 
obtained with pertussis antigen are any better than 
those achieved with the intact bacillus. 

Success in prophylaxis has caused a revival of 
interest and has stimulated further investigations 
into the value of the newer vaccines or antigens in 
treatment. Stallings and Nicholls ê treated 232 
patients in the catarrhal and paroxysmal stage of 
whooping-cough with undenatured pertussis antigen. 
Abatement of symptoms appeared to follow, but the 
experiment was inadequately controlled. It is 
generally agreed that, if success is to follow vaccine 
therapy, the initial injections must be given early 
in the disease, large doses must be injected, and smooth 
colonies must be used in the preparation of a vaccine. 
Although such a vaccine has been enthusiastically 
advocated, the few adequately controlled experi- 
ments which have been carried out do not show that 
it is of any value in the treatment of whooping-cough. 


PRESENT INVESTIGATIONS 


It should be emphasised that we were not concerned 
with prevention. An attempt was here made to 


assess the value of a pertussis vaccine in the treat- 
ment of early cases of whooping-cough. Certain 
limitations are immediately imposed on such an 
experiment in hospital practice. It is the general 
experience that only in severe epidemics are whooping- 
cough cases admitted to hospital in the early catarrhal 
stage of the disease. This is probably due to the 
fact that, during marked prevalence, every cough is 
regarded with suspicion. In less severe epidemics, 
on the other hand, suspicion is not aroused until 
the cough has become paroxysmal or until a whoop 
develops. During the period of this investigation 
the epidemic was of moderate severity and, in 
consequence, early cases were limited to those already 
in the paroxysmal stage of the disease. 

The investigation was conducted along the following 
lines : (1) Cases of whooping-cough, in the paroxysmal 
or early whooping stage, numbering 60, were graded 
according to severity on admission. (2) All the 
cases received routine treatment such as fresh air 
and simple drugs when indicated. (3) Half of them 
received, in addition, a specific pertussis vaccine. 
(4) In a certain number of cases leucocyte counts 
were done on admission and in early convalescence. 

Classification of severity.—This is avowedly unsatis- 
factory in whooping-cough. Nevertheless, some 
classification is necessary for purposes of comparison 
and the following simple one was used :— 


1. Total spasms in 24 hours did not exceed 10. 
Character of spasms mild—cyanosis never seen. 

2. Total spasms in 24 hours exceeded 10 but not 20. 
Spasms of moderate severity—cyanosis occasionally seen. 

3. Total spasms in 24 hours exceeded 20. Severe 
spasms with cyanosis the rule—convulsions occasionally. 


All the cases in this series fell into the first or 
second group of this classification on admission. 
No case with a severe respiratory complication such 
as broncho-pneumonia was included. 

Vaccine administration.—The vaccine was prepared 
from recently cultivated smooth strains of Haemophilus 
pertussis and put up so that 1 c.cm. contained 
10,000 million organisms. Bacilli used in making 
the vaccine were of proven virulence on guinea-pig 
injection, and when used for active immunisation of 
rabbits could protect them against fatal doses of a 
virulent culture of the same organism. Alternate 
cases of similar age and apparent clinical severity 
were given a routine course of this suspension sub- 
cutaneously. A course consisted of 0:2, 0-5, 1, 
1-5, 2, and 2:5 c.cm. at intervals of 2-3 days. It 
was always possible to complete a course within 
14 days of admission. 


Reactions after vaccination.—Local reactions consist- 
ing of erythema and induration were common but 
transient. General reactions were rare. Three 
children had a sharp rise of temperature on the evening 


_of injection, but by the next day the temperature 


had fallen to normal, A clinical impression was 
gained that children occasionally experienced an 
increase in frequency and severity of their spasms 
during the course of injections. The discussion 
of the significance of this finding we will leave for 
the moment. 

VALUE OF VACCINE THERAPY 


Children of approximately the same age and at 
the same stage of disease were alternately placed 
in the vaccine or control series and in this way two 
groups of cases were obtained. Table I. has been 
compiled to show the result of this classification, 
It will be seen in section A of this Table that, as far 
as age and stage of disease is concerned, the distribu- 
tion is almost identical. It was hoped that the two 


‘ 
` 


THE LANCET] ` 


DRS. BEGG & COVENBY : SPECIFIC VACCINE IN WHOOPING-COUGH 


~ 


(san. 11, 1936 83 


groups would be also identical as far as severity on 
admission was concerned. Reference to section B 
of the Table will show that this was not achieved. 
The distribution is less favourable for the vaccine 
series a8 the percentage within the Group 2 classifica- 
tion of severity is greater than that for the controls. 
This is readily explained by the fact that classification 


TABLE I . 
Showing Percentage Distribution of Cases: (A) according to 
Age and Stage of Disease: (B) according to Severity 
on Admission. 


A B 
Controls. Vaccine. 7 ; 
Age. Pwo] @ 9 
ee A e À . aa S a 
: — ~ ~~ 
Sa Syl 3 $ On} 3 |83] a| 8 
oa Bs © aa ae © n fe 1) > 
Ay h E | Op z E 
0-4 yr. | 100| 6-7| 167| 67| 6-7| 13-4 
+2 yrs.| 133| 20-0] 33-3} 13-3| 200| 333| 1 | 700| 50-0 
2-5 ,, |200| 16-7| 36-7| 13-3] 267| 400| 2 | 30-0| 50-0 
5-10 ,, | o | 13-3| 13-3] 6-7! 6-6| 13-3 
e 43-3| 56-7|100-0| 40-0! 60-0|100-0| .. 1100-0 |100-0 
100-0 100-0 
N =30 N=30 


was attempted on the actual day of admission, in 
order that there should be no delay in the administra- 
tion of vaccine. Early classification of severity in 
such a variable disease as whooping-cough has 
obvious disadvantages, and in this case has resulted 
in a disparity for which allowance must be made in 
any comparison of results between the two series. 
Allowance can be made in this way. If it can be 
assumed that the vaccine-treated cases, distributed 
according to severity on admission, would experience 
the same increases in severity after admission as 
the control series, then the total number of vaccine 
cases who might be expected to get worse would be 
15:23. The actual number was 17 (Table Il.). 
In like manner comparisons can be made between 
the number of vaccine cases who might be expected 
to cease whooping at a particular period of the 
disease and the number who did in fact cease at that 
period. Reference to Table II. will show that the 
vaccine cases behaved exactly as might be expected, 
except in the first four weeks of the disease. Here 
it is significant to note that approximately five fewer 
vaccine cases ceased to whoop at the end of two weeks, 
but that five more than were expected had ceased 
whooping at the end of four weeks. 


It seems reasonable to assume, from the figures | 


given in Table II., that the only demonstrable effect 


of the vaccine was a tendency to increase the severity 
‘of the spasms and to prolong the whoop beyond the 


14-day period during which vacciné was being injected. 
This effect is in agreement with the clinical impression 


- obtained during this investigation and has been 


previously recorded by Howell 5 in an investigation 
at this hospital. It need not necessarily be inter- 
preted as a result of vaccine per se and might be 
attributed to a psychological effect. Information 
on this point could be gained in a future investigation 
by injecting the control series with small quantities 
of sterile water. 


EFFECT OF VACCINE ON BLOOD COUNT 


In conclusion an attempt was made to determine 
whether the injection of pertussis vaccine had any 
effect on the leucocyte response in whooping-cough. 
Of 23 children, who formed the subject of this 
investigation, 12 had received vaccine and the 
remaining 11 acted as controls. A leucocyte count 
was done on admission and repeated 14 days later— 
i.e., at the usual termination of a vaccine course. 
It was found that both groups showed leucocytosis 
and lymphocytosis on admission, but that 14 days 
later the count had returned to normal irrespective 
of whether vaccine had been given or not. Thus 
it was impossible to demonstrate, from these counts, 
any leucocyte change which could be attributed to the 
injection of vaccine. 

CONCLUSIONS 


The position with regard to vaccine treatment, as 
judged by this investigation, would seem to be clear. 
The injection in the paroxysmal stage of large doses 
of a pertussis vaccine prepared in accordance with 
modern methods and beliefs is shown neither to 
curtail the duration of the disease nor to ameliorate 
the symptoms. Indeed the only effect obtained 
was an undesirable one, although not serious. It 
is noteworthy. that no case in the vaccine or control 
series was fatal. This, in face of the not inconsider- 
able mortality which prevailed for the general run 
of cases in the epidemic, appears to be a potent 
argument for the early hospitalisation of whooping- 
cough, 

We desire to acknowledge our indebtedness to Dr. R. A. 
O’Brien, of the Wellcome Research Laboratories, for 
supplying the vaccine and for information concerning 
its preparation; and to Dr. E. H. R. Harries, medical 
superintendent of the North Eastern Hospital, for his 
coöperation and for his permission to publish this paper. 


REFERENCES 


. Madsen, T.: Jour. Amer. Med. Assoc., 1933, ci., 187. 

. Krueger, F.: Proc. Soc. Exper. Biol., 1933, xxx., 1097. 

. Munns, G. F.,and Aldrich,C. A.: Jour.of Pediat., 1934, v.,590. 

. Stallings, M., and Nichols, V. C.: Amer. Jour. Dis. Child., 
1934, xlviii., 1183. i 

. Howell, Nancy G.: L.C.C. Annual Report, 1930, vol. iv. 
(Part III.), p. 136. 


Qo RUN ee 


TABLE II 
SHOWING (1) INCREASES IN SEVERITY, (2) DURATION OF WHOOP, IN CONTROL AND VACCINE SERIES 


to Control series. Vaccine series. 

S l 

5 Duration of whoop Duration of whoop 

5 Increase Tor EeneE : 

Pa n, severit 

= Cases} severity Cases} ~ Y- | 2 weeks. | 4 weeks. | 6 weeks. | 8 weeks. 
p st oe 2 weeks. | 4 weeks. | 6 weeks. | 8 weeks. SSS ee SSS SS S 
J | Act.| Exp. Act| Exp. Act, Exp. Act.| Exp.| Act.| Exp 
1 | 21 | 12 (57-1) | 11 (52-4) | 9 (42-3) | 1 (48) |o (COO) f 15 |12| 86] 5 | 7-9 | gi64{/2io710 | 0 

2 | 9 4 (44-4) 2 (22:2) 4 (44-5) 2 (22-2) 1 (11:1) 15 5 6-6 2 3:3 | 10 6:7 2 3:3 1 1:7 


| TS | | LY RT | gen 


| 30 | 16 (53-3) 


Act. =actual. 


ne Pe Le ae: 


Exp. =expected. 


84 THE LANCET] | 


[san. 11, 1986 


CLINICAL AND LABORATORY NOTES 


A SIMPLE TEST FOR GROSS NITROGEN 
RETENTION IN THE BLOOD 


By Joun F. BARRETT, B.Sc. 


ASSISTANT IN BIOCHEMISTRY IN THE COURTAULD INSTITUTE, 
MIDDLESEX HOSPITAL, LONDON 


Andrewes! in 1924 described a chemical test on 
the blood for the diagnosis of uremia, which aroused 
considerable interest. Later workers,’ assessing the 
value of this test, concluded that the reaction is found 
only in uremia or severe renal inefficiency and stated 
that the retention of indican does not necessarily 
run parallel to that of nitrogenous bodies. The 
following test, which is much simpler to perform, does 
give results which follow the retention of nitrogenous 
substances, since a positive reaction is due to an 
increase in the creatinine fraction of the blood. 

Reagent.—Add 25 c.cm. of 10 per cent. potassium 
iodide to 100 c.cm. of Nessler’s reagent. Under the condi- 
tions of the ‘test; this solution no longer reacts with 
ammonia or with glucose in the concentration in which 
it occurs in the blood filtrate. 

The test is performed by adding one volume of this 
reagent to one volume of tungstic acid filtrate from blood. 
It is considered: positive if a definite greyish-white tur- 
bidity, resembling milk diluted with water, appear within 
45 seconds. The test-tube should be held against a 
black surface and the temperature of the solutions should 
be 15-20° C. 


Since this test takes two minutes to perform and 
requires only 1c.cm. of blood filtrate, it should be a 
valuable aid to the laboratory analyst. In all 
positive cases smaller quantities of filtrate should 
be employed for the determination of urea and non- 
protein nitrogen, thus preventing ruined analyses 
due to large quantities of ammonia encountered 
unexpectedly. 

' Experiments indicate that the reaction is positive 
when the creatinine content of the blood is greater 
than 2-5-3 mg. per 100 c.cm. Blood preserved with 
formalin cannot be used for this test. 


AN UNUSUAL .CONTRA-INDIGATION TO 
THE OCCLUSIVE TREATMENT OF 
VARIGOSE VEINS 


By A. L. D’ABREU, M.B. Birm., F.R.C.S. Eng. 


SENIOR ASSISTANT IN THE SURGICAL UNIT, THE WELSH NATIONAL 
SCHOOL OF MEDICINE, THE ROYAL INFIRMARY, CARDIFF 


IN examining cases of varicose veins of the leg 
I have twice encountered a condition which contra- 
indicated any attempt at obliteration. Both patients 
hopefully requested a cure by injection, but had 
such treatment been adopted it might well have 
led to disaster for both were suffering from thrombosis 
of the inferior vena cava. The diagnosis can be made 
by a glance at the abdomen. The usual practice is 
to examine the saphenous openings before instituting 
injection treatment, and the. purpose of this note is 
to recommend that the abdomen also should be 
scrutinised. Neither of the patients informed me 
of the condition of the abdominal veins. 


1 Andrewes, C. H.: THE LANCET, 1924, i., 590. 
i a erties G. A., and Hewitt, L. F.: Brit. Med. Jour., 1927, 
las . f 
* Koch, F. C., and McMeckin, T. L.: Jour. Amor. Chem. Soc., 
1924, xlvi., 2066. . . 


The accompanying’ photograph of one of them 
shows the enormously dilated, tortuous veins coursing 
upwards from the saphenous openings to communicate 
through the superficial circumflex iliac venous system, 
with the lateral thoracic vein, which drains into the 
axillary vein; on the right side the superficial 
epigastric vein is dilated and anastomoses with the 
veins of the thoracic wall. The veins in both the 
lower limbs were enormously dilated and varicose. 
A similar picture was presented by the other case. 
Both patients were middle-aged men and in good 
health and on further questioning both admitted 
that the venous enlargements had been present for 
many years, though strangely enough neither could 
state accurately the date of onset of the condition ; 
one had been in the tropics for many years and had 
suffered from ‘‘tropical diseases.” The commonest 
causes of thrombosis of the inferior vena cava are 
infections, especially typhoid fever and puerperal 


5 Se ee oe 
` z A > 


Abdomen of one of the patients. 


sepsis, trauma, or malignant disease of the kidney, 
suprarenal glands or liver (Pleasants,! Kerr?), but 
neither the history nor the clinical examination of 
my patients disclosed any such cause of their condi- 
tion. That they had survived for many years the 
occlusive effects of inferior vena cava thrombosis 
with no disability worse than that of severe varicose 
veins is not exceptional, for Parkes Weber,’ Shattock,4 


_and Kerr? have all reported their experience of 


cases with long survival and few symptoms, 

The appearance in the case illustrated is character- 
istic of thrombosis of the inferior vena cava ; 
Robinson ® has recently published a similar picture. 
My object here is not to inquire into the pathology 
and clinical features of this disease, at least 318 
cases of which have been recorded, but to indicate 
the value of looking at the abdomen before embarking 
on the injection of massive varicose veins of the 
legs. Sclerosis of such veins by injection must 
hamper unjustifiably the adequate collateral venous 
circulation that has been established. 


REFERENCES 


. Pleasants, J.H. : Johns Hopkins Hosp. Reps., 1911, xvi., 363. 
Kerr, R. R.: Brit. Med. Jour., 1921, ii., 1112. 
. Weber, F. : Proc. Roy. Soc. Med., 1921, xiv. (Sec. Med., 


P. 
p. 9). 

. Shattock, S. G.: Ibid., 1913, vi. (Section of Path., p. 126). 

. Robinson, R. H. O. B.: Brit. Jour. Surg., 1935, xxiii., 296. 


THE LANCET] ` 


CLINICAL AND LABORATORY NOTES 


[sait 1936: 85 ' 


S a a E ee N 


A VASOVAGAL ATTACK: ` 
By T. E. GUMPERT, M.B. Sheff., M.R.C.P. Lond. 


MEDICAL REGISTRAR AND PHYSIOLOGIST, ROYAL HOSPITAL, 
SHEFFIELD è | 


FAINTING is a common occurrence and usually 
excites but little comment. Some years ago Lewis 1 2 
drew attention to the slowing of the pulse and the 
lowering of the blood pressure observed during an 
ordinary attack of -fainting. More recently he? 


again stressed these features under the heading of. 


vasovagal attacks and pointed out that most faints 
in the absence of postural causes and heart-block 
are in fact vasovagal in origin. The slowing of the 
heart is due to increased vagal tone and is relieved 
by the injection of atropine,? but the lowered blood 
pressure is an independent phenomenon and pre- 
sumably due to dilatation of the splanchnic vessels. 
The combination of these two factors is sufficient 
to rob the brain of an adequate supply of blood with 
the result that consciousness is either completely or 
partially lost. | l 
` The other day I had the good fortune to take an 
electrocardiogram of a patient during a fainting 
attack. 

He was a man of 46 and was known to have suffered 
from cedema and ascites a few months before I saw him 


at the out-patient department at the Royal Hospital, 


but there was no reason to suspect that he had heart- 
block. (In this connexion it is interesting to note that 
Lewis * considers the commonest cause of- fainting in 
cardiac subjects to be the ordinary vasovagal attack 
and not heart-block.) I had just removed a few cubic 
centimetres of blood from a vein at the elbow for a sedi- 
mentation test. At the sight of the blood in the syringe 
he became pale and sweated, but did not actually lose 
consciousness. A few minutes later whilst sitting in the 
electrocardiograph chair he fainted., The pulse ‘at’ the 
wrist- was impalpable. With a nurse supporting him 
I was able to obtain an electrocardiographic 
record of the vasovagal attack. 


the P-wave is completely lost it must be buried 


in the ventricular complex, and for this to occur- 
the impulse must have arisen low down (anatomically) 
in the A.V. node at such-a point' that the auricles 
and ventricles are stimulated: simultaneously (the 
auricle by retrograde spread from the A.V. node). 
Presumably with the increase of vagal tone the S.A. 
node has been thrown out of action and the A.V. 
node, which is known to possess less inherent excita- 
bility, has taken over its function as pacemaker. 
Equally interesting is lead III. (Fig. 1) in which the 
rate has risen to 52 per minute and an inverted 
P-wave makes its appearance.: The P-R interval is . 
also a little shorter than in lead I. before the attack 
had begun. Evidently the impulse is still arising in 
the A.V. node, but at a higher level. such that the 
auricles are stimulated to contract before the ven- 
tricles. The inversion of the P-waves indicates that 
the spread in the auricle is still retrograde. The 
second electrocardiogram (Fig. 2), which was taken 
after recovery, resembles lead I. of the first and 
denotes complete restoration of sino-auricular rhythm, 
the level of impulse formation having shifted from 
the upper level of the A.V. node to the sino-auricular 
node itself. 


CONCLUSIONS 


(1) An electrocardiographic record of a vasovagal 
attack is shown. (2) The slowing of the heart is 
due to the auriculo-ventricular node having taken 
over the function of the sino-auricular node as pace- 
maker. Separate leads show the impulse arising at 
different levels in the auriculo-ventricular node. 
(3) On recovery sino-auricular rhythm with its 
enhanced rate is restored. 


REFERENCES 


1. Lewis, Sir Thomas : The Mechanism and Graphic Registration 
of the Heart Beat, London, 1925, p. 420. 

2. Cotton, T. F., and Lewis: Heart, 1918, vii., 23. 

3. Lewis: Diseases of the Heart, London, 1933, p. 98. 


Lead I. (Fig. 1) was taken just before 


he fainted ; it shows normal sino-auricular 


rhythm at a rate of about 70 per minute. 
The T-wave is inverted. Leads II. and III. 


(Fig. 1) were taken during the attack. It 


will be seen that the rate is considerably 


slowed. In lead II. (Fig. 1) the rateis 42 per 


minute, no P-wave can be made out, and 
the R—T interval is prolonged. In lead III. 


(Fig. 1), whilst he was slowly regaining 


consciousness, the rate has risen to 52, the 


P-wave has reappeared but is inverted, and 


the P—R interval is shortened. 


The second electrocardiogram (Fig. 2) 


was taken within five minutes of the first. 


By this time he had completely recovered. 
The heart-rate is 71, 68, and 68 respectively 
in the three leads, there is no longer any 
inversion of the P-waves, and the P-R 


FIG. 1.—Lead I., before attack. 


II., unconscious. III., coming round. 


(and R-T) intervals are the same as before 


the attack. 


No blood-pressure readings were 


taken, but it was noted that the pulse 


had disappeared at the wrist during 
the time he was unconscious. The 


striking features in the electrocardio- 


gram are the disappearance of the 


P-waves during the unconscious stage 


and its reappearance, inverted, whilst 


he was coming round. It would ap- >= 


———— se --r-- _-:- 


pear that the sino-auricular node [a 


= - 


-4 


— 


; a Tay => 
was temporarily in abeyance and = === 


PR, 
E i 
= 
o 

$ 


— si neon LA E if, 
iE SS SSS SS SS SESE DS= SS = r 


that the auriculo-ventricular node 
had taken over its function. Since 


FIG. 2.—After recovery from attack. 


86 THE LANCET] | 


MEDICAL SOCIETIES 


[san. 11, 1936 


ROYAL SOCIETY OF MEDICINE 


SECTION OF SURGERY 


'AT a meeting of this section on Jan. Ist, Mr. 
W. Sampson HANDLEY, the president, being in the 
chair, Mr. G. H. STEELE read a short paper and 
showed a film on 


Retrograde (sophagoscopy 


The results of treatment of cancer of the cesophagus 
were, he said, highly unsatisfactory. Only a few 
cases could be operated on, because of the age of the 
patient and the wide spread of the growth, and the 
operative mortality was enormous. Irradiation treat- 


ment could be described as hopeful but no more.. 


The ideal technique seemed to be deep X rays, 
und some remarkable cases had been recorded, 
but this seemed to make the patient very ill and 
sometimes caused fibrosis of the lungs, while the 
relief granted was only temporary. The application 
of radium transpleurally had a very high mortality 
and poor results, while large doses in the lumen were 
unsatisfactory. The operations of intubation and 
gastrostomy were purely palliative. Better results 
were obtainable from insertion of radon seeds through 
the wsophagoscope. This did not upset the patient 
and caused no appreciable mortality. In many 
cases it produced definite healing of the visible 
upper end of the growth with relief of dysphagia 
for a period varying from six months to three years. 
If the lower end were approached from below almost 
tho whole length of the esophagus became accessible. 
Both ends of the growth could be irradiated, but the 


extra-cesophageal spread would have to be dealt 


with by X rays. The operation, which was shown 
in the film, was performed with a Jobson’s introducer, 
the csophagoscope being passed by direct vision. 
Cures were not claimed, only a great increase of 
comfort. Of four cases treated from both ends, one 
had died six weeks later from innominate artery 
hemoptysis. At post-mortem the growth was healed 
in the csophagus but had extended to the artery. 
The second patient had lived perfectly comfortably 
for nine months and then had died of aortic hemat- 
emesis. In a third case the two operations had 
been performed simultaneously—perhaps a mistake— 
and the patient had died of mediastinitis five days 
later. The fourth was alive and well after six months 
and having deep X rays for the extra-csophageal 
extensions. 

Prof. J. PATERSON Ross said that the technique at 
St. Bart.’s had been modified to obviate fibrosis 
of the lung, and asked Mr. Steele how he estimated the 
depth of the growth. Dealing with it from both 
ends was a great advance.—Mr. STEELE replied that 
radiographs taken in the recumbent position gave a 
fair idea of the extent of the growth. He had not 
attempted irradiation during the operation. 

Mr. T. B. JOBSON complimented Mr. Steele on the 
advance he had made. Chevalier Jackson had told 
him he had never had a cure. If only a case could be 
treated early enough, there was no reason why cure 
should not be obtained by Mr. Steele’s method. 
The film showed that the radon seeds introduced 
from below overlapped those introduced from above. 

The PRESIDENT commented on the advantage of 
intra-tumoral methods and thought that a combina- 
tion of these with deep X rays would be better than 
the latter alone. The present method also facilitated 


_ gastrostomy, if this were necessary. If the patient 


refused radiation, pancreatic ferment with sodium 
bicarbonate by the mouth might give relief in many 
cases, healing the ulcerated surface and restoring 
the power of swallowing. 


Dr. H. L. MARRIOTT read a paper by himself and 
Dr. A. KEKWICK on 


Continuous Drip Blood Transfusion 


The average in 87 cases, he said, was 5 pints and 
29 hours, the largest figures being 11 pints and 
62 hours. Present conceptions in regard to dose 
needed revision ; a pint was woefully inadequate for 
an anemic patient, especially if he were bleeding. 
The principle should be made one of quantitative 
measurement and the restoration of a normal hemo- 
globin percentage. Hemoglobin estimations should 
check the transfusion. Clinical results were com- 
mensurate. The necessity for slower administration 
followed from these large doses. There was, however, 
more in administration than met the eye. A. E. 
Boycott and C. L. Oakley, working with rabbits, 
had shown that large transfusions did not affect 
the plasma volume ; the added plasma was extruded 
and the added cells retained. This ‘process went 
on during the transfusion if given slowly enough. 
The best rate was to try to increase the patient’s 
hemoglobin by 10 per cent. every four hours—i.e., 
in the non-bleeding patient, a pint in four hours, 
or 40 drops a minute. In bleeding patients the 
rate must be governed by hemoglobin estimations. 
If the patients were weak there should be three stages 
at intervals of a few days. The apparatus had been 
described fully in THE LANCET (1935, i., 977, and 
ii., 78). The blood was kept stirred ,by bubbling 
through it a slow stream of filtered oxygen. It 
was important to bleed donors by a closed method, 
to avoid droplet infection from the operator. On 
an average four or five donors were used for each 
transfusion. The great majority had been friends 
and relatives, as it did not seem right to deplete 
the Red Cross service for large transfusions. The 
approach to the relatives was important; the onus 
of finding ten or twelve donors must be put on them 
and no responsibility should be taken by the surgeon. 

This method had proved extraordinarily effective. 
Most of the patients had had bleeding peptic ulcers 
or had needed transfusion before or after operation. 
Results had been very satisfactory and in some cases 
remarkable. In peptic ulcer the blood could be 
run in as it was lost ; 18 out of 22 serious cases had 
lived and at least half of them could not have lived 
without the massive transfusion. Three of the 
deaths had been due to pneumonia and one to 
perforation. Eight cases of aplastic anemia had 
been treated, but it was better to transfuse them 
once a week and not give the blood by the continuous 
method. Four transfusions had been done during 
operation, the blood being run in as the patient 
lost it and the hemorrhagic element of shock 
eliminated altogether. 

Mr. V. H. RIDDELL demonstrated by slides and a 
film a technique with an electrically-driven. pump 
and pointed out its advantages and disadvantages. 
The latter were financial and mechanical. The 
apparatus cost 60 guineas, was manufactured abroad, 
and removed all the romance from blood transfusion. 


It was, however, simple and reliable and there was 
Less tubing 


only a single rubber tube to sterilise. 
was needed than in Dr. Marriott’s apparatus, so that 


4 


THE LANCET] 


‘ROYAL ACADEMY OF MEDICINE IN IRELAND 


[zan. 11, 1936 87 


obstruction due to clotting was less frequent. The 
rate of flow was absolutely constant and could be 
regulated. The blood could be introduced at body 
temperature, its container being surrounded by a 
bowl of water at 108°F. or a thermostat. The 
transfusion gave itself. The motor was supplied 
with a gear system and a reverse, and a revolving 
cam pressed the rubber tubing against the sides of 
the metal cup in which it rotated. The tubing was 
first filled with 3-8 per cent. citrate. 

Mr. A. H. BURGESS asked whether this country 
could not do something similar to what was being 
done in Russia, where large quantities of blood were 
collected: from the vessels of the newly dead. 
Accidental, suicidal, and cardiac deaths were used 
for this purpose. 

Mr. ZACHARY. COPE asked whether citrated blood 
was as good as other forms, and if there had ever 
been rigors in long-continued transfusions. 

Mr. RoGERS asked what rate was used for children 
and how blockage was dealt with. i 

The PRESIDENT said that surgeons could be divided 
into ritualists and evangelicals ; some liked elaborate 
methods while others sought simplicity. Blood 
transfusion seemed to be no exception. 


Dr. MARRIOTT replied that the point of their work 
was dose and rate, not apparatus. A pump had 
advantages only in children; it was difficult to 
keep a rate of about 5 drops a minute steady by 
gravity, and the pump was therefore better. Gravity 
drip must be watched by a nurse, as it might block 
and cause reflux. The cooling effect in large trans- 
fusions was negligible and it was not worth while 
to warm the blood, with the risk of cooking it. 
Citrated blood was better than other kinds: as the 
citrate had a hemostatic effect in the body. Rigors 
were due to dead bacteria in the saline or citrate, 
and could be obviated. In the last thousand cases 
of drip saline at the Middlesex there had been 16 rigors, 
and ten of the patients had had them before. Stale 
blood clot in the tubing might also cause rigor, and 
fresh tubing should be used for every patient. 


Mr. C. JENNINGS MARSHALL read a paper on the 
treatment of | 


Diverticulitis of the Colon 


The condition was, he'said, a newcomer to the patho- 
logical consciousness, but was nowadays frequently 
diagnosed clinically. Patients complained of. left 
iliac fossa pain, and an acute attack often started 
while straining at stool. Local pain, backache, 
and slight pyrexia characterised chronic cases. The 
elongated swelling contrasted with the restricted 
tumour of cancer, which was afebrile and without 
backache. -Gross obstruction was; in his experience, 
rare in diverticulitis. Radiographically there was 
a saw-tooth appearance with distortion and rigidity, 
but the appearance was suggestive only. The 
causative diverticulum was never seen, because 
it was obstructed and did not admit the opaque 
fluid. Stereoscopic radiography was particularly 
useful in determining relationships and operability. 
A perforating carcinoma might not infrequently 
have arisen in a diverticulum. Chronic cases needed 
very full investigation. The presence of blood and 
mucus in the fæces favoured cancer but did not 
prove it. l ' : 
Acute cases were associated either with abscess 
or with perforation. Abscesses might be found in 
the loin or mesosigmoid. The abscess should simply 
be drained and the condition otherwise left alone. 
Perforating cases needed pelvic drainage followed by 


-Fowler’s position. The organism was generally a 


foul proteolytic germ. Feces were not extravasated 
in the pelvis to any great extent on account of the 


‘obstruction of the diverticulum and the acute swelling 


surrounding it. There might be extravasation after 
separation of a slough. Stitching up was more 
likely to cause extravasation than to prevent it. 
There was no need to worry much; it was enough 
to anchor the appendices epiploice under the incision 


-and drain. Nevertheless the ideal procedure, when 


it was possible, was a first stage Paul’s operation, as 
this provided radical cure. ; 
Chronic cases, correctly termed peridiverticular 


cellulitis, were amenable to careful treatment, but 


this was prolonged and irksome. The less nocuous 
lactic-fermenting intestinal flora should be encouraged 
by a low protein -or wholly fruit and milk diet. 
Intestinal lubricants and lavage should be used to 
keep the stools soft. Roughage must be excluded. 
During active exacerbations glycerin per rectum 
was very useful. Cases should be regarded as 
‘ medical until proved surgical.” Did diverticulitis, 
he asked, in fact recur elsewhere after excision ? 
Persistence of pain, fever and obstruction, fistule 
and relapses were the chief indications for surgery. 
The Paul-Mikulicz method was the preferable one. 
Colostomy was necessary in severe pelvic matting 
and vesico-fistula. 

Mr. M. F. NICHOLLS agreed that perforation did 
not cause gross infection and quoted a case in which 
the peritoneal exudate had been sterile and the 


diverticula had recovered without local treatment. 


A curious abdominal catastrophe was very likely 
to be a diverticulitis. . 

Prof. PATERSON Ross spoke of the difficulties and 
dangers of vesical fistula. In one case a colostomy 
had been closed after six months and the fistula 
into the bladder had promptly reopened. 

Mr. BURGESS agreed that there was no continuous 
leakage in diverticultis any more than in appendicitis, 
but communication might reopen when inflammation 
subsided, and go on indefinitely, as it did in vesico- 
colic fistula. The colon was far more septic in 
diverticulitis than in cancer, and any attempt to 
free it was very dangerous. A transverse colostomy 
was the best operation, and it might have to be 
postponed for six or twelve months. Any septic - 
part became aseptic if completely short-circuited ; 
therefore the transverse colon must be cut completely 
across and the ends separated. Eventually any desired 
operation could be done to clear up the condition. 

The PRESIDENT corroborated: the suggestion that 
diverticulitis might end in carcinoma, and said he 
had also found it to cause obstruction. 


ROYAL ACADEMY OF MEDICINE IN 
IRELAND 


AT a meeting of the section of medicine on Dec. 13th, 
1935, with Dr. V. M. SYNGE, the president, in the 
chair, a paper on the 


Infective Factor in Rheumatic Fever 


was read by Dr. W. R. F. CoLLIs. He showed charts 
demonstrating the following points :— 


_ (1) Rheumatic fever follows acute hemolytic strepto- 
coccal throat infections in a high percentage of already 
rheumatic subjects and in a small percentage of non- 
rheumatic patients. 

(2) Both recrudescences and primary rheumatic attacks 
follow hemolytic streptococcal infection only—not other 
infections. 


$8 “THE LANCET] 


‘ROYAL ACADEMY OF MEDICINE’ IN IRELAND 


[san. 11; 1938 


(3) Rheumatic subjects are hypersensitive to the strepto- 
coccal endotoxin.. 

(4) In every case there is a definite sequence : acute 
_pharyngitis — silent period (10-20 days) — acute rheu- 
matism. 

(5) Although the organism disappears from the surface 
of the pharynx soon after the pharyngitis subsides it 
-can be obtained many months afterwards at autopsy 
from the centre of the tonsils, from the cervical and 
‘mediastinal glands, and occasionally from the spleen. 

(6) Hemolytic streptococci may be divided into bio- 
logical groups: some of these cause throat infections 
which precede rheumatic fever ; others do not. 

(7) The blood of patients with acute rheumatism shows 
streptococcal antibodies (e.g., precipitins and anti- 
streptolysin). These are present while the disease is 
active but are low or absent during good health. 

(8) There is a definite resemblance between the arthritis 
of serum sickness—which follows 10-20 days after 
injection of horse serum and occurs when the antigen 
(horse serum) and the antibody (precipitin) reach a certain 
titre in the patient’s blood—and that of the acute 
rheumatic recrudescence. 


Dr. Collis submitted that the infective factor in 
rheumatic fever is the hemolytic streptococcus, and 
that the disease is due to interaction between break- 
down products of the organism and the liquids and 
tissues of the body. 

The PRESIDENT said he was interested to note 
Dr. Collis’s remark that antibody production might 
be delayed by the giving of aspirin, and that this 
might prevent cardiac complications. If toxin- 
producing streptococci were the cause of rheumatic 
fever it seemed queer that scarlet fever should never 
be followed by the rheumatic type of valvular disease. 

Dr. R. E. STEEN was not absolutely satisfied that 
the hemolytic streptococcus was the cause of the 
rheumatic relapse. If a hemolytic streptococcal 
.sore-throat was the cause of acute rheumatism, it 
was surprising that one so seldom saw acute nephritis 
as a complication. ; 

Dr. G. C. DocKERAY pointed out that the incidence 
of streptococci in throats was very high.—Dr. L. 
-ABRAHAMSON also referred to cases in which hemo- 
lytic streptococci were present in the throat but the 
patients had neither. clinical sore-throat nor rheu- 
matism. It was sometimes stated that acute rheu- 
‘matism was seen only in the poor, but this was not 
` altogether true ; he saw a good deal of it in private 
‘practice. 

Dr. ALAN THOMPSON said it was well known that 
the titre of antibody corresponding to a particular 
organism might rise in response to any non-specific 
pyrexia. He thought it quite possible that the 
clinical exacerbations of rheumatic fever merely 
stimulated the. rise of the streptococcal antibodies. 
In his opinion the experimental work described by 
Dr. Collis required considerable amplification before 
it could. be accepted definitely—Dr. J. C. FLOOD 
suggested that the work should be -carried a stage 
further by trying to reproduce the lesions in animals. 


- Dr. Corts, in reply, said he fully realised that 
his hypothesis could not be accepted out of hand. 
The most important fact established was the associa- 
tion of the hemolytic streptococcus and acute 
rheumatism. Criticism had centred chiefly on two 
points: (1) that the organism was often found in 
the throat of normal people and often caused acute 
haryngitis umnassociated with rheumatic fever; 
2) that his hypothesis did not satisfy Koch’s postu- 
lates or the genorally accepted principles of disease 
processes... In reply to the former, he pointed out 
that the-same could -be said ‘of nearly all germs 
found in the nasopharynx ; recent work had shown 


that many very different organisms are at present 


Included under the wide heading of ‘‘ hemolytic 


streptococci,” and in future the mere hemolysis of 
blood corpuscles would not be sufficient description 
for these organisms. As to Koch’s postulates he 
could only say that he thought they were dead. 
It had been shown that erythema nodosum could 
in different circumstances be caused by infection 
with different organisms. A new and revolutionary 
attitude was needed towards disease, for the reactions 
of the body were as important as the invading germs 


-in the causation of disease syndromes, 


Dr. ABRAHAMSON and Mr. J. OWENS each reported 
a case of Syphilis of the Lung. 


Genital Prolapse 


Dr. J. F. CUNNINGHAM’S presidential address 
to the section of obstetrics and gynecology dealt 


with the choice of operation in the treatment of | 


genital prolapse. No one type of operation, he said, 
was effective for every degree and type of prolapse, 
and the cause of the condition should be carefully 
investigated in every case. He had found five 
different operations useful, with occasional slight 
modification. Simple colporrhaphy and _perineor- 
rhaphy was adopted for cases of small cystocele 
and rectocele when the tissues were good and the 
fascia capable of being repaired, and where there was 
no definite prolapse of the uterus. The Manchester 
operation was used in cases of uterine prolapse of 
the first or second degree, especially during the child- 
bearing period ; but in patients near or past the 
menopause, where a large cystocele was the main 
feature, the interposition operation was preferred as 
being more certain in the ultimate result. Cases 
subjected to this operation must be carefully selected 
and the operation performed with close observance 
of detail, if unsatisfactory results were to be avoided. 
Vaginal hysterectomy,: after Mayo, or combined 
with a Manchester colporrhaphy, was performed in 
cases of complete procidentia; this gave the best 
results, but attention must be paid also to the repair 
of the posterior vaginal wall and Douglas’s pouch. 
Finally, Le Fort’s operation was occasionally useful 
in elderly subjects where a more extensive operation 
might be dangerous. Dr. Cunningham quoted 161 
cases operated on for prolapse ; 121 by colporrhaphy 
(including Manchester), 16 by interposition, 19 by 
vaginal hysterectomy, and 5 by Le Fort’s method. 
There was one death, from lobar pneumonia, and, 
on inquiry, 7 recurrences had been reported, 3 being 
in cases of colporrhaphy followed by one or more 
subsequent deliveries at term. Two were genuine 
recurrences, one was urinary incontinence, and one 
was a cervical hypertrophy. The conclusions drawn 
from the series were that colporrhaphy is unreliable, 
especially in elderly patients with atrophic pelvic 
fascia, but is the best type of operation in younger 
patients whose tissues are good. Interposition is 
excellent, but only in selected cases. Vaginal 
hysterectomy should be done in very bad cases, 
especially where the uterus is diseased. | 

Dr. GIBBON FITZGIBBON said he was glad that the 
President laid emphasis on the place of vaginal 
hysterectomy in cases of genital prolapse. A cause 
of confusion was the association of cystocele, rectocele, 
and prolapse all under the term ‘“‘prolapse.” The 
three were individual entities and needed definition. 
It was in cases of high rectocele that removal of the 
uterus enabled the uterosacralligaments to be reached 
and incorporated with the lateral ligament in’ the 
restoration of the pelvic fascia to close the hernial 


THE LANCET] 


MANCHESTER MEDICAL SOCIETY 


(san. 11, 1936 89 


-namely, (1) a high amputation of. the cervix with 


opening. The cure in these cases by operative treat- 
ment really depended on what part of the fascia was 
damaged, and the repair of that part of it. He 
did not believe in the necessity for the interposition 
operation. Where there was dropping of the cervix 
and cystocele, it was in his opinion never successful. 

Dr. A. H. Davipson said that since seeing the 
Manchester operation carried out in Liverpool he 
had done most of his prolapse work by this 
technique and found it gave good results.. He had 
supposed that abdominal operations for prolapse 
had disappeared, but in London recently he had seen 
ventral fixation done for prolapse of the uterus. 
He was not very favourably disposed towards the 
operation of interposition, but thought it had a 
place—though an extremely limited one—in cystocele. 
He did not believe that vaginal hysterectomy was 
a cure for prolapse. It seemed to him important 
to stress the etiology of prolapse: it was usually 
due to extremely bad midwifery. 

Dr. T. M. HEALY agreed that the interposition 
operation cured cystocele. The difficulty was that 
the patient had no guarantee that she would not 
afterwards get a descent of her cervix, and the cure 
of this condition was extremely difficult. Vaginal 
hysterectomy was not a cure for prolapse unless the 
supports of the uterus were used to keep up the 
bladder, and the number of cases in which vaginal 
hysterectomy was necessary to cure prolapse of the 
bladder were relatively few. If anything was wrong 
with the uterus it should be removed, otherwise 
removal was unnecessary if the Manchester operation 
had been properly learned and if the technique was 
carefully carried out. Abdominal fixation of the 
uterus was good in elderly women with prolapse 
of the vagina, and a small uterus, when short 
anesthesia was desirable. 

Dr. O’DONEL Browne thought there was no doubt 
that anterior colporrhaphy and perineorrhaphy would 
cure cystocele and rectocele with one exception—high 
rectocele. Most of the cases in. which. good results 
were obtained by shortening the ligaments were 
cured by fibrosis. Prolapse of the rectal canal 
could be cured by injections of absolute alcohol.— 
Dr. A. W. SPAIN said he got very good results from 
the Manchester operation; any trouble he had 
was in the posterior wall. He thought that patients 
should be kept in bed. for three weeks beforehand 
and given hot vaginal douches. He would never 
remove the uterus unless it was absolutely necessary 
to do so, and if a woman in the child-bearing age 
could be kept comfortable by the insertion of a 
pessary this ought to be done.—Dr. BOUCHIER 
Hares believed that the whole question was really 
one of pelvic fascia and fibrosis.. | 

Dr. R. M. CORBET said it was possible to have a 
cystocele without any prolapse, and it seemed to 
him unnecessary to push up the bladder and shorten 
the ligaments unless those ligaments appeared to 
be lengthened. He was rather in favour of vaginal 
hysterectomy for the larger type of prolapse; he 
agreed with Dr. Healy that it was not the hysterectomy 
but the bringing together of the ligaments that did 
good. He would advise spending more time in the 
preoperative treatment of these cases. Operation 
for high rectocele should if possible be postponed 
until the child-bearing period was over. | 

Dr. BETHEL SOLOMONS said that the Manchester 
operation suggested the conclusion that the main 
thing in dealing with prolapse was to shorten the 
tissues about the cervix and to repair. the hernias, 
from which he had evolved his present technique— 


shortening of the wuterosacral ligaments; (2) 
approximation of the bladder pillars with an extensive 
anterior colporrhaphy and. colpoperineorrhaphy. The 
results had been good in his own hands and in the 
hands of some of his assistants. Le Fort’s operation 
was excellent for the old patient, but he did not 
believe that any abdominal operation was necessary, 
and unless the uterus was diseased hysterectomy 
should never be done. : | 


The PRESIDENT, in replying, said he was not an 
advocate of drastic surgery in prolapse cases, and 
was not enthusiastic about vaginal hysterectomy or 
interposition. The important thing for keeping 
the organs in place was the fascia. He had at one 
time done interposition ; then he had got enthusiastic 
about the Manchester operation and had done it ; 
but now he had gone back to interposition. If the 
uterus was too big he did some other operation, 
and if it was too small he never did an interposition. 
He did not think the operation suitable in cases of 
procidentia. Vaginal hysterectomy alone did not 
cure prolapse, and he regarded ventral fixation as 
a bad operation for prolapse. | 


MANCHESTER MEDICAL SOCIETY 


AT a recent meeting of this society Prof. A. D. 
MACDONALD, opening a discussion on the 


Choice of an Angzesthetic 


said that the ideal local or general anesthetic has yet 
to be discovered. Only the’ volatile anzsthetics 
possess the controllability which makes possible the 
adjustments to varying needs and varying suscepti- 
bilities. The action of mixtures of aliphatic com- 
pounds is the sum of the actions of its components ; 
there is no evidence of potentation, such as exists 
for morphine and other alkaloids followed by anæs- 
thetics. The use of mixtures, such as A.C.E. and 
Schleich’s, in which the volatilities of the com- 
ponents differ widely, is pharmacologically unsound. 
Premedication with non-volatile ‘drugs is only justi- 
fiable in doses well below the average anesthetic 
dose ; it is possible that some may affect vital centres 
before they depress ordinary reflexes. eo 

Dr. E. FAULKNER HILL, in all grave risks where 
time. allowed, would invoke the aid of surgeon, 
physician, and biochemist as well ‘as anesthetist to 
estimate the survival power of the patient, and then 
enhance this power to the utmost by suitable prepara- 
tion, diet, rest in bed, and appropriate treatment 
before operation. In the course of time this would 
lead to a codrdinated and unbiased opinion of the 
merits of the various methods in common use. But 
the organisation of such a service would seem to call 
for the appointment of'a special officer. 

Mr. GARNETT WRIGHT, from a-small personal 
experience of splanchnic anesthesia, was hopeful 
that by its use (1) chest complications might be 
much reduced, (2) palliative gastrectomy for carci- 
noma might be safely undertaken more frequently, 
by operation for acute hemorrhage might be rendered 
safer. = 

A lively discussion followed. 


TIVERTON AND DISTRICT HOSPITAL.—An up-to- 
date operating theatre, an X ray room with new plant. 
and an anezsthetising room are being added to this 
hospital which has been much ‘enlarged during the 
last few years. The new extensions will cost about £3000, ‘ 


90 THE LANCET] 


[san. 11, 1936 


REVIEWS AND NOTICES OF BOOKS 


' 


Milk : Production and Control -- 


By W. CLun Harvey, M.D., D.P.H., M.R.San.I., 
and Harry HiL, M.R.San.I., A.M.I.S.E., M.S.I.A., 
Medical Officer of Health and Sanitary Inspector 
respectively, Borough of Southgate. London: 
H. K. Lewis and Co., Ltd. 1936. Pp. 555. 21s. 


THE different aspects of milk are so numerous and 
the literature on the subject so vast that it is not 
really practicable in one volume even so large as 
this one to cover adequately every aspect of it. 
Many matters of importance are here ignored, but 
the authors have succeeded in writing a book of 
considerable value which covers, particularly on 
the practical side, all the essentials of milk production 
and control. It is on the scientific side—i.e., the 
‘basis upon which production and control must be 
founded, if sound methods are to endure—that the 
volume is inadequate. A saving of space on 
some of the technical points which are treated in 
unnecessary detail would have enabled rather more 
evidence on the scientific side to have been incor- 
porated, giving the book a better balance. 

As a practical handbook it can be praised with but 
few reservations. While critical enough in some 
directions, as for example on the subject of 
designated milks, the authors seem to be somewhat 
timid in exposing the essential defects in our present 
legislation. This diffidence is associated with a 
curious attitude to some recent studies upon milk. For 
example, when discussing designated milk and the 
classification of milk the authors_do not refer to the 
important report of the Committee on Cattle Diseases 
issued by the Economic Advisory Council in 1934. 
That committee. after the most exhaustive study 
and examination of expert witnesses agreed on a 
complete policy and made explicit suggestions as to 
the different standards for milk. The chapter on the 
Future of the Milk Industry might have been much 
more valuable if this report had been discussed. 
The impression left by the account of the Tuberculosis 
Order and Ostertag’s method for reducing bovine 
tuberculosis is that these methods are capable of 
yielding good results if improved, whereas in fact 
they are now recognised to be unsound. The reason 
for the fact that Ostertag’s method is not favoured 


outside Germany is that it has had no effect in reduc- 


ing bovine tuberculosis. 

As a practical guide to clean and safe milk produc- 
tion, however, this book will be extremely useful. 
Everywhere there is evidence of the authors’ 
familiarity with this side of their subject. The 
chapter on the cowshed is particularly good, although 
many authorities will disagree with the contention 
that the value in double sheds of positions of head-to- 
head as against tail-to-tail is equally balanced. 
The dairy, clean milk production, and the distribu- 
tion of milk are well discussed ; a long chapter deals 
in, great detail with the treatment of milk by heat, 
and not very well-known processes such as stassanisa- 
tion and pasteurisation in the bottle are explained. 
The important matter of the control of pasteurisation 
plants by the inspector is fully described, but the 
possible defects of such plant and the ways to detect 
them are not detailed, while some essential points 
are omitted. ‘Existing legislation is conveniently 
set out, as are also the essentials of laboratory and 
other control. ` The section on chemical analysis 
seems out of place, for analysts would hardly refer 


to it and its omission would have enabled some of the: 


bacteriological laboratory problems to be discussed 
in more detail. The important phosphatase test is 
not even mentioned. Other chapters deal with the 
composition of milk, milk and disease, and the cow. 

The monograph will certainly be found useful by 
medical officers of health and sanitary inspectors, | 
while those concerned on the commercial side will 
find much instructive matter in its pages. The 
book is clearly printed and written in an attractive 
manner; the views expressed will be accepted by 
authorities as sound in the main, while there are 
many valuable illustrations. The bibliography is 
rather a poor affair. 7 


Optical Rotatory Power 


By T. Martin Lowry, C.B.E., M.A., D.Sc., 
F.R.S., Professor of Physical Chemistry in the 
University of Cambridge. London: Longmans, 
Green and Co., Lid. 1935. Pp. 483. 30s. 


Tus book is a record of work and progress in 
polarimetry extending over a period of 120 years, 
from the original discovery of the optical rotatory 
power of quartz to the recent theoretical work of 
Max Born in Cambridge. It is a complete exposition 
of the subject by one who not only knows all its 
complexities, but has himself contributed much of 
the original work described. The first part of the 
book is mainly historical, but contains an interesting 
general account of the principles of rotatory polarisa- 
tion. A reader with little knowledge of the subject 
will be able to appreciate and understand its elements. 
The work of Pasteur forms the basis of this section 
and reminds us that a man to whom medicine is 
greatly indebted has also contributed largely to 
an almost unrelated branch of science. The second 
part deals with the practice of polarimetry, of which 
the applications are almost unlimited. The measure- 
ment of rotatory dispersion in both the ultra-violet 
and infra-red portions of the spectrum is clearly 
dealt with and a description is provided not readily 
available elsewhere. The book concludes with a 
theoretical account of the subject, which of necessity 
assumes an adequate knowledge of mathematics in 
the reader. 

Prof. Lowry has produced a bock on a difficult 
subject that is admirable both in intention and 
execution. 


The Microscopic Anatomy of Vertebrates 


By G. G. Scorr, Ph.D., Professor of Biology, 
City College, New York City; and J. 1. KENDALL, 


Ph.D., Instructor in Biology in the College. 
London: Henry Kimpton. 1935. Pp. 306. 
17s. 6d. 


HUMAN anatomy is made both more intelligible 
and more interesting if taught from a comparative 
standpoint. The same could be said of histology, 
though in this case the comparative method has 
seldom been applied. The chapters of this book 
deal separately with the microscopic structure of the 
main vertebrate organs. In spite of the authors’ 
implication to the contrary in their preface, the 
emphasis is placed entirely upon mammals. The 
brief account of the particular organ as found in the 
lower vertebrates, which in some places precedes a 
description of the mammalian structure, is seldom 
full enough to afford a valuable comparison. . Neither 
the evolutionary nor the functional significance 


THE LANCET] 


REVIEWS AND NOTICES OF BOOKS 


[yan. 11, 1936 9] 


of the changes in microscopic structure is emphasised. 
In several instances, a notable example being the 
pineal body which has a particularly interesting 
evolutionary history, no mention whatever is made 
of the structure as found in the lower vertebrates. 
There is little value in descriptions of a variety of 
types unless relationships are discussed. This book 
will certainly provide a useful introduction to 
mammalian histology, but the authors have not 
succeeded in presenting the subject in a truly 
comparative manner. l 


A Companion to Manuals of Practical 

Anatomy 

Fourth edition. By E. B. Jamigeson, M.D., 

Senior Demonstrator and Lecturer on Anatomy, 

‘University of Edinburgh. London: Humphrey 

Milford, Oxford University Press. 1935. Pp. 661. 

128. 6d. 

HERE, packed into small space, is a mass of detailed 
and highly accurate information. The section on 
the central nervous system is worthy of special 
mention. The adoption of the English terminology 
(Birmingham revision) has doubtless contributed to 
the success of this little book which is as useful a 
pocket manual as anyone could wish for. 


Minor Medical Mysteries 
By LEONARD WILLIAMS, M.D. Glasg. Foreword by 
Lord HORDER. London: Cassell and Co., Ltd, 
1935. Pp. 211. 5s. 


Dr. Leonard Williams is well known as an accurate 
clinical observer, possessing clear-cut and often 
individual views, and as a pungent writer. These 
qualities appear in his latest collection of essays in 
which, however, he hardly does himself justice. The 
reason for this may be that many of the essays were 
communicated to magazines where space has to be 
dictated by the editor to the disadvantage of the 
contributor. It is clear that when 30 medical or 
semi-medical subjects, all of a sort that invite dis- 
cussion, are dealt with in 200 small pages, the author 
cannot develop his theme, and this will be a matter 
of regret to Dr. Williams’s readers, because of the 
challenging nature of many of his statements and 
conclusions which are put down with wit and wisdom. 
Lord Horder’s foreword is a just encomium. 


Fifty Years a Surgeon 
By RosBert T. Morris, M.D. London: Geoffrey 
Bles. 1935. Pp. 276. 10s. 6d. 


THERE have been many books published composed 
of personal reminiscences centring round the develop- 
ments of medicine in the nineteenth century, but 
Dr. Morris’s addition to their number has a claim 
to attention. It is well and brightly written, and the 
picture supplied of surgical advance in the United 
States is dramatic. We have a picture of a great 
American medical school in the ’eighties, and the 
revolution caused in the Bellevue Hospital, New 
York, by the introduction of antisepsis. The great 
advances in technique now made possible are set 
out, while the perfecting of the methods of administer- 
ing ansesthesia are shown to have enormously extended 
the range of the surgeon’s utility. There is nothing 
new in these chapters to the medical reader, but the 
general public should be edified by their contents. 
The personal record of private and special practice 


is written with zest and leads to a chapter entitled 
“the fourth era in surgery,” by which Dr. Morris 
means the appreciation in surgical treatment of the 
influence of the patient’s own physiology. This is 
probably the section whose writing determined 
Dr. Morris on publication. It is an able but partisan 
denouncement of surgical interference where the 


‘chances of recovery without operative aid have been 


underestimated. And we learn with no surprise 
that some of the author’s colleagues have not been 
in agreement with his views. 

The book ends with chapters on such much- 
discussed topics as osteopathy and therapeutic 
fads, psycho-analysis, birth control, and certain forms 
of professional delinquency, where the opportunity 
for telling stories is happily made use of. 


Diseases of the Liver, Gall-Bladder, Ducts 
and Pancreas 


Their Diagnosis and Treatment. By SAMUEL 
Weiss, M.D., F.A.C.P., Clinical Professor of 
Gastroenterology, New York Polyclinic Medical 
School and Hospital. With a chapter on Surgery 
by J. Prescott Grant, M.D., F.A.C.S., M.R.C.S., 
Professor of Surgery, and a chapter on Roent- 
genology by A. Jupson QuimBy, M.D., F.A.C.R., 
Professor of Roentgenology at. the same school. 
New York: Paul B. Hoeber, Inc. 1935. Pp. 1099. 
$10. | 
Prof. Weiss has written this book at the request 
of his colleagues and students, and offers it as 
“ primarily a practical one’’ to the medical student, 
the general practitioner, and ‘“‘ even the specialist.” 
It is in the form of-a large and fairly comprehensive 
systematic treatise. -Historical, anatomical, and 
physiological aspects of the subject are briefly dealt 
with at the beginning. Descriptions of morbid 
anatomy appear in their proper places, but over- 
stressing of pathology is deliberately avoided. Clinical 
descriptions of disease, methods of examination— 
including large numbers of laboratory methods—and 
treatment occupy most of the book. It is profusely 
illustrated with drawings, photographs, and radio- 
grams, all beautifully reproduced. Paper and print 
are beyond cavil ; our only criticism of the production 
is that the book is uncomfortably large and heavy. 
Some of its bulk might easily have been reduced, since 
the white margin round every page is so excessively 
broad that its area exceeds that of the printed part. 
The text is curiously unsatisfactory. Its English 
style, when due allowance has been made for recog- 
nised Americanisms, often lacks the precision that 
should characterise a scholarly work; the clay- 
or putty-coloured stool of obstructive jaundice, for 
example, is repeatedly described as “discolored.” 
Where the author is noting his own observations, or 
clinical conditions familiar to him, he is naturally 
happier, but much of his material is drawn from the 
literature, and interjected in the form of short para- 
graphs; critical appraisal of these contributions and 
synthesis of them into a coherent picture is often 
wanting, and at times indeed an entirely wrong 
impression emerges. Thus under the heading “ pan- 
creatic diabetes’ a two-page account of diabetes is 
included for the sake of completeness, and it opens 
with the sentence, ‘‘ The causes of diabetes are the 
causes of obesity, the two conditions being constant 
companions’’; this is surely an overstatement even 
of Joslin’s view. In “bronzed diabetes hzemo- 
chromatosis’’ it is said that the skin and organs are 
red-brown—in most cases the skin is actually leaden- 


92 


THE LANCET] 


REVIEWS AND NOTICES OF BOOKS 


[yan. 11, 1936 


grey—and that in the final stage of the disease diffuse 
carcinoma of the spleen is common. Even where the 
author draws directly on his own experience he is 
often disconnected and unconvincing, as where he 
describes a case of thyrotoxic auricular fibrillation 
with congestive heart failure and hepatic enlargement 
to illustrate the connexion between gall-bladder 
disease and cardiac pain. This sort of muddled 
presentation is so pronounced in the chapter on 
cirrhosis of the liver that it must reflect a confusion, 
and therefore an inaccuracy, of thought. A broad 
classification into ‘‘Laennec’s cirrhosis (atrophic, 
portal, multilobular) ” and ‘‘ Hanot’s cirrhosis (hyper- 
trophic, biliary, monolobular)’’ is first adopted. 
The author then describes a number of varieties of 
cirrhosis, whose relation one to another is by no 
means clear, and the reader, among other uncer- 
tainties, has no means of telling whether the two 
separate descriptions, of “‘ simple hypertrophic cirrhosis 
(Hanot-Gilbert)’’ on pp. 417-420, and of “biliary 
cirrhosis (Hanot’s syndrome)” on pp. 430-438, refer 
to the same disease or not. 

The book as a whole contains a great deal of valuable 
material, but it seems to have been put together by 
a hurried compiler rather than built by a careful 
architect, and on that account it does not fully 
justify either the beauty of its production or the 
labour that has gone to its preparation. 


Streamline for Health 


By Pup B. Hawk, Founder of Food Research 
Laboratories, Inc. New York and London: Harper 
and Brothers. 1935. Pp. 186. 10s. 6d. 


Dr. P. B. Hawk will be remembered as one of the 
collaborators with Rehfuss in certain fundamental 
physiological inquiries which were published in the 
American medical literature soon after the war. 
His system for safe weight reduction consists chiefly 
in a low calorie diet based on cow’s milk, orange 
juice, and lettuce, and of periods of repeated fasting, 
or semi-fasting, with restricted diet in between them. 
Some would call the style of this book racy, others 
would say that it was full of frank Americanisms. 
In any case the language is such as to make little appeal 
to the majority of Enghsh readers. This is the more 
regrettable because it is essentially one of the sounder 
books on weight reduction recently’ published. 
Readers who can struggle through chapters with 
titles such as ‘‘Is Science cockeyed ? Hay! Hay!” 
will find accounts of many instructive experiments 
and apt criticisms of many unscientific methods of 
“ reduction.” 


Russell A. Hibbs 


Pioneer in Orthopædic Surgery, 1869-1932. By 
GEORGE. M. Goopwin.. London: Humphrey 
Milford, Oxford University Press. 1935. Pp. 136. 
10s. 


Dr. Goodwin has written an instructive book about 
an interesting man. The story of Hibbs’s life is 
worth more attention than many of the medical 
biographies which reach the public to-day, for the 
reasons which led to his success call for record alike 
as a surgical innovator and a hospital administrator. 
Throughout a very busy life he seems never to have 
departed from the one idea which he set before 
himself—namely, to be a champion of the cause 
of the crippled child. All that he did centred round 
that object. With no private backing or influence, 
but rather by determination, he obtained a post in 


an orthopedic hospital which needed reform and 
which, when reformed, would call for extension. 
He became immediately involved in a dispute with 
a superior officer, and to the disgust of that superior 
was held by the lay authorities of the hospital to be 
right. But many prominent members of his specialty 
resented the victory of the junior man and proved 
less than helpful to him when his private practice 
began to grow. The brief biography shows how 
Hibbs was able to overcome professional opposition 
and to reach a high position as an orthopedic 
specialist, although certain of his theories were 
never universally accepted. What they were, and 
how he gave practical effect to them, will be gathered 
from a series of cases, added as appendices, which 
make informing reading. 


Genetics 


By H. S. JENNINGS, Henry Walters Professor of 
Zoology and Director of the Zoological Laboratory 
in the Johns Hopkins University. London: Faber 
and Faber Ltd. 1935. Pp. 351. 15s. 


MODERN genetics has given rise to more unwarranted 
and dogmatic generalisations than almost any other 
branch of science. At every stage in its development 
the particular facts have seemed to point in an- 
attractive manner to far-reaching general conclusions. 
Popular books on the subject seldom describe the 
experimental evidence fully enough to allow the 
reader to judge for himself of the validity of these 
conclusions, and this is unfortunate in view of the 
interest taken by the educated public in the possible 
application of genetic principles to human affairs. 
The groundwork of the subject however, as Prof. 
Jennings points out, ‘“‘involves detailed facts and 
relations which must be thoroughly grasped,’ and 
the general reader who wants to be put into a position 
to form opinions is faced with some hard work. 

Prof. Jennings gives a clear account of the chromo- 
some theory with continual reference to the original 
work on which the theory has been based. He does 
not doubt that in a stable environment all inherited 


characteristics are determined by the genes, which 


are borne in a linear fashion upon the chromosomes. 
Beyond this point he suspends judgment, presenting 
the facts and various different..conclusions which 
might be drawn from them. He shows how the 
original idea of the fixed action of a gene is being 
rapidly undermined. There is now some evidence 
that the action of a gene is dependent upon its position 
in relation to other genes. Should this prove to be 
correct ‘‘it would require a reinterpretation of many 
of the accepted ideas of genetics.” The unsatis- 
factory state of our knowledge about the relative 
influence of hereditary and environmental factors 
on human characteristics is emphasised. The book 
concludes with two interesting chapters on genetic 
variations, natural and induced by radiations. There 
can be no doubt that many species have diverged 
from a common stock to a limited extent as a result, of 
eliminations, reduplications, and translocations of 
chromosomes. But Prof. Jennings seems to be of the 
opinion that, whatever kind of variation has formed 
the basis of progressive evolution, the changes in 
the action of single genes which have so far been 
observed and are known as mutations have not 
necessarily thrown much light upon the problem. 
Tbis is certainly an unorthodox suggestion, but it 
must be admitted that the mutation theory. of 


evolution is by no means as firmly established as 


is often assumed, 


THE LANCET] 


. PHYSICAL EDUCATION 


/ 


[san. 11, 1936 93 


THE LANCET 


LONDON: SATURDAY, JANUARY 11, 1936 


PHYSICAL EDUCATION 


THE year 1935 will be a memorable one in the 
history of physical education in this country. 
The prominence given to physical fitness by the 
King’s Jubilee Trust Fund has stimulated official 
and voluntary organisations concerned with 
gymnastics and games for children and young 
people to greater energy, while the need for 
recreative and enjoyable occupation for unem- 
ployed men and women in distressed areas has led 
to the setting up of schemes for physical training 
which, it is hoped, will be developed and extended 
to the great benefit of national health and 
physique. Physical training has been slow to 
receive adequate recognition in England. It first 
became a normal and regular part of the elementary 
school curriculum in 1909. Sir ROBERT Morant, 
then secretary of the Board of Education, realised 
not only its importance to the health of the 
growing child, but its close association with the 
school medical service and hygiene. Therefore he 
entrusted the preparation of a revised syllabus of 
physical exercises to the medical department of 
the Board, and placed the newly appointed staff 
of special inspectors under the general control and 
guidance of Sir GEORGE Newman. The progress 
of physical education may be read in the successive 
reports of the chief medical officer. “A new syllabus 
was called for in 1919, and yet another in 1933 ; 
from time to time supplementary matter has been 
issued dealing with particular problems such as 
the organisation of games, the work in small 
country schools, the value of playing fields, and so 
forth ; and there are other books now in prepara- 
tion which will provide for the needs of the older 
boys and girls in the senior schools.’ 


The general policy of the Board of Education 
has been to leave physical training in the elementary 
schools in the hands of the class teachers ; to give 
all teachers some special training, but to encourage 
them to supplement this by attendance at suitable 
vacation courses and classes ; and to support the 
appointment by local education authorities of 
expert organisers whose duties include general 
supervision of physical training and advice to 
individual teachers. This policy has been successful, 
but it is pleasing to note that the Board now 
appear to be pursuing it with greater energy, and 
that increased attention is being paid to secondary 


‘See the report of the C.M.O. of the Board of Education for 
the year 1934. H.M. Stationery Office. 2s. 6d. 


education in this subject. Systematic physical 
training, as apart from games, has been seriously 
hampered in public and secondary schools for 
boys by the lack of trained gymnastic masters ; 
even now there is only one training college for 
men—viz., Carnegie Hall, founded at Leeds a 
few years ago by a grant from the Carnegie United 
Kingdom Trust—whereas for 50 years there have 
been facilities for the training of women. For- 
tunately the growing demand for teachers and 
“leaders ” is bound to result in more ample 
opportunities for training, as well as greater scope 
for employment after qualification. But the 
authority of the Board is limited to schools and 
educational work, and there is a strong feeling 
that much more might and should be done for 
the promotion of physical. activity in its broadest 
sense, not only among young men and women, 
but among older persons of both sexes. The 
“keep fit” movement, for -example, which 
originated in Sunderland and is rapidly spreading 
over the whole country (see p. 125), is providing 
healthy physical interests for hundreds of women, 
many of mature age, who had never experienced 
the joy of movement before. Gymnastic classes 
and games are doing the same for young men. 
The Central Council of Recreative Physical Train- 
ing, a representative and voluntary organisation 
established early last year under the patronage of 
the Kine and QUEEN and the presidency of Lord 
ASTOR, has been formed to coérdinate and encourage 
all types of recreative activity.2 The national 
playing fields association, organisation for the 
promotion of athletics, swimming, camping, hiking, 
as well as games, dancing, and gymnastics, are all 
combining to arouse a much wider appreciation of 
the value of exercise, open air, and sunshine, and 
to show that no one need feel too old or too stiff 
to enjoy some form of exercise. 

In this country we have long been proud of 
our traditional games, though they have been 
played by the few rather than the many. Our 


: system of gymnastics was borrowed mainly from 


the Scandinavian countries. But at long last we 
are beginning to develop a scheme of physical 
education of our own, which we hope will be 
characteristically national. We shall take full 
advantage of the experience and knowledge of 
other lands, but shall adopt,‘ modify, and add to 
this so as to meet the ‘needs of our climate, our 
social and educational conditions, and our national 
habits and customs. Physical education, wisely 
used, has an immensely important contribution to 
make towards a state of positive good health, 
which is something much better than the mere 
prevention of disease. 


THE CYTOLOGICAL EXAMINATION OF MILK 


' THE microscopical . examination of milk for 
tubercle bacilli is preferable to the biological test 
in so far as it is simpler and quicker. Unfortu- 
nately these advantages are counterbalanced by 

* This council has just issued its first news leaflet, which may 


be had from the organising secretaries, 11, Doughty- -street, 
London, W.C. 1. l 


94 THE LANCET] ` 
the fact that the organisms cannot be seen in 
milk under the microscope unless present in enor- 
mous numbers. According to' D. R. Woop? the 
microscopical test is 500 times less sensitive than 
the biological; and estimates of the same order 
have been made by other workers. Such com- 
parisons refer to the classical method of examina- 
tion which consists in laboriously searching smears 
of milk deposit under the oil-immersion lens for 
acid-fast bacilli; and the weary observer derives 
little comfort from the reflection that the finding 
of such organisms carries no assurance that they 
really are tubercle bacilli and not saprophytes. 
More recently attention has been turned from the 
direct examination of films for acid-fast organisms 
to the study of the cells found in milk and their 
relation to tuberculosis. H. L. TORRANCE ? drew 
attention to the occurrence of certain more or 
less characteristic groups of cells to be found in 
tuberculous milk. Other workers have confirmed 
these findings, and S. T. Cowan and L. Mappocks 3 
now report the results of a careful study of the 
cytology of 229 samples of milk from single cows. 
If centrifuge deposit is spread in a thin film and 
stained the cells are for the most part distributed 
uniformly over the whole surface; but here and 
there clumps of cells are encountered. These 
may be composed of endothelial cells, non- 
endothelial cells, or of a mixture. Cowan and 
Mappocks found that whilst such cell groups might 
be present either in tuberculous or non-tuberculous 
milk, more of them, particularly of the endothelial 
type, were observable in tuberculous milk. It 
was also found that in tuberculous samples acid- 
fast bacilli showed a tendency to collect near the 
cell groups; bacilli lying far away from these 
groups were more likely to be non-pathogenic ones. 
Thus a large surface of a smear may be looked 
over rapidly under a low magnification, and the 
areas containing endothelial cell groups can then 
be subjected to examination for the presence of 
acid-fast bacilli under a high magnification. The 
229 samples examined in this way by Cowan and 
Mappocks were also tested on guinea-pigs. From 
38 of them tuberculosis was produced in these 


animals, in 7 of these cases the degree of con- 


tamination being slight if judged by the extent 
of the lesions produced. By microscopical exami- 
nation acid-fast bacilli associated with cell groups 
were found in 21. samples. None of the 7 lightly 
contaminated samples was detected in this way. 
In 2 samples acid-fast bacilli were found unrelated 
to cell groups, ‘and were given a preliminary label 
of saprophytes, this diagnosis being confirmed later 
by guinea-pig inoculation. Tubercle bacilli were 
never found in the complete absence of cell 
groups and only rarely in association with 
groups containing no endothelial cells. 


logical test. It emerges that attention to the 
cytological. picture is a most useful preliminary to 
the microscopical. examination of campes of milk 


2 3 The Analyat: 1931, Ivi.. . 179. ee 
a Veterinary Roc.. 1922, ii., 289, and a oe 815. 
- 3 Jour. Path. and Bact., 1935, xli., 373. 


THE CYTOLOGICAL EXAMINATION OF MILK 


No 
positive results were obtained by microscopical . 
examination which were not confirmed by bio- 


(yan. 11, 1936 


from single cows, for evidence of contamination 
by the tubercle bacillus increases considerably 
the proportion of positive results obtained. Even 
in its improved form, however, this method is not 
sufficiently sensitive to justify the omission of 
guinea-pig inoculation, while when bulk milk is 
being tested it is of very little value. 

The cytological study of milk is not con- 
fined to the diagnosis of tuberculosis. Attempts 
have also been made to diagnose other forms of 
mastitis, in particular the economically important 
streptococcal form, by this means, but the value 
of the method is still in dispute. In extreme cases 
no difficulty arises; milk containing enormous 
amounts of leucocytic deposit clearly comes from 
an abnormal udder, whilst a sample which con- 
tains no leucocytes has probably come from a 
healthy udder. In intermediate cases interpreta- 
tion of findings is more difficult, for it has frequently 
been noted that in milk from healthy udders the 
cell count may be high during the late colostral 
period and when drying off, though low at other 
times. It is thus necessary to have a full history 
of the cow from which the sample comes. Where 
milk from several cows has been mixed the high 
cell content of one fraction may be cloaked by 
dilution with normal milk. A differential cell 
count is of far greater value than a total count 
in judging the quality of milk. A high cell 
count including erythrocytes, monocytes, eosino- 
phils, or pus cells showing phagocytosis suggests 
inflammatory changes, whereas desquamated 
epithelial cells, round cells, and neutrophils are 
less significant. Differential counts are, however, 
tedious to carry out and require considerable 
experience, whilst the dilution factor still comes 
into play. 

One of the most serious defects of the cytological 
examination of milk as a diagnostic measure is 
that even where inflammatory exudate can be 
demonstrated, evidence is still lacking as to the 
cause of the inflammation, except on the compara- 
tively rare occasions when it is possible to demon- 
strate the causal organism microscopically. Inflam- 
matory exudate may be found in cases of mastitis, 
due to the tubercle bacillus, the streptococcus, 
and the staphylococcus as well as in other less 
important types of mastitis. Of these infections, 
contamination of milk by B. tuberculosis is of 
course a danger to public health. Streptococcal 
mastitis is of importance from the point of view 
of health of the consumer only in so far as such 
infection may affect the nutritive quality of the 
milk; but from the economic aspect such in- 
fection is of immense importance to agriculture. 
Staphylococcal mastitis is relatively unimportant 
economically but may have a public health signi- 
ficance. The significance of the mastitis in short 
depends on the nature of the causal organism, 
which for the most part can only be ascertained 
by resort to other methods. ‘The microscopical 
examination of milk may sometimes prove a 
useful and a rapid aid to diagnosis, particularly’ 
in tuberculous and occasionally in other types 
of mastitis, but such an examination is not‘an_ 
adequate substitute for cultural or biological tests. 


THE LANCET!) 


HISTIDINE TREATMENT OF PEPTIC ULCER 


THE multiplicity of the methods of treatment 
devised for. peptic ulcer emphasises alike the 
incompleteness of our knowledge and the need for 
caution. The chronicity of the disease, and its 
tendency towards relapse and remission, make it 
an awkward subject for therapeutic investigation, 
and we are also, handicapped by the difficulty of 
reproducing in animals the typical chronic ulcer 
found in man. Among the more interesting of the 
remedies now on trial is the amino-acid histidine, 
given by injection. The work on which its use is 
based begins with observations of MANN and 
WILLIAMSON in 1919, when they found that if the 
duodenal secretions of dogs are diverted into the 
lower end of the ileum the animals soon develop 
peptic ulcers like those of human beings, and severe 
nutritional disturbance leading to death in a few 
weeks. ARON of Strasbourg, repeating these 
experiments (with Weiss) in -1933, reported ' 
that of five animals thus operated on two died 
with ulcers whereas the other three, which had. 
received histidine and tryptophane injections, 
showed no ulceration at all. These injections were 
given in the belief that the development of ulcers 
in the dogs was in some way due to amino-acid 
deficiency resulting from the surgical interference 
with protein digestion. Further work led ARON 
to apply his theory to the treatment of peptic 
ulcer in man, and using intramuscular injections of 
a 4 per cent. solution of histidine hydrochloride— 
prepared by Messrs. Hoffmann-La Roche under 
the name of Larostidin—he reported very good 
results in 17 cases. Since this first paper by ARON 
and WEISS appeared in 1933 some eighty other 
records of the use of larostidin have been published 
in America, Germany, Italy, and other countries. 
The new form of treatment has been adopted with 
unusual readiness because its advocates have 
claimed from the first that it largely, if not wholly, 
takes the place of diet, alkalis, and rest in bed. 
Such claims demand even more careful study 
than those made for remedies which are merely 
ancillary to the better established therapeutic 
measures. | 

It will be generally admitted that, whatever the 
treatment, medical or surgical, the 
prognosis as regards cure of peptic ulcer is at 
present none too good. Statistics of permanent 
cure vary between 50 and 90 per cent., but if a 
long enough margin is allowed—it cannot be less 
than five years and should properly be much more 
—the final percentage is probably not above 75, 
and less for duodenal lesions. On the other hand, 
almost all forms of treatment seem capable of 
producing temporary improvement in almost every 
uncomplicated ulcer. Simple dieting may bring 
immediate relief ; moderate or massive alkali treat- 
ment, duodenal feeding, and sometimes merely rest 
and freedom from worry, will often do the same. 
For many years, since HOLLER first recommended 
injections of protein in 1921, various forms of 


parenteral therapy have been recommended and: 


4 Aron, E.: Recherches sur l’ulcére experimental, Thèse de 
Strasbourg, 1933. l 


HISTIDINE TREATMENT OF PEPTIC ULCER 


ultimate 


[san. 11, 1936 95 


widely used in support of dietetic or other régimes. 
Among them, vegetable proteins, milk, vaccines, 
emetine, pepsin, and many others have been given 
favourable reports. Indeed, it seems that non- 
specific protein therapy may be expected to 
hasten healing and lower gastric acidity, and these 
are grounds for using it. Histidine treatment 
differs from the others because it is based upon 
the view that peptic ulcer is at least partly a 
deficiency disease, and that injection of this amino- 
acid will correct part of the deficiency. It does not 
appear probable, however, that the diet of the 
patient, who afterwards gets an ulcer, is con- 
sistently deficient in protein—in fact many are 
normally big meat-eaters—and if such deficiency 
arises through faulty digestion or absorption of 
proteins no cause for the failure is yet known. 
The effects of drastic interference with the digestive 
secretions of dogs cannot be applied to man 
without reserve, and the rationale of histidine 
treatment requires further support. Judgment of 
its value must therefore be formed largely on 
clinical experience. | 

The dose recommended is 5 c.cm. of a 4% solution 


_ histidine hydrochloride given daily by intramus- 


cular injection for a period up to three or four 
weeks and repeated as required. There are said 
to be no dangers, the patients need not be kept 
on a restricted diet, alkalis are unnecessary, and 
rest in bed is usually not required. Relief from: 
symptoms follows as a rule in two to six days, 
and some 60-90 per cent. of cures. are recorded. 
But as most workers point out—for example, 
BULMER? and SMITH? in this country and 
RaFsky,* Eaps,° BoGENDGRFER,® and Weiss’ 
abroad—it is far too early to assess the value 
of this treatment. Already some disappointing 
relapses are known and there will probably be. 
general agreement with Izar® that histidine 
is not a specific remedy for peptic ulcer, in the 
sense that it does not counteract the cause.. If 
this is so, it must seem unwise to relax attention 
to dietetic and general measures while carrying 
out injection treatment. . The longest case-histories 
hitherto reported are less than two years, and the 
word “cure ” is therefore inappropriate to any of 
them. At the same time the many accounts. of 
relief of symptoms, increase in weight and well- 
being, and removal of clinical and radiographic. 
evidence of active ulceration point to the treatment: 
being in some way beneficial. Whether its action 
will turn out to be in any sense specific or is merely: 
(as seems likely) comparable to that of other 
injected substances, and whether it can lead. to 
lasting cure or replace other therapeutic measures, 
are questions that can be decided only by further 
study. The time has not yet come for accepting 
an entirely new theory of ulcer-causation, and 
for abandoning the ordinary rules of diet and 
management. | ee. 


$ 


- 3 Bulmer, E, : THE LANCET, 1934, ii., 1276. 
-* Smith, D. : Brit. Med. Jour., 1935, ii., 154. 
t Rafsky, H. A.: Med. Rec., Sept. 18th, 1935, p. 289. 
$ Eads, J. T.: Amer. Jour. Digest. Dis. and Nutrit., 1935,ii., 426. 
* Bogendorfer : Münch. med. Woch., 1934, lxxxi., 1270. 
1 Weiss: Schweiz. Rundschau. f. Med., 1934, No 21. 
l * Izar, G.; Policlinico, 1935, 1., 2447. 


96 THE LANCET] 


THE BAR ON THE CORONER 


THe General Council of the Bar would insist 
upon the necessity of a legal training for coroners. 
It also protests against the action of certain 
important local authorities in stipulating that the 


coroners whom they appoint must have a dual 


qualification in law and medicine. So much we 
learn from the annual statement of the Bar Council 
wherein is reported a summary of the barristers’ 
official representations to the Home Office Com- 
mittee now inquiring into the law and practice 
relating to coroners. The Bar does not want to 
see inquests abolished, but it wants them brought 
into line with other courts. Its demand for 
recognition of the right of barristers and solicitors 
to examine and cross-examine witnesses before 
coroners was inevitable. In practice this right 
is conceded already save in extreme cases where 
legal representatives get at loggerheads with their 
tribunal. Another by no means revolutionary 
recommendation is the demand that committal 
for trial upon coroners’ inquisitions be abolished. 
Such committals have been greatly diminished 
by the 1926 Act, and they are sometimes made 
to look a little forlorn at the resultant prosecution. 
The solemn extravagance and. anticlimax of 
Lord DE CLIFFORD’Ss trial in the House of Lords 
last December might never have been staged but 
for a coroner’s committal. It is a question of 
expediency whether the rare occasions when these 
committals catch a criminal who would otherwise 
escape are sufficient justification; there are, of 
course, plenty of committals from other courts 
than the coroner’s which prove abortive. 

The Bar Council’s demand for adherence to the 
strict rules of evidence is a more awkward business. 
A great part of the coroner’s usefulness to the 
community is his power of sifting local gossip in 


PSYCHOGENIC FACTORS IN ASTHMA 


[yan. 11, 1936 


cases of suspected crime. In almost every court 
of law some bit of technically inadmissible evidence 
sometimes slips in and is consciously disregarded. 
There seems no reason why a coroner should not 
be trusted to distinguish between good and bad 
evidence. When the police make preliminary 
inquiries, they are glad enough to listen to hearsay, 
and it may well be that those reponsible for bringing 
our criminals to justice will successfully object 
to the Bar Council’s proposal. The mysteries 
of the strict rules of evidence—one of the causes 
why it is popularly believed that the truth does 
not always emerge in a court of law—are based 
on the fact that certain parties are admitted to the 
legal proceedings and certain issues have been 
carefully defined beforehand as the case which the 
court is to try. It is not going to be a simple 
matter to practise these mysteries at an inquest 
where it is often the coroner’s task to find out what 
parties may be concerned and what issues may be 
expected to arise. Naturally the more complicated 
the procedure the greater the need for legal coroners 
and legal intervention at inquests. But if the 
inquest is to be converted into something like an 
inquiry before a stipendiary magistrate, it will 
cease to be the institution which has proved its 
usefulness by surviving through so many centuries. 

Which are the better coroners, doctors or 
solicitors ? It is doubtful whether persons who are 
in a position to decide the question would venture 
any sweeping generalisation in reply. The public, 
at any rate, probably detects little difference 
between a solicitor-coroner with a knowledge of 
medicine and a doctor-coroner with a knowledge 
of law. Best of all is the coroner who is duly 
qualified in both law and medicine. Yet it is 
this dual qualification which the Bar Council 
cannot abide. There is, it seems, nothing like 
leather. 


ANNOTATIONS 


PSYCHOGENIC FACTORS IN ASTHMA 


Two papers in the Guy’s Hospital Reports describe 
an important advance in the understanding of the 
asthma-eczema-prurigo syndrome. The work on 
which they are based was stimulated by the experi- 
ence—already mentioned in reports to the Asthma 
Research Council 1—that in intractable cases children 
sent to a convalescent home show immediate improve- 
ment and remain in good health until they return 
to their own homes, when they relapse at an equally 
striking rate. The first paper? shows the factors 
concerned in this phenomenon and tells how clinical 
results proved that the psychological environment of 


child patients is as important as the physical. More-, 


over, one kind of personality is predominant among 
this group of cases. It is noted that, for example, 
in a group of enuretic children one finds almost any 
type of personality, whereas child sufferers from the 
asthma-eczema-prurigo syndrome present with unusual 
frequency a combination of high intelligence, ready 
manifestation of anxiety and insecurity, and strong 
tendencies towards aggressiveness and egocentricity. 


1See THE LANCET, 1934, ii., 1171. E 
* Rogerson, C. H., Hardcastle, D. H., and Duguid, K.: 
Hosp. Rep., 1935, Ixxxv., 289 


Guy’s 


On the parental side is found with similar frequency 
a nervous, Over-anxious protective attitude that is 
plainly the cause of a part of the child’s emotional 
state. Psychotherapy directed in accordance with 
these observations has been sulfliciently successful for 
the writers to suggest that it has at least as much 
to offer as any other available kind of treatment for 
this type of asthma patient. 

These results are gratifying, and the way in which 
the theoretical aspect of the subject is handled marks 
a forward step in methodology which raises the work 
well above the level of another addition to the 
numberless ‘“‘cures”? of asthma. The emotional 
determination of the asthma attack is no new dis- 
covery, but for some workers the mind-body antithesis 
has so great a hold that the demonstration of allergic 
phenomena excludes any need for psychological 
examination of a patient or, conversely, the curative 
effect of psychotherapy settles the problem of 
causation. Dr. Strauss? claims as established the 
point that one cannot correctly talk about “ true 
asthma ” and ‘“‘ psychogenic asthma,” and sets out as 
the object of research the evaluation of the degree in 
which the psyche participates in the asthmas in 


3 Strauss, E. B.: Ibid., p. 309. 


THE LANCET] 


' CHRONIC. CYSTIC MASTITIS ?” — 


[gan. 11, 1936 97 


general. References to his own experience show that 
asthma can be—or behave as—a symptom of con- 
version hysteria or an anxiety equivalent, but such 
cases are only on the surface of the problem. Dr. 
Rogerson ? indicates its more profound difficulties 
when he notes the impossibility of separating the 
intellectual and temperamental endowment of the 
individual from his physical endowment, to disregard 
the one and call the other constitution. Apparent 
contradictions that have hitherto been used as 
arguments in controversy present themselves no 
longer as contradictions but as problems needing 
ananswer. The appearance of allergic reactions in an 
infant of six months, for example, calls for an 
explanation of the curious clinical picture—a. dis- 
abling physical illness from infancy which appears 
to respond to a modification of the psychic milieu. 
This work, original as it is, does not stand alone. 
We have commented upon the results of the psycho- 
logical examination of gastric ulcer patients by 
Draper and Touraine,* who found throughout that 
group peculiarities which marked them, like these 
asthma subjects, as possessing a specific personality 
picture. Similar results have been claimed in the 
examination of migrainous subjects, and apart from 
possible therapeutic applications, all these observa- 
tions point to some underlying general principle the 
discovery of which may perhaps give a new direction 
to the study of physiological processes as influenced 
by that indefinite something that we call the psyche. 


“CHRONIC CYSTIC MASTITIS ” 


DESPITE repeated efforts on the part of various 
writers to clarify the subject, by changes in 
nomenclature and by fresh conceptions of the under- 
lying pathology, there still exists much confusion 
about that condition of the breast which used at 
one time to be labelled and dismissed without more 
ado as ‘‘chronic cystic mastitis.’ Two conflicting 
views now held by different schools of thought have 
never been adequately balanced—one that the 
disease is characterised by such an aberrant type of 
epithelial activity as to make carcinomatous change 
a dangerous possibility in every case; the other, 
that chronic cystic mastitis is essentially an exaggera- 
tion of a normal physiological change, and that 
malignancy, when it does complicate the simple 
disease, is as. fortuitous as it is in the “‘ normal” 
breast. The former view is upheld vigorously by 
Cheatle and Cutler5; the opposite opinion, at 
least as regards the likelihood of malignant change 
in the affected breast, was re-stated only recently 
in our columns as the experience of Mr. Eric Pearce 
Gould. The outcome of this disagreement is that 
when a surgeon meets with the common type of 
“lumpy ” breast, he is embarrassed by the knowledge 
that whatever line of treatment he may advise is 
open to serious criticism. Dr. Percy Klingenstein ’ 
in a recent paper draws comfort from a statement of 
Bloodgood’s that cases of doubtful malignancy 
treated by radical operation have done well. Klin- 
genstein himself does not advise such drastic measures. 
He quotes figures to show that conservative surgery 
has a definite place in the treatment of “ chronic 
mastitis.» Where some may be inclined to join issue 
with him is in his recognition, with Cheatle, of 
“mazoplasia’’ as a physiological state, as distinct 
from cysts and intracystic and intraductal papillo- 
mata, which he regards as of true neoplastic forma- 


‘See THE LANCET, 1934, iL, 661. 
ê Tumours of the Breast, London, 1931. 
© THE LANCET, 1935, ii., 899. 
? Ann. Surg., 1935, ci., 1144. - 


tion. J. S. Rodman 8 is much impressed with the 
extent of epithelial development and involution 
characteristic of the menstrual cycle. There does 
not seem to be any sound proof that the glandular 
menstrual changes in the breast are as profound as 
he believes. E. K. Dawson’s ® observations on 
normal breast tissue have, in fact, led her to an 
opposite conclusion. While the gaps in our knowledge 
of normal breast histology and physiology are still 
so wide, it is a matter of difficulty to interpret the 


more generalised states of epithelial change, 
particularly, perhaps, in patients before the 
menopause. 

The observations of Mr. Harold Burrows 1° are 
suggestive. He found that in their response to 


cestrogenic substances, the breasts of some of his 
mice showed more pronounced hyperplasia and less 
marked cystic dilatation, while in others a 
pronounced dilatation was accompanied by relatively 


little hyperplasia, that, in fact, the two conditions 


seemed to occur in inverse ratio. As far as these 
experimental results go, they suggest that cyst 
formation in itself, though pathological, may be 
found actually to carry a more favourable prognosis 
than hyperplasia of the epithelium, for Burrows 
has found the latter condition to result from a more 
prolonged administration of ostrin, and to be a 
later effect than is cystic dilatation. It seems 
likely that the localised lesions of the breast, such 
as adenomata (whether of the fibro-adenoma, or the 
adeno-fibroma type); blue-domed cysts; papillo- 
mata; and intracanalicular fibromata, are in patho- 
genesis more similar to “chronic cystic mastitis ” 
than was at one time generally thought. Encapsulation 
of these tumours may be very imperfect, as is well 
known tothe surgeon who attempts their removal under 
local anesthesia. A more or less generalised change 
in the surrounding breast tissue is not infrequent. 
In sections right through a breast which is the site 
of “ chronic cystic mastitis ” all the above changes— 
papillomata, fibrosis, cysts, and adenomata—may 
be found in miniature, as it were. This consideration 
complicates the treatment of tumours clinically 
localised. Rodman regards all these changes as 
aberrations due to interference with the proper 
growth and involution characteristic of the sexual 
cycles. 


When we attempt to come to conclusions about 
the prognosis and treatment of this condition, we 
meet the further difficulty that the criteria are 
missing on which, in individual cases, the transition 
from simple to malignant hyperplasia may be decided. 
Also—and it should be possible in time to fill this 
gap in our knowledge—there is a great paucity in the 
literature of follow-up results of cases treated by the 
more conservative measures. What we want to 
know is whether these patients return later with 
cancer. Klingenstein followed 54 patients who had 
been treated by partial breast excision, and found 
that, with two exceptions, they remained free of 
malignancy for periods of 2-11 years. The two 
exceptions developed cancer of the. breast, one 
seven years and the other one year after operation. 
Klingenstein quotes a report of Greenough and 
Simmons on 83 cases of cystic mastitis, treated by 
local operation, in 4:8 per cent. of which cancer later 
developed. Rodman follows Cheatle in accepting 
the incidence as being 15-20 per cent. in patients 
over 35. He advises watching patients over this 


s Amer. Jour. Surg., 1935, xxvii., 452. 
* Edin. Med Jour., 1934, xti., 653. 
10 Brit. Jour. Surg., July, 1935, p. 191. 


98 THE LANCET] 


age for two months. If a lump in the breast, which 
has been diagnosed as benign, does not in this time 
show evidence of disappearance, he advocates simple 
amputation. In patients under 35, he would watch 
for changes in the swelling before, during, and after 
the menstrual period ; if there is no change he would 
amputate. The significance of a serohemorrhagic 
discharge in these cases is considered by Klingenstein. 
He regards it as indicating the advent of intracystic 
or intraductal epithelial proliferation. Few surgeons 
would take the risk of not removing the breast in a 
case of mastitis comphcated by a serous or sero- 
hemorrhagic discharge, spontaneous or induced by 
gentle massage in the direction of the nipple. The 
great importance of sending every breast removed for 
pathological examination, if it were not otherwise 
recognised as a wise precaution, would be proved 
by the difficulty in recognising diffuse intraduct 
carcinoma. The macroscopic similarity between this 
admittedly rather rare condition and 
mastitis’? has been sufficiently demonstrated. 


THE BIRTH CONTROL MOVEMENT 


THE National Birth Control Association, with 
which the Birth Control Investigation Committee is 
incorporated, has published this week its fifth annual 
report, and a history of five years of work offers to 
the governing body a good opportunity to summarise 
the past, review the present, and indicate plans for 
the future. When this Association started in 1930 
the Ministry of Health had issued no memoranda 
defining the powers of local authorities in the matter 
of giving birth control instruction, and no local 
authorities had opened clinics although there were 
16 voluntary bodies of this description. The staff 
consisted of the secretary and there were no local 
branches.. To-day the Association has 28 local 
branches and the staff consists of seven, including 
three organisers—by no means an extravagant staff 
considering the amount of ground that is covered. 
The Ministry of Health has issued 3 memoranda, 
66 municipal and .47 voluntary clinics have been 
established, 42 local authorities send patients to 
private doctors or clinics, 56 have passed favourable 
resolutions, while 14 have expressed themselves 
willing to lend or hire premises to local branches for 
voluntary clinics. The total expenditure, apart from 
research, has come to just over £6000 for five years’ 
work. 7 se | 
' The present situation indicates that the next five 
years should show an increasingly rapid development. 
In 1934 the circular issued by the Ministry of Health 
elucidated previous ‘provisions and made it clear 
that the maternity and child welfare authority has 
the power to give advice at a gynecological clinic to 
all women in need of medical counsel: The 56 local 
authorities mentioned above as having shown a 
favourable. attitude towards the work must be 
induced to implement their goodwill; but there 
still remain over 250 child welfare authorities in 
England and Wales which have taken no action 
of any sort. The Association possesses evidence 
that organising work produces quick results, the words 
of the report being : | 

“In many a town, an organiser who on her first visit 
was greeted with suspicion and apprehension so that 
many of those upon whom she called were afraid to discuss 
birth control, has at the end of a few months established 
a branch with a strong committee, influential supporters, 
and a flourishing clinic.” = 


The public attitude to the work is shown by quota- 
tions from the reports of medical officers of health 


E 


THE BIRTH CONTROL MOVEMENT 


“ cystic 


[JaAN. 11, 1936 


and from borough councils, one from a Welsh urban 
district council stating that a comparison with last 
year’s statistics shows that the number of women 
attending on account of debility, due to too frequent 
child-bearing, has increased from 18 to 26 per cent. 
There is also an increase in the number of patients 
suffering from debility due to miscarriage or abortion. 

From the investigation committee, of which Sir 
Humphry Rolleston is chairman and Dr. C. P. Blacker 
the honorary secretary, and from the medical subcom- 
mittee, of which Dr. Helena Wright is chairman, come 
also evidence of progress, and, as might be expected, 
the increased activities call for, while they justify, 
an increased income. The need, as stated, is 
remarkably modest ; the Association wants, in order 
to pay its way and meet expansion, at least £1800 
per annum, but possesses an income of £1000 only. 
Its call for further support is amply justified, and the 
latest record of work done should lead to the necessary 
increase of members. Subscriptions and donations 
should ‘be sent to the hon. treasurer, National Birth 
Control Association, 26, Eccleston-street, London, 
S.W. 1. The annual subscription of members is £1 1s. 


A BIOLOGICAL ASSAY OF LIVER EXTRACTS 


Many attempts have been made to devise a method 
for biological assay of liver preparations. None 
has hitherto proved of practical use. It has hitherto 
been essential to test all material of unknown potency 
upon patients with Addisonian pernicious anzmia. 
Such patients should have a red cell count below 
2,000,000 per c.mm., and no complicating factors 
such as sepsis present. Recently however, two 
promising lines of attack on the problem have 
been proposed. Miller and Rhoads! by feeding 
swine with a modified form of the diet which 
produces black tongue in dogs have produced 
a symptom-complex, not unlike that of per- 
nicious anemia, which is relieved by the administra- 
tion of potent liver extracts. These observations 
suggest that in the future such anemic swine may 
be used as test animals. Landsberg and Thompson ? 
and Jacobson è working independently have shown 
that the guinea-pig reacts to the administration of 
potent liver preparations by &a reticulocytosis. 
Jacobson employed adult male pigs weighing between 
300-800 g. and kept on a diet of oats, carrots, and 
lettuce. He found that 30-70. per cent. of the 
animals showed a significant rise in the number of 
reticulocytes following parenteral injection of active 
liver preparations when first given. -The uninjected 
guinea-pigs offer no clue that might seem to 
differentiate between the two classes of guinea-pigs— 
i.e., those that will react and those that will not. 
Further tests of initially non-reactive animals may 
show them later to have become reactive. Conditions 
in the guinea-pig necessary for a reaction to occur 
are not yet clear. Using known reactive animals, 
it has been possible to show that for every active 
material there exists a minimal effective dose which 
is termed the guinea-pig unit of hemopoietic activity 
and which is a quantitative expression of the degree 
of activity. - It would appear justifiable to conclude 
that ‘the capacity to induce a reticulocytosis is 
confined to materials effective in pernicious anzemia, 
since, when an assay on guinea-pigs of crude extract ` 
from human livers was made, a control healthy human 


1 Miller, D. K., and Rhoads, C. P.: Jour. Clin. Invest., 1935, 
and Thompson, M. R.: 


xiv., 153. 

* Landsberg, J. W., Jour. Amer. 
Pharm. Assoc., 1934, xxiii., 964, T 

® Jacobson, B. M.: Jour. Clin. Invest., 1935, xiv., 665 and 67 9.: 


THE LANCET] 


THE CANADIAN MEDICAL ASSOCIATION 


fran. 11, 1936 99 


liver gave a value of 127,000 guinea-pig units, while 
that of a case of pernicious anemia in partial remission 
had a value of 47,000, and that of two cases in relapse 
had a value of only 650 and 380 guinea-pig units. 
The material in liver, therefore, which is reticulo- 
cytogenic in the guinea-pig is at least closely related 
to the material effective in pernicious anæmia. 
The administration of the extrinsic factor of Castle 
alone to guinea-pigs was ineffective, but extrinsic 
factor predigested with gastric juice was reticulocyto- 
genic. Comparative studies of potency of certain 
materials carried out on guinea-pigs and patients 
gave results which agreed in a satisfactory manner. 
The rise in reticulocytes considered positive by 
Jacobson is slight, but from considerable experience 
he claims that provided a rigorous technique is 
employed the results obtained are significant and 
he concludes that regardless of the obscurity of 
the basis of the phenomenon the guinea-pig test is 
a valid indicator of the therapeutic efficiency ` of 
materials effective in pernicious anemia, 


THE CANADIAN MEDICAL ASSOCIATION! ` 
THAT the history of medicine is, speaking in general 


terms, a history of civilisation, is becoming more 
obvious as more historical reading is placed before us. 


For numerous books which have been published 


during the last 20 years tell the story of medical 
improvements and developments as they are con- 
temporary with the evolution of general politics. 
The fact that throughout the most troublous times 
in the story of nations medicine has gone steadily 
on its way, while dominions and powers disappear 
or are modified out of their original schemes, contrasts 
the record of medicine as a continuous one with general 
history which has been subjected to countless breaks 
and setbacks. One great example only of this steady 
progress will suffice—it. stares us in the face. The 
recent European war has seen a complete dissolution 
of many political systems, while the science of medicine 
has not only maintained its progress but has benefited 
in obvious directions by the opportunities given for 
new work to meet new circumstances. Dr. 
MacDermot in telling the story of the Canadian 
Medical Association shows very well that when 
once the idea of coéperative action has been perceived, 
the medical spirit will lead to organised action, and 
that the results of that action will be for the public 
good, whatever troubles general society as a whole 
may be going. through. The Canadian Medical 


Association grew from small beginnings and for: 
its position was quite precarious, 


many years 
Attempts to organise medicine in Canada were 
made at least 90 years ago, but for the first 50 years 
they were abortive, or only useful in affording 
experience to others who were resolved to carry 
onthe work. At the end of the last century, however, 
and indeed up to the breaking out of the European 
war, the Association became representative of the 
Canadian profession, established a relationship with 


local and provincial medical societies, and issued 


4 journal which promised to be well established. 
Then came the war when the systematic work of the 
Association was sharply curtailed, for its individual 
members were.mostly involved in military duties and 
a mere skeleton of the organisation remained. It 
was contrived,. however, to keep the. journal alive, 
and three years after the war a strong committee 


restored the Association to a stable position, so that 


History of the. Canadian l Association, 1867-1921. 
Bs H., E. MacDermot,. M.D., PRI S.(C.). Toronto: Murray 
Printing Co., Ltd. 1935. Pp. 20 


potential eclamptic. 


to-day, while looking back upon an honourable past 
a useful future is open to it. Dr. MacDermot supplies 
an interesting chapter in medical history. 


HIGH PROTEIN DIETS IN: ALBUMINURIA OF 
PREGNANCY. 


To the devising of diets for the toxæmias of 
pregnancy there is no end, nor is there likely to be 
as long as the ætiology of these disorders remains 
obscure. But while most of the régimes which 
have been proposed have enjoyed only transient 


or local vogue, there is a fairly widespread and 


persistent impression that protein is bad for the 
How this impression has gained 
credence is not clear, for the idea of eclampsia. as a 
result of rotting of flesh food in an obstructed bowel 
seems to depend more on vegetarian superstition 
than on scientific fact. Nevertheless, the super- 
stition dies hard and there is little doubt that protein 
restriction is widely practised, not only in toxemia 
but also in normal pregnancy. There is no convincing 
evidence that the practice does good, but is it certain 
that protein restriction is not harmful in pregnancy ? 
After all the full-term uterus and its contents repre- 
sent a considerable mass of protein which must come 
either from the mother’s diet or from the protein 
reserves of her own muscles. A recent paper by 
M. B. Strauss t has some bearing on these reflections, 
for he reports that the protein content of the diet 


-and also the concentration of protein in the blood 


plasma is consistently lower than normal in cases of 
pre-eclamptic toxemia. Moreover, he found that 
when he treated such patients with diets poor in 
protein the oedema and albuminuria were aggravated ; 
whereas a high protein diet led to a reduction of the 
edema and improvement of the toxæmic symptoms. 
The significance of these observations is not, as yet, 
clear, for the improvement in the latter group may 
have been partly due to simultaneous administration 
of vitamin B. The number of cases so far treated 
has also been small and it is well known that simple 
rest in bed will often cause considerable improvement. 
It would certainly be unwise to infer that protein 
Starvation is an important cause of toxsemia, for it 
must be remembered that the incidence of eclampsia 
was abnormally low in the starving central European 
countries during the last war. The problem goes 
deeper than that; but Strauss’s paper should at 
least prompt the obstetrician to ask himself whether 
he is justified in depriving the pregnant woman of 
protein. 


SYMPATHECTOMY FOR DYSMENORRHCEA 
THE cause of primary dysmenorrhea has never 


been ascertained. On the assumption that it may 


arise from some disturbance or imbalance of the 
sympathetic innervation of the uterus, interruption 
of the sympathetic supply has of recent years been. 
advocated and practised with considerable success. 
Of the several methods which have been devised 
that of Cotte (resection of the superior hypogastric 


` plexus) seems to be the most satisfactory. V. 8 


Counseller and W. McK. Craig? have reported 
14 cases from the Mayo Clinic, of which it is stated 
that 9 obtained 100 per cent., 2 obtained 95 per 
cent., and’ 3 obtained 75 per cent. relief ; there were 
no deaths and no serious complications. A discus- 
sion held by the section of obstetrics and gynxcology 
of the Royal Society of Medicine*® two years ago 


~ Amer. Jour. Med. Sci., December, 1935, p. 811. ` 
ı 8 Amer. Jour. Obst. and Gyn., 1934, xxviii., 161... 
* Proc. Roy. Soc. Med., 1934, xxvii., 258. 


100 THE LANCET] 


URETERO-INTESTINAL ANASTOMOSIS 


[JaN. 11, 1936 


produced a number of case-reports by different 
surgeons: Mr. A. A. Davis gave his percentage of 
one-year cures as 50; Mr. Malcolm Donaldson 
reported 16 cases, of which only 1 failed to obtain 
relief ; of 8 cases reported by Mr. Sidney Forsdike 
2 were completely, and 5 partially, relieved, while 
1 derived no benefit at all. The last-named speaker 
emphasised the necessity for care in the selection 
of cases for operation, pointing out that the com- 
parative ease and safety of the procedure renders 
it liable to abuse. F. S. Wetherell,4 who has had 
several successful cases, also utters a warning against 
too ready resort to what is in effect a major abdo- 
minal operation accompanied by distinct risks. 
F. E. Keene © lays stress on the occasional anato- 
mical difficulties and added dangers; the inferior 
mesenteric vessels, for example, may be situated 
further to the right than is usual, so that dissection 
of the nerve plexus from beneath them may be very 
difficult and fraught with danger to the vessels. 

In a paper which we publish this week, Mr. Davis 
describes 6 cases treated by alcohol injection of the 
pelvic plexuses in the neighbourhood of the uterus. 
This method, first used by Blos, has the great advan- 
tage over sympathectomy that it is a comparatively 
minor procedure and does not carry the risks insepar- 
able from laparotomy. The chief drawback seems 
to be that it does not allow of possible gynzcological 
lesions being discovered and treated, and these 
cannot always be excluded, especially in stout women, 
without operation. 


URETERO-INTESTINAL ANASTOMOSIS 


A CONDITION which calls for uretero-intestinal 
implantation is serious enough, without the added 
inconvenience to the patient resulting from leakage 
or: an ascending infection. Every method so far 
devised of forming a uretero-intestinal anastomosis 
has its inherent disadvantages and none is suitable 
for every case. Some of the methods advocated have 
resulted in a high percentage of failures, no matter 
how skilfully the operation has been performed. 
Others, whilst theoretically sound, are attended by 
such technical difficulties that only a surgeon with 
a large experience of this type of work can overcome 
them. In the December number of Surgery, Gyneco- 
logy, and Obstetrics Dr. Frank Hinman describes 
a method of implantation in many ways simpler 
than those advocated by Coffey and no more liable 
to subject the patient to the risk of complications 
such as ascending pyelonephritis, compression of the 
ureters, or leakage of urine or fecal material at the 
site of implantation. Hinman’s method also has the 
advantage of allowing both ureters to be trans- 
planted simultaneously ; it dispenses with the use 
of ureteric catheters or fine rubber tubes. Pre- 
operative treatment involves a non-residue diet for 
at least three days and the clearing of the bowel by 
castor oil and repeated enemata as well as the use 
of urinary antiseptics. : 

The operation consists essentially in the formation of 
peritoneal flaps and the isolation of the ureters. The 
peritoneum is slit alongside that portion of the pelvic 
colon into which the ureter is to be implanted. The 
outer flap of peritoneum is then stripped up, the ureter 
found, and held by passing under it a rubber tape. By 
traction on this tape, the juxta-vesical portion of the 
ureter is made visible under the peritoneum and a small 
incision allows it to be reached and divided between 
ligatures close to the bladder. Convenient sites for 


¢ Amer. Jour. Obst. and Gyn., March, 1935, p, 334, 
“© Thid., October, 1935, p. 534. ` 


avoiding both lumina. 


implantation are then selected, preferably not at the 
same level and marked on the bowel by stay sutures 
at either end of the imaginary incision. The ureters are 
then implanted with seven sutures. The method of 
doing this is to make a clean cut from 2-5 to 3cm. long 
in line with the stay sutures, over the muscular coats 
which are teased back to expose the surface of the mucosa. 
The sutures are inserted by means of an atraumatic 
needle passed through the submucosa of the bowel, 
and through the adventitia of the outer side of the ureter 
Dr. Hinman gives explicit details, 
clearly illustrated, concerning the method of inserting 
these sutures so as to avoid constricting the ureter, and 
to ensure a good fit. Flaps of peritoneum are then 
adjusted so as to cover the lines of sutures, care being 
taken that neither bowel nor ureter is pulled out of line 
by these flaps, and the abdomen is closed in layers 
without drainage. 


Dr. Hinman reports that 12 patients have under- 
gone simultaneous bilateral implantation by this 
method ; 5 have died, but only 1 of these deaths is 
directly the result of the operation (broncho- 
pneumonia). Three of the deaths followed an 
attempt to remove radically at a second operation 
the bladder, prostate, and vesicles for carcinoma. 
In none of the 12 patients was there any urinary or 
fecal leakage at the site of implantation. 


ASCHOFF’S SEVENTIETH BIRTHDAY 


SOME eighteen months ago British pathologists 
took the opportunity of his seventieth birthday to 
pay a tribute to the doyen of their science in this 
country, Sir Robert Muir. To-day, Jan. 10th, they 
join with their German colleagues in celebrating 
the seventieth birthday of Prof. Ludwig Aschoff. 
For the last 30 years his institute at Freiburg has 
been the mecca of young men from all countries 
who have sought inspiration and guidance in methods 
of pathological research ; and none has come away 
empty-handed. Aschoff’s last visit to England was 
in the summer of 1932, on the occasion of the cen- 
tenary meeting of the B.M.A. The section of patho- 
logy was being addressed by one of his former disciples 
when the door opened to admit a late-comer whose 
agitated progress to a seat was somewhat impeded 
by an overcoat, suitcase, and umbrella. A gleam of 
delighted recognition was followed by an exchange 
of solemn bows before the discourse was resumed. 
On the next day the visitor himself delivered a 
remarkable address, and was subsequently enter- 
tained to lunch by a joyous assemblage of friends 
and admirers of all ages. Aschofť is a great master 
of morbid anatomy; there is scarcely a branch of 
the subject which he has not illumined by his know- 
ledge and enthusiasm. At the age of 70 he retains 
that living interest in pathology which has proved 
a stimulus to generations of his students. To 
hear Aschoff lecture, to see that frail form quivering 
with the eagerness of exposition, is an experience 
never to be forgotten. One is reminded of a racing 
speed-boat, throbbing with the power that shakes 
the whole craft into impetuous motion. Such men 
have little to fear from the encroachment of the 
years, 


Mr. F. D. Donovan, surgeon-dentist to H.M. 
Household, was created a Commander of the Royal 
Victorian Order in the New Year honours list. 


THE tenth British Congress of Obstetrics and 
Gynecology will be held at Belfast from April Ist 
to 3rd under the presidency of Prof. R. J. Johnstone. 
Details are given on p. 124. \ 


` 


THE LANCET] 


[san. 11, 1936 101 


_ PROGNOSIS 


A Series of Signed Articles contributed by invitation 


LXXXIV. : 
PROGNOSIS IN CHRONIC BRONCHITIS 
AND EMPHYSEMA 


In chronic and slowly progressive conditions 
prognosis is often as much concerned with the out- 
look in regard to economic capacity and outdoor 
activities as with the probable length of life. This 
is particularly true in patients suffering from chronic 
and recurrent infections of the air-passages and in 
those with emphysema, the more so since the patients 
are usually in the middle and later periods of life 
when business and family responsibilities are serious. 
In these conditions prognosis is therefore an important 
practical problem and demands most careful con- 
sideration of a number of factors, to each of which 
due weight must be given. It is convenient here to 
consider and discuss these in a definite order, such 


as would be adopted in the assessment of a particular. 


case. : 3 , 

Family history—There can be little doubt that 

a tendency to emphysema may be inherited. It is 
sometimes found comparatively early in life in the 
absence of any cause of chronic expiratory stress. 
In such cases a family history, in parents or collaterals, 
of chronic bronchial conditions and of early death 
from respiratory diseases or cardiac failure may be of 
significance. Cohnheim went so far as to suggest a 
congenital defect in the elastic tissue of the lung as 
a factor in the genesis of emphysema. Osler, writing 
of arterio-sclerosis, referred to ‘‘ vital rubber,” and 
suggested that in early family incidence of that 
condition, it could not be explained ‘‘in any other 
way than that in the make-up of the machine bad 
material was used for the tubing.” It is also generally 
recognised that elastic tissues tend to deteriorate 
with advancing years. 
. Personal history may be of the greatest signi- 
ficance in prognosis. The age at which the yearly 
winter cough started, the number of years during 
which it has occurred, and the length of the summer 
intermission, are all of importance. It is usually 
found that this intermission becomes progressively 
shorter and its reduction in length is in some degree 
a measure of the progress of the condition, and 
therefore of prognosis. In this connexion Kingston 
Fowler pointed out that the abrupt cessation of the 
summer intermission, in other words, the persistence 
of the cough through the summer months in cases 
where there had previously been some weeks or 
months of freedom, should always arouse a suspicion 
of the presence of tuberculosis, and this I have often 
verified. Since emphysema tends to mask the signs 
of early tuberculosis this is an important observa- 
tion, and indeed in the past many cases of tuberculosis 
in elderly people have masqueraded’ as chronic 
bronchitis and emphysema, and have been respon- 
sible for widespread family infection. The recogni- 
tion of its presence may lead to a more serious 
proghosis in such patients than the previous history 
would suggest. 

Respiratory diseases in early life leading to chronic 
cough or to fibrosis with bronchial dilatation, either 
fusiform or saccular, are important factors in leading 
to chronic expiratory strain and thus inducing 
widespread emphysema. They certainly must be 
considered as unfavourably influencing the prognosis 
in regard to the full expectation of life and in regard 


to full economic activity in middle life. In the 
future it is to be hoped that more attention may. 
be given to convalescence after such conditions, and 
to special measures such as breathing exercises to 
obviate or mitigate their after-effects. 

Long-continued asthma, especially when: asso- 
ciated with bronchial infections, leads to increasing. 
emphysema, and therefore may influence prognosis 
unfavourably, though spasmodic or allergic asthma; 
being often intermittent, is less serious in this regard. 
Coexisting renal or cardiac disease and conditions. 
such as diabetes, obviously tend to render prognosis. 
more serious. l 


Occupation, habits, and habditation.—Occupations 
involving exposure to inclement weather, to dust, 
and to risks of infection are unfavourable, as also 
are those involving heavy muscular strain or pro- 
longed exertion. Blowing wind instruments has long 
had a bad reputation in this regard, but it may be 
questioned if it is altogether deserved, especially if 
adequate training in breathing and blowing has been 
given. l a: 
- Habits are also of some significance in prognosis. 
Over-smoking, especially the inhaling of cigarette 
smoke, tends to produce chronic cough and hawking, 
and patients should be warned of its ill-effects.’ 
Alcoholic over-indulgence is also unfavourable by 
promoting infection, and leading to earlier cardiac 
breakdown. Habitation is also of great importance, 
particularly at times other than the summer. Patients 
with chronic bronchitis and advancing emphysema 
are most comfortable in dry, warm climates, especi- 
ally in places where high atmospheric pressures are 
common. Cold, damp localities are unfavourable, 
and predispose to further catarrhal manifestations. 
High altitudes and rarefied atmospheres tend to 
induce dyspnea in advanced cases and are contra- 
indicated. 

Social state is a factor of great importance in 
prognosis. Those in comfortable or affluent circum- 
stances can avoid unfavourable winter conditions by 
migrating to sheltered areas in this country, such as 
the south and west coasts of England, and certain 
parts of the Welsh coast, or to resorts in Egypt, 
North Africa, the Mediterranean, the West Indies, 
California, South Africa, or the antipodes. Even 
those less favourably circumstanced may do much to 
protect themselves by remaining indoors in damp, 
foggy, and windy weather, though in older people 
this may involve weeks or even months without 
outdoor exercise. Such precautions are clearly 
impossible for the vast majority of those, both men 
and women, who have to earn their living by work 
away from home. In the large industrial towns in 
this country the daily journey to and from work, 
with the incidental risks of exposure, infection, chill, 
and wetting, gravely affects the prognosis in workers 
who develop chronic bronchitis and emphysema, 
and the problems offered to medical men in treating 
and advising precautions in these conditions are 
difficult in the extreme from the absolute inability of 
many such patients to follow the advice given. 


Symptoms and physical signs.—Symptoms often 
afford valuable information in regard to prognosis, 
particularly cyanosis, dyspnea, and cough. Cyanosis 
is to some extent a measure of the degree of emphy- 
sema and of the extent of the stress on the right 


102 THE LANCET] 


heart resulting from it, though it is in part due to 
the incomplete oxygen saturation of the blood and 
the resultant polycythemia. It should, however, be 
remembered that patients with this condition may 
show an extreme degree of cyanosis and yet be able 
to walk about and work. - When the cyanosis is 
associated with secondary heart failure and edema 
its prognostic significance becomes greater and more 
serious. TEE 

Dyspnea apart from intercurrent acute bron- 
chitis is a serious indication and suggests advanced 
emphysema or increasing circulatory failure. This 
may be evidenced not only by effort but also by the 
number of pillows used by the patient at night. 
Spasmodic dyspnea of asthmatic type is common 
and is often induced or aggravated by intercurrent 
acute or subacute bronchial infections. Its prog- 
nostic significance is difficult to determine. If it is 
long continued, it is of serious import, both by 
increasing the emphysema and by promoting 
circulatory stress. 

Cough is often troublesome and serious for similar 
reasons. It may also cause disturbed nights and so 
react unfavourably. It sometimes happens that a 
violent paroxysmal cough develops in which the 
patient becomes deeply cyanosed, and may even 
become momentarily unconscious. This is usually 
an unfavourable prognostic indication. Expectora- 
tion varies from little or none to copious amounts of 
frothy fluid or of tenacious muco-pus. In the latter 
case it suggests some degree of bronchial dilatation 
and is an unfavourable sign. Heemoptysis is rare and 
should excite suspicion of latent tuberculosis, or 
** silent’? bronchiectasis. 

The physical signs are perhaps less significant in 
regard to prognosis than the symptoms; indeed, 
Cabot has raised a doubt as to the characteristic 
barrel-shaped chest being diagnostic of, or the result 
of emphysema. In any case, the rigid chest of this 
type in pronounced degree, associated with marked 
extension of the resonance or hyper-resonance beyond 
normal limits, obliterating or diminishing the areas 
of cardiac and liver dullness, connotes considerable 
diminution of respiratory efficiency, but is less signi- 
ficant in relation to prognosis than signs of right 
ventricle engorgement or failure. Evidence of 
tricuspid regurgitation is usually a serious portent. 
Persistent rhonchi, especially of the sibilant type, 
particularly when associated with constant bubbling 
rales at the bases of the lungs, are unfavourable, 
indicating chronic inflammation of the smaller 
tubes. Fine rales on deep inspiration heard near the 
sternum or in the axillæ are frequent in mild cases 
and of less significance. 

Small-lunged emphysema is usually a senile, 
atrophic, or degenerative process and is associated 
with less dramatic symptoms until cardiac failure 
supervenes, 

X ray appearances in large lunged cases are some- 
what characteristic, showing the increased extent 
and trans-radiancy of the lung tissues as well as the 
degree of cardiac enlargement, and these may give 
some indication of the degree of the condition. 


Special tests.—Estimations of the vital capacity 
may give useful information. This may be very 
considerably reduced, and a diminution approaching 
half of the normal should be regarded as serious. 
Other tests, such as the manometer test, Flack’s 
endurance test, and those devised by Moncrieff are 
not yet in general use, but can be employed in special 
cases. Effort response tests and electrocardiographic 
investigation may also give useful indications, 


PROGNOSIS IN CHRONIC BRONCHITIS AND EMPHYSEMA 


(san. 11, 1936: 


especjally in regard to the degree of circulatory 


impairment resulting. 


Complications and intercurrent diseases.—Chronic 
renal disease, organic heart disease, raised blood 
pressure, diabetes, asthma, and pulmonary tuber- 
culosis all affect prognosis in chronic bronchitis and 
emphysema adversely, while the risks of intercurrent 
febrile conditions such as influenza or pneumonia 
are gravely increased. 


Treatment.—The results of treatment, especially 
that designed to prophylaxis of bronchial infections, 
are of great importance in regard to prognosis. 
Inoculations with vaccines, either autogenous or 
stock, may in some cases help greatly in mitigating 
or even preventing the winter cough. Even one 
free winter secured by this means or by an escape to 
more favourable conditions for the winter months 
in some resorts like those already mentioned may 
serve to arrest or to delay the advance of the emphy- 
sema. Treatment by compressed air baths at a 
pressure of 1% atmospheres is often helpful, especi- 
ally in cases complicated by bronchial asthma. The 
special respiratory treatments afforded at certain 
spas, notably La Bourboule, Mont Dore, Reichenhall, 
and Ems, can also be helpful in lessening the catarrh 
of the air-passages, relieving asthmatic spasm, and 
possibly in increasing resistance to infection. It is to 
be hoped that in the future similar methods may be 
tried systematically at some of the British spas. 


SUMMARY 


Chronic bronchitis and emphysema are not in 
themselves fatal conditions, or indeed even direct 
causes of death, though they may, either alone or 
in association, be the means of shortening life, by 
leading to earlier respiratory and cardiac breakdown, 
or by rendering more grave the struggle in serious 
intercurrent disease such as influenza, pneumonia, 
or pleurisy. 

It is difficult to assess the prospects of a particular 
patient on the lines of the numerical method now 
used in life assurance offices, especially in America. 
In this method, numerical debits are given for 
unfavourable factors such as heredity, unsuitable 
occupation, bad habits, and progressive physical signs, 
while credits are given for favourable indications 
such as social state, comfortable conditions of life, 
and habitat. A careful assessment on these lnes of 
all the factors considered above might enable some 
useful conclusions to be formed in a particular case. 
In general terms, a young patient with hereditary 
tendencies and with a personal history of respiratory | 
disease early in life leaving persistent lesions and 
signs is likely to be economically damaged in or 
before the fourth decade of life, more especially if 
the conditions of living and work are bad. Such 
a patient would certainly be rated up for life assur- 
ance either by the addition of several years to the 
age or by the limitation of the assurance to an endow- 
ment at 50. years of age, and even then probably 
with an extra. On the other hand, a patient who 
does, not develop bronchitic tendencies until the 
middle or late forties, who is comfortably circum- 
stanced, whose work does not involve exposure or 
unfavourable conditions, and whose symptoms and 
physical signs are only slowly progressive, may well 
live nearly the normal span and be enabled to work 
to the age of 60 or after; but even such a case would 
probably be rated up for life assurance. 


R. A. Youne, M.D., F.R.C.P. Lond., 


Senior Physician, Middlesex Hospital; Consulting Physician, ` 
Hospital for Consumption, Brompton. 


THE LANCET] ` 


[san, 11, 1936 103 


SPECIAL ARTICLES 


THE CONTROL OF MEASLES * 
By J. A. H. BRINCKER, M.B. Camb., D.P.H., FLC. 


- A PRINCIPAL MEDICAL OFFICER OF THB PUBLIO HEALTH 
DEPARTMENT, LONDON COUNTY COUNCIL . 


MEASLES has no doubt been with us always. It 
is a disease usually affecting children and occurring 
in London in epidemic form biennially from autumn 
to spring, though it has been known to appear 
epidemically in. hot months and to affect adults 
severely. In temperate climates and in city popula- 
tions it reappears with almost clock-like regularity 
biennially at the end of October. It crops up in 
one or more separate places and gathers momentum 
until it reaches epidemic proportions in January’ and 
February, after which it subsides. By the end' of 
June it has more or less disappeared, not to reappear 
in epidemic form. until the following. October twelve- 
month. , 

EPIDEMIOLOGICAL FEATURES 

Measles is a disease which fulfils with somarkabie 
accuracy the conditions of an epidemic cycle (Fig. 1); 
its waves of prevalence, with their respective rises 
and falls, are interspersed with periods of absence. A 
disease affecting a large human community, it has 
interested many epidemiologists, for it provides 
admirable. material for the detailed study of an 
epidemic. In London it began to- assume special 
prominence in- 1900, and a medical officer was 
appointed to deal with the health of the London 
school population. The picture it presented at that 
time was of a severe epidemic descending on a large 
school: population, affecting within six months some 
35,000 to 40,000 children, killing a large proportion 
of them and maiming more, causing the absence 
from school of those affected and of their brothers 
and sisters, necessitating frequent school closure for 
indefinite periods during the epidemic and paralysing 
the educational. machinery. At that time little 
was known about the behaviour of epidemics generally 
and the precautions to be taken to deal with them. 
Such measures as were adopted were invariably of a 
panic nature and were always undertaken too late ; 
it was the usual tale of closing the stable door after 
the horse was out. It was not even suspected that 
the elder children, infected in school, were, on the 
closing of the schools, being sent home to infect 
their younger brothers and sisters who were not 
attending school. : It was assumed that all children 
would sooner or later contract the disease and that 
they would have to take their chance of recovery 
or death. Treatment of patients by attention to 
general hygiene methods and by the provision of 
home nursing, or removing them to hospital to 
prevent complications, was not thought of and 
children affected were only admitted to the wards 
of poor-law hospitals when they were dangerously ill. 


The study of the epidemiology of measles in London 


commenced, then, in 1900, chiefly with the observa- 
tion of school-children and the keeping of statistical 
records relating to schools. The chief aim in dealing 
with an epidemic was to stop it or at any rate slow 
it down. Various measures were adopted with this 
end in view, such as complete closure of schools, 
closure of infant departments or of classes in infant 
departments attended by the younger children, and 


exclusion of children who had not previously suffered. 


° 4 paper read to the Hunterian Society on Dec. 16th, 1935. 


500 


from the disease, either. for. the whole period of the 
epidemic or for the period during which they would 
be likely to contract the disease—i.e., from the ninth to 
the sixteenth day after exposure. Complicated rules 
were drawn up and were faithfully carried out by 
school teachers, school nurses, and attendance 
officers, and much praise is due to them for their 
coöperation in the AMOI DER made to deal with these 
epidemics. 

. These precautions, with Variations, were carried out 
during every succeeding epidemic, but they proved 
futile and were finally given up in 1918. Though 
these. Sx pernents were a failure so far as controlling 


| Epidemic Cycle of tae j l 
900 
850 
800 
750 
700 
650 
600 
550 


450 
400; 
350 
300 
250 
200 
150 
100 


_ 1933-34 


FIG. 1.—Chart showing the number of admissions for measles 
to L.C.C. fever hospitals (plain area) and inoculations of 

k adult serum (black area) for each week from Nov. Ist to 
August 31st during the epidemic periods 1931-32 and 1933-34. 


the spread of the disease was concerned they taught 
us many things about the behaviour of an epidemic 
of measles which are now generally accepted. For 
instance, in addition to those characteristics already 
mentioned, it was observed that :— 


l. A measles epidemic did not arise in a community 
of children until the susceptibles rose to 25 per cent. 
and the epidemic did not stop until this susceptible 
population was reduced to under 20 per cent. 

2. Epidemics when they started did not flare up at once, 
but required both time, inflammable material, and the 
right weather conditions to gather momentum. 

3. In London, at any rate, measles was a disease affecting 
children under 7 years of age, and therefore boys and 
girls in the upper classes of schools were of no account in 
the spread of the disease. 

4. Contacts only became active in spreading the disease 
from the time the coryzal symptoms developed and the 
risk of transmitting infection diminished rapidly after the 
disappearance of the rash; in fact, the greatest risk of 
communicating infection occurred in the _ pre-eruptive 
stage, from the ninth to the twelfth day of incubation. 

5. The disease itself did not kill, but predisposed the 
patient to the great risk of secondary infection by hzemo- 
lytic streptococci (resulting in deadly complications such 
as broncho-pneumonia) and to others such as otitis media 
and ophthalmia, which, while not so deadly in themselves, 
could give rise to life-long disability. 


104 THE LANCET] 


DR. J. A. H. BRINCKER: THE CONTROL OF MEASLES 


(san. 11, 1936 


6. The most susceptible age, both for measles and 
complications, was the pre-school age and by far the 
greatest number of deaths occurred in the second and 
third years of life. 

P. Stocks later pointed out that the old belief that 
all children were bound to suffer from measles was 
not correct. For every 100 children suffering from 
a clinical attack of measles in a densely populated 
area about 300 others become temporarily immunised, 
presumably by subliminal doses of the virus, but 
of these 300 some 250 lose their immunity again 
before the next epidemic. It is these children who 
have lost their immunity, together with those born 
subsequent to the epidemic, who make up the 
vulnerable population ready to start the next epidemic. 


FAILURE OF QUARANTINE 


By 1918 sufficient knowledge had accumulated 
to demonstrate the necessity of attacking measles 
by other means. First and foremost it was clear 
that quarantine, on which so much faith had been 
placed in the past, and which had been found wanting, 
was based on erroneous ideas. It was therefore 
necessary to abandon it finally and completely. 
As already stated, it was established that measles 
was particularly dangerous to the pre-school child 
and the success which attended the experiment of 
dealing with cases at home on open-air lines and by 
hygienic methods showed the need for home nursing 
and medical assistance. 
empowering the borough medical officer of health 
to call in such aid. By the Maternity and Child 
Welfare Act of 1918 local health authorities were 
not only able to provide medical and nursing aid, 
but also, through the establishment of child welfare 
clinics, to educate the mother in matters of health 
and hygiene. In 1910 measles began to be admitted 
to the fever hospitals of the late Metropolitan Asylums 
Board. 
After a 
conference 
held in 
1926 be- 
tween re- 
presenta- 
tives of 
the Board, 
the Minis- 
try of 
Health, 
of the 
London 
County 
3,000 Couneil, 
2000 and of the 
1000 borough 
medical 
officers 
of health, 
it was 
decided 
to admit 
measles to the wards of the fever hospitals pari 
passu with scarlet fever, the criteria for admission 
being the type of home and the facilities therein for 
the proper care of the patient, rather than type of 
case. To these criteria was subsequently added 
the age of the patients, in view of the high mortality 
amongst children under the age of 2. At each of 
the subsequent epidemics of measles more and more 
cases were admitted to the fever hospitals (Fig. 2). 
In the 1931-32 epidemic 11,368 cases were admitted 


Increasing Hospitalisation of Measles 
in London 
14.000 
13,000 
12 000 
11.000 
10,000 
9.000 
8.000 
7.000 
6,000 
5,000 
4000 


1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 


FIG. 2.—Chart showing the total admissions for 
measles to London fever hospitals (M.A.B. 
and L.C.C.) from 1924 to the present time. 


THE LANCET, 1930, i., 796. 


These were provided by. 


during the 10 epidemic months and in the 1933-34 
epidemic 10 months 12,730 cases, selected in this 
way, were treated in the wards of the L.C.C. hospitals. 
By this means many lives were saved, as the case- 
mortality demonstrates, for of admitted cases in 
successive epidemics this was 7, 6-5, 5-3, and 5-1 per 
cent. respectively. It may be of interest to note 
that patients are treated to a considerable extent in 
open wards and that under such conditions even cases 
of severe broncho-pneumonia, otherwise considered 
hopeless, are nursed back to health. . 

It is obvious that hospitalisation provides for 
large numbers of children treatment such as it would 
be impossible for them to receive at home. In 
addition to being skilfully nursed in bed in well- 
ventilated wards with plenty of fresh air, and provided 
with suitable diet and medical treatment, many 
accessory lines of treatment are available. Thus 
many patients are now treated with antistreptococcal 
serum in the hope of preventing complications. 
The oxygen tent has been found of great value in 
dealing with broncho-pneumonia and, in cases of 
empyema, success has attended the use of the Drinker 
apparatus to prevent permanent collapse and fibrotic 
changes in the lung. Skiagrams are now considered 
necessary for the treatment of the after-effects of 
measles. 

SERUM PROPHYLAXIS 

Once measles has been contracted serum is of no 
use; the aim is either to prevent or to attenuate 
the disease in those exposed to it. It must therefore 
be used during the period of incubation. The 
first attempt to modify measles was made by 
L. Weissbecker 40 years ago. He employed con- 
valescent measles serum in the early stages of 
the disease. The first published report on the 
procedure was made by Nicolle and Conseil in 
1918. Since then Degkwitz (1920) and other 
workers have used convalescent serum to modify 
the disease. Until the 1929-30 epidemic in London 
little or no attempt had been made to control 
the disease by the prophylactic use of immune sera. 
It is true that in America and Germany attempts 
had been made to procure immune sera from animals, 
but all these proved valueless or unreliable and their 
use was ultimately abandoned. Among such sera 
were those prepared by Tunnicliff, Ferry and Fisher 
and Degkwitz. Before the 1929 experiments a few 
pioneers were at work, the most conspicuous among | 
them being Dr. £. H. R. Harries, then in Birmingham, 
Dr. D. N. Nabarro at Great Ormond-street Hospital, 
and Dr. W. Gunn at the Park Hospital. They used 
serum prepared from the blood of persons who had 
recently recovered from an attack of measles. During 
the 1929-30 epidemic in London, however, con- 
valescent measles serum obtained from the blood of 
such persons was tried on a large scale. This serum 
proved very eflicacious both in preventing an attack 
and in attenuating the disease. Whether the one 
or the other was attained depended on the dose of 
serum given and the time at which it was administered. 
The varying eflect of dosage and the day of injection 
was very carefully observed and from the experience 
thus gained any desired result could be attained. 
Convalescent measles serum thus proved’ of great 
value, particularly in preventing children already 
seriously ill with some other complaint or those about 
to undergo an operation from contracting the disease 
after a known exposure. Its use also obviated the 
need of placing a children’s ward in quarantine on the 
occurrence therein of a case of measles. 

Unfortunately most of the patients suffering from 


ILLNESS OF INFECTION Too mild 


DAYS! 2345 67 8 9 10 Il l2 B 


IMMUNE PROTECTION ATTENUATION ATTENUATION 
SERUM Complete Constant Inconstant 


FIG. 3.—Synoptic chart showing the typical course of measles: 


DR. J. A. H. BRINCKER : THE CONTROL OF MEASLES 


(san. 11, 1936 105 


Bronchopneumonia 


ATTENUATED 
ATTACK 


i © 
© 

'/\ Desirable degree 

4 4 N CXS -@ 


Pd 

one Naaa 
I4 15 16 |7 18 19 20 2i 22 23 24 25 26 27 28 
——— amaa Ann ee 


EFFECT ANTIBODY CONTENT INFECTIVITY 
Doubtful Highest Absent 


(1) uncomplicated, (2) with the two commonest complications, 


(3) attenuated by immune serum (a) to the desirable degree and (b) to an undesirable degree with an attack too mild to 
confer lasting immunity. The dosage of serum and the time-tabie ot its administration are as follows :— 


. Prophylaxis. 
Nature of serum. Dose in c.cm. Dosage factor. Route Treatment. 

Protection. Attenuation. 

Convalescent 5—20. Age x 2 Intramuscular. 1Ist—5th day. 5th—9th day. 
Within 6 days of onset. 
Normal adult .. 10—40. Age x 4. Intramuscular. lst-3rd day. 3rd—9th day. Dosage factor : age x 4. 
Route: intravenous. 

Whole blood .. | Double its serum. Age x 4, Intramuscular. lst-3rd day. 3rd-9th day. 


measles are very young children from whom blood 
cannot well be abstracted and the number of adults 
suffering from the disease is so small that the amount 
of convalescent measles serum available in any 
epidemic must be very limited. Moreover, to be of 
value an immune serum should be available at the 
commencement of an epidemic and not towards its 
end. Chiefly for these reasons other sources of 
antibodies had to be sought. It is well known that 
an attack of measles produces a permanent immunity 
and that, in London at any rate, most adults have 
either suffered from measles in childhood or are 
immune. It was, therefore, suggested: that serum 
obtained from young healthy adults might have some 
immunising property. To determine if this were 
80 serum was obtained from healthy adults who had 
volunteered to give it and tested in the same way as 
convalescent measles serum. This serum is referred 
to as adult measles serum to distinguish it from the 
convalescent measles serum obtained from those 
recently recovered from measles. 


I will now summarise the experience which followed 
the use of this serum culled from an account of the 
1931-32 London epidemic. The type of children 
in whom complete protection is advisable are those 
who are weakly or debilitated ; those suffering from 
any serious intercurrent disease, infectious or other- 
wise; and all children under 3 years of age, whatever 
their condition. Forthese a minimum dose of 10 ¢.cm. 
adult measles serum is recommended. From the age 
of 3 years onwards the dose is reckoned in cubic 
centimetres by multiplying the age in years by four. 
To ensure protection, the serum should be administered 
Within five days of the earliest known exposure to 
infection ; the earlier the injection is made, the more 
likely is complete protection to follow. The injections 
should be given intramuscularly, preferably into the 
vastus externus. The duration of the immunity 
conferred is roughly three to four weeks. 


After the age of 3 years, provided that the physical 
state is satisfactory, it is desirable to aim not at 
complete protection but at a modification of the 
attack of measles if circumstances permit. This is 
achieved by injecting the serum, in the doses already 
recommended, later in the incubation period—viz., 
from the sixth to the ninth day after exposure. The 
same results may be attained, with resulting economy 
in serum, by halving the dose and giving the injection 
within the first five days. The immunity which 
follows a modified attack appears to be permanent. 
Of course, if the patient has had measles previously 
the administration of serum is unnecessary and in 
fact wasteful. 

The statistical analysis of the clinical data in the 
1931-32 epidemic makes interesting reading. I 
will assume that if a susceptible child exposed to 
measles is given intramuscularly a sufficient dose of 
this serum within five days of exposure he will be 
protected, and that, if the same dose is given between 
the sixth and ninth day of exposure, or half the usual 
dose within the first five days, the child will suffer 
from a modified attack of the disease. From the 
data available it would appear that of every 100 
children exposed to risk and not given serum 75 
will take measles, whereas of every 100 children given 
serum less than 14 will fall ill, and that four out of 
every five attacks of measles would be averted or 
postponed by the administration of serum. 

When we come to deal with the efficacy of adult 
serum as compared with convalescent measles serum 
the data must be submitted to careful statistical 
analysis. To quote from Dr. Gunn’s report ? :— 

“In an ideal scientific test of a prophylactic method 
one would use the method in alternate cases, e.g.,in every 
school or hospital every other inmate exposed to risk 
would be given a dose of serum. In such circumstances, 


? L.C.C. Report on the 1931-32 Measles Epidemic. 
P. S. King and Son, Ltd. 1933. No. 2996. 2s. 6d. 


London: 


106 THE LANCET] 


DR. J. A. H. BRINCKER: THE CONTROL OF MEASLES 


(san. 11, 1936 


the protected and unprotected are strictly comparable 
and simple comparison of results, institution by institution, 
must give an answer to the question proposed—viz., 
Does the method of protection in fact protect ? Administra- 
tively, no such plan could be carried out. We must, 
therefore, fall back upon the less satisfactory method of 
using, as controls of the prophylaxis, such unprotected 
children as, for various reasons, become available.” 


The conclusions arrived at in the statistical examina- 
tion of the use of adult serum in the 1931-32 epidemic 
were as follows: 


The total number of observations recorded was 2362. 
The adult serum series, consisting of 1475 observations, 
was divided into two groups: the first in which complete 
protection was desired consisted of 1133 cases, and the 
second in ‘which attenuation was desired numbered 
342 cases. The results of 680 injections of convalescent 
serum and observations on 207 uninjected contacts during 
the same epidemic period were utilised to form the control 
series. 

The clinical results of the administration of convalescent 
and adult serum were compared; the figures were 
standardised to make allowance for variations in the age- 
distributions. ‘The analysis showed that convalescent 
serum is a more potent prophylactic agent than the adult 
serum for each age-group, but that the difference between 
them is of statistical significance only in respect of children 
under 5 years of age. The difference is greatest in the 
1-3 years age-group, at which period susceptibility is 
at its highest. After the age of 5 years there is nothing 
to choose between the two sera, and after the age of 10 years 
the effect of either serum on the issue is negligible; at 
any rate as far as the London school-child is concerned. 

When the results with convalescent serum in the 
infectious diseases hospitals are compared with those of 
adult serum (similar age-distribution and probability of 
effective exposure) the significant difference favouring 
convalescent serum is limited to children under 3 years 
of age. The difference favouring convalescent serum 
remains true only in respect of injections given on or 
before the third day after contact. The attenuating 
results following one-half the standard dose given before 
the sixth day are as good as those after the full dose given 
on or after the sixth day. 

Finally, the analysis showed conclusively that adult 
serum is a valuable measure in measles prophylaxis. In 
its protective and attenuating action, it is only slightly 
inferior to convalescent serum and merits a high place 
in any future policy of measles control. 


In the 1931-32 epidemic 24,085 c.cm. of adult serum, 
roughly 2408 doses, were collected by the medical 
staff of the L.C.C. and in the 1933-34 epidemic 
27,335 c.cm., roughly 2733 doses. These amounts 
were of course far too small to allow work to be done 
on an adequate scale. Up to the present, voluntary 
donors, usually the nursing staff in the L.C.C. hospitals 
and medical students, have been relied on for blood 
for the preparation of adult serum. The Council 
has, however, just given authority for an appeal 
to be made for donors generally, and has agreed to 
pay each of them 5s. for providing their blood. In 
a healthy young adult 250 c.cm. of blood can easily 
be withdrawn and this provides about half its bulk 
in serum. By this means it is hoped to obtain 
sufficient material to carry out the effective control 
of measles during the current epidemic. 


If attenuation can be carried out on a large scale 
in residential and day schools, measles instead of 
producing havoc in deaths or physical impairment 
and causing dislocation of school organisation will 
definitely be under control. Imagine what a boon 
this will be to medical officers in public schools where 
measles, although occurring in older boys and girls, 
produces considerable dislocation of school attendance. 
Alternatively, in the case of delicate or sick children 
in hospitals, or those about to undergo operations, 


prevention will result in removal of the risks 
associated with the disease in those least able to 
stand up to it. Prevention may also be aimed at in 
the wards of hospitals to avoid placing them in 
quarantine after a case of measles has occurred. 

Fig. 3 gives in concise form typical temperature 
charts of cases of measles, uncomplicated and com- 
plicated, and of children exposed to measles where 
serum is used to obtain either complete immunity or 
attenuation. The temperature may be taken to show 
the reaction of the body to the poison and is therefore 
an index of the amount of the poison in the child’s 
circulation. The chart also shows what happens to 
the child from the date of infection until convalescence 
is established, along with the doses of serum and the 
dates on which it is to be given in order to modify 
the disease. 

ae PLACENTAL EXTRACT 

It is well known that infants under 9 months old 
are generally immune to the common infectious 
diseases. This immunity is ascribed to their obtain- 
ing the antibodies from their mothers. If this 
assumption is correct these immune bodies must be 
supplied to the child through the mother’s placenta. 
As a practical outcome of this theory placental 
extracts have been employed to produce protection 
or attenuation. In placentas it is apparently the 
globulin which contains these immune bodies. 
Globulins have been abstracted from placentas and 
submitted to test. It has been shown, for instance, 
that such globulin contains 5 units of diphtheria 
antitoxin per c.cm. and that, tested by the Schultz- 
Charlton reaction, it contains quite an appreciable 
amount of scarlatinal antitoxin. There is no means 
of testing such globulin for the presence of measles 
antibodies except by the direct method of using it 
with a view to the prevention of the disease in 


contacts. This has been done in some cases with 
promising results. The substance is called immune 
globulin. It is being prepared in sufficient quantities 


in the L.C.C. laboratories to be tried side by side 
with convalescent and adult human serum and it is 
hoped to accumulate sufficient data by the end of the 
coming epidemic to say whether, like adult serum, 
it can play a part in the control of measles, Various 
preparations of human immune globulin have been 
tried in America and a full account of the trial has 
been given.® 

Two commercial preparations of placental extract— 
i.e., of human immune globulin—are now available ; 
they are (1) Placimmunin prepared by E. R. Squibb 
and Son, and (2) immune globulin (human) prepared 
by Lederle. These two products have been submitted 
to the Council on Pharmacy and Chemistry of the 
U.S.A. They withheld comment on Squibb’s product 
on the ground that the data supplied were insutiicient, 
but they reported as follows on Lederle’s preparation. 


1. The product is as efficacious for prevention as 
convalescent serum. 

2. The clinical results show sufficient evidence to warrant 
the doses recommended for prevention. On the available 
evidence those for attenuation are questionable. 

3. Although it is a promising immunising agent more 
evidence of its value is needed before it is recommended 
for general use. 


We are hoping to test this preparation in London 
during the present epidemic. . 

However inadequate and incomplete this account 
of the past, present, and possible future of measles 
may be, I hope I have shown that the older methods 


> Jour. Amer. Med. Assoc., 1935, cv., 493. 


THE LANCET] 


MEDICINE AND THE LAW 


[yan. 11, 1936 107 


of control have failed and that, by means of passive 
immunisation by serum or placental extracts, we 
have entered on a promising stage in the battle against 
measles. Much work on the epidemiology of the 
disease remains to be done, and those of us to whom 
the control of infectious diseases in hospitals, schools, 
and homes is entrusted are fully alive to the need 
for constant experiment. 


I am indebted to Dr. W. Gunn for the loan of the 
three charts on which the figures are based. 


MEDICINE AND THE LAW 


Supervision of Special Treatment 
Establishment 


THE London County Council has, by tot Ast, 
statutory powers of licensing -massage and special 
treatment establishments. Under these powers a 
licence was granted to Mr. Alexander Barthels, of 
Weymouth House, Hallam-street, with a condition 
that he should not give ultra- violet ray treatment 
without the supervision of a medical practitioner. 
An inspector of the L.C.C. found that the condition 
was being broken and Mr. Barthels was summoned 
at Marlborough-street police-court last week. The 
inspector’s evidence was that a patient who was 
undergoing such treatment was asked if she had seen 
a doctor and if a doctor had recommended the treat- 
ment. The patient answered that she had been to 
many doctors and had received no benefit and had 
therefore decided to try Mr.. Barthels. There was 
no question of Mr. Barthels’s competence. His 
legal representative was prepared to elaborate the 
defendant’s skill, but the magistrate observed that 
his competence was irrelevant. The summons was 
dismissed under the Probation of Offenders Act on 
payment of £5 5s. costs to the L.C.C. and on the 
defendant undertaking not to commit a further breach 
of his licence. The licensee could hardly contend 
that he was unaware of the restrictive condition. 
Deliberate violation of the condition is hardly the 
proper method of appealing against it. 


Fraudulent Conversion by Hospital Secretary 


Offences between January and October last year 
formed the subject of charges at West Sussex Quarter 
Sessions last week against Major W. I. Rogers, 
former secretary of the Bognor Regis War Memorial 
Hospital. He pleaded guilty to various charges of 
fraudulent conversion, intent to defraud, and omission 
to make entries as to orders of stamps. It was 
urged in mitigation of sentence that the accused 
had formerly borne an exemplary character and had 
received inadequate pay. The chairman of the 
bench, Mr. Roland Burrows, K.C., observed that 
judges had from time to time commented on the 
fact that it was only persons with an exemplary 
character who obtained posts where they could 
commit offences of this kind. Passing sentence of 
12 months’ imprisonment in the second division, he 
expressed the view that the checking of the hospital 
accounts appeared to have been lamentably lax, 
and that, with better supervision, the defendant 
would not have found himself in his present position. 


Unfitness to Plead 


A careful paper on ‘ unfitness to plead,” read last 
year by Dr. W. Davies Higson, medical officer of 
Liverpool Prison, before the annual conference of 
prison medical officers, is published in the Journal of 


Medical 


Mental Science (1935, cxxxi.,.822). He points out 
that this preliminary question of fitness to plead in 
criminal proceedings is one with which prison doctors 
may often have to deal. It is common experience, 
indeed, that.. judges pay ' special respect to their 
evidence. It might. be added that the Atkin Com- 
mittee on Insanity and Crime stressed the importance 
of medical officers of prisons having special knowledge 
of mental disorder. . As has sometimes. been pointed 
out, the courts examine a prisoner’s fitness to plead 
more carefully in serious charges like murder than in 
merely trivial offences, and, on the whole, the propor- 
tion of prisoners found unfit to plead is advancing. 
The Atkin committee advised that a man should 
not be found unfit to plead except on the evidence 
of two doctors at least ; one of these would usually 
be the medical officer of the prison. The committee 
recommended the retention of the procedure. 
Mental disorder is sometimes so obvious that trial 
would be a farce; on the other hand, where there 
is any element of doubt, it is a strong step to put 
a man away as a criminal lunatic when he has not 
been found to have committed a criminal act. The 
committee approved the standing orders of the 
Prison Commissioners which recommend that. a 
prisoner be left to stand his trial unless there are 
strong reasons to the contrary. It remarked that 
it was aware of evidence of persons of unsound mind 
having pleaded guilty either to gratify an insane 
desire for punishment or to avoid inquiry into their 
mental condition. The evidence which justifies 
a finding of unfitness to plead consists of showing 
that a prisoner suffers from such defect or disease 
of the mind as not to be able to understand the nature 
of the proceedings against him, or the difference 
between a plea of “guilty” and a plea of “not 
guilty,” or that he is unable to follow the course of the 
trial or instruct counsel in his defence or appreciate 
that he has the right to challenge a juror. On these 
points the medical witness can state the facts he has 
observed and the conclusions he has formed, but it is 


for the jury to decide the issue. The law sees no inherent 


difficulty in a man or woman being insane and yet fit 
to plead. 

By way of illustration Dr. Higson mentions 
two instances of the kind of complication which may 
be introduced. A woman was to be tried at Liverpool 
assizes for murder of her child. She was brought 
from Manchester where the medical officer had 
reported that, during remand there were no indica- 
tions that she would be likely to be unfit to plead on 
arraignment. Yet on arrival at the Liverpool 
assize-court she was in such a state of extreme 
emotion and mental distress that the medical witness 
was prepared to give evidence, from further observa- 
tion, that she was not fit to plead. In the other 
instance the prisoner had been charged with shooting 
with intent to murder. His mental condition 
indicated a straightforward case of paranoia. Medical 
witnesses for the defence testified that he was unfit 
to plead. He protested and, his counsel not objecting, 
the judge told the jury to return a verdict that the 
man was fit to plead. He was then indicted and, 
in spite of protests from his counsel, he pleaded 
guilty ; the result was a sentence of 20 years’ penal 
servitude. Dr. Higson records the interesting opinion 
of one of the medical witnesses, who discussed the 
case afterwards, that the judge overlooked the 
unlikely contingency of the prisoner pleading guilty, 
and that the jury was the more ready to follow the 
direction to find the man fit to plead because they 
were anxious to hear what was rather a sensational 
case, , 


108 THE LANCET] 


STERILISATION IN THE U.S.A. 


[san. 11, 1936 


STERILISATION IN THE U.S.A. 


eS 


In May of 1934 a committee of the American 
Neurological Association was appointed to evaluate 
in a critical manner the problems of the inheritance 
of various mental abnormalities and neurological 
disorders. The committee consisted of Dr. Abraham 
Myerson (chairman), Dr. James B. Ayer, Dr. Tracy 
J. Putnam, Dr. Clyde E. Keeler, consultant in 
eugenics, and Dr. Leo Alexander, research associate. 
The committee was subsidised by a grant from the 
Carnegie Foundation. The conditions under which 
it was appointed and the method of its procedure 
have something in common with those which related 
to'the recent Departmental Committee on Sterilisa- 
tion (the Brock Committee). Its report shows that 
the possible benefits of sterilisation seem to have been 
exaggerated in America in much the same way as in 
this country. In a preface the committee states : 

We have tried to free our minds from the obsessive 
traditions of psychiatry and eugenics and this report is, 
we believe, as unbiased and critical and as nearly objective 
as we can make it. We hope that the subject matter of 
the report and the recommendations will be of value 
both in evaluating past work and as the basis for legis- 
lative and especially for research activity. 


THE COMMITTEE’S FINDINGS 


The findings of this committee are set forth in 
12 chapters, of which the last consists of a valuable 
and comprehensive list of references occupying no less 
than 16 pages. Arguments commonly used for and 
against sterilisation receive careful consideration. In 
the fourth chapter of the report the contention that 
a need for sterilisation is created by the increase of 
mental disorders in the United States is examined. 
An interesting analysis is made of the commitment 
rate in two States wherein the psychiatric services 
are highly perfected—namely, Massachusetts and 
New York. The conclusion is reached that if certain 
relevant factors are taken into account, there are no 
valid reasons for supposing that an increase in mental 
disorders has taken place. The better organised the 
hospital services, the greater will be the inducement 
to solicitous relatives to consent to the commitment 
of mentally abnormal persons ; the increasing age of 
the ¢ommfnity, moreover, naturally leads to an 
increase in the proportion of senile psychoses admitted 
into mental hospitals. 


In a discussion of the relation of genetics to 
eugenics, the American committee reaches con- 
clusions closely similar to those of the Departmental 
Committee. They stress the importance of the 
interaction between hereditary and environmental 
factors. Recent genetic investigations are quoted in 
support of the view that “the environment may be 
conceived as a releasing agent for the manifestation 
of a character without which, so to speak, the 
character could not appear.” Chapter 7 consists of 
some shrewd criticisms of widely accepted investiga- 
tions bearing upon the inheritance of mental diseases 
and defects. These criticisms pave the way for the 
committee’s chief recommendation, namely, that a— 
“ concerted, co-ordinated and planned long-time research 
should be instituted in some State which is well-organized 
psychiatrically and socially, and which has a stable 
population. A central group headed by a full-time 
director should determine, after due study, the technique 
of research, this being the first and all important step. 
Certain hospitals might be selected to study the mental 
diseases, feeble-mindedness and epilepsy, through the 
operations of a genetic group stationed therein. Arrange- 
ments could be made for the study of samples of the total 


population through schools, universities, factories and 
such other institutions and social aggregations as may be 
decided upon.” | 


As is to be expected, the report is sceptical as to 
the possibility of eliminating crime by genetic methods. 
“ Most writers,” they say, “agree that while there 
may be a constitution (favouring criminality), the 
effort to breed it out by any eugenical measures is, in 
the present state of our knowledge, not to be recom- 
mended and that more fruitful approaches to crime 
are to be found in social measures of one type or 
another.” With regard to the relation between 
genius and mental abnormalities, the committee state 
categorically that ‘“‘feeble-mindedness breeds no 
genius and that we have nothing to fear on that 
score from the sterilisation of the feeble-minded ”’ ; 
but a different view is taken of the effect of the 
indiscriminate application of the sterilisation law to 
manic-depressives. Referring to the work of Lange- 
Eichbaum, they are satisfied that valid and reliable 
evidence has been adduced to indicate that sterilisa- 
tion, applied as a wholesale measure to manic- 
depressives and their relatives, might well cut off from 
the race some of its most valued and valuable members. 


RECOMMENDATIONS 


The committee’s most important recommendation, 
the promotion of further research, has already been 
noted. But they make some further recommendations 
which they preface by the three following statements 
of opinion: (1) our knowledge of human genetics does 
not justify us in advocating the sterilisation of people 
who are themselves normal; (2) there is at present 
no scientific basis for sterilisation on account of 
immorality or character defect; (3) nothing in the 
acceptance of heredity as a factor in the genesis of 
any condition considered by this report excludes the 
environmental agencies of life as equally potent and, 
in many instances, as even more effective. 

In the light of these statements, the following 
recommendations are submitted to the American 
Neurological Association for its considerations : 


(1) Any law concerning sterilisation passed in the 
United States under the present state of knowledge 
should be voluntary and regulatory rather than com- 
pulsory. ‘ 

(2) Any law concerning sterilisation should be applicable 
not only to patients in State institutions, but also to those 
in private institutions and those at largein the community. 

(3) The central machinery for administering any law 
should be one or several Boards composed chiefly of 
persons who have had special training and experience in 
the problems involved. These should study each case on 
its individual merits and should strongly urge, suggest, 
or recommend against sterilisation according to its 
findings. Cases could be brought before such a Board 
by superintendents of institutions, private physicians, 
parents, or guardians, or by the patients themselves. 

(4) Adequate legal protection for members of such a 
Board and for the surgeons carrying out such recom- 
mendations should be secured by statute. 


The committee feels that sterilisation is not to be 
recommended as a general measure applicable to all 
persons of whose infirmity a certain diagnosis has been 
made; they recommend it rather as applicable in 
selected cases of certain’ diseases subject to the 
consent of the patient and those responsible for him. 
They regard the measure as appropriate to the 
following conditions in the order given :— 

(a) Huntington’s chorea, hereditary optic atrophy, 
Friedreich’s ataxia, and certain other disabling degenera- 
tive diseases recognised as hereditary. 

(b) Feeble-mindedness of familial type. 

(c) Dementia priecox (schizophrenia). A = 


THE LANCET] 


(d) Manic-depressive psychosis. 

(e) Epilepsy. 

A COMPARISON . 

The general resemblance between these recom- 
mendations and those of our own Departmental 
Committee will be obvious to persons familiar with 
the latter. Both committees advocate voluntary 
measures only, they recommend that they should 
apply to selected cases only, and that facilities for 
sterilisation should be made available to patients 
whether in State institutions or not. Both ask for 
adequate legal protection for the doctors concerned. 
The chief point of difference resides in the procedure 
recommended by which patients should apply to be 
sterilised. The Departmental Committee recom- 
mend that wherever possible the patient himself 
should apply; the American committee wishes to 
make it possible for superintendents of institutions 
and private physicians also to apply. The Depart- 
mental Committee recommends that each application, 
supported by two medical recommendations, be 
communicated to the Minister of Health who should 
be vested with the power of authorising or vetoing 
an operation ; the American committee recommends 
that each case be adjudicated by a specially appointed 
Board. In this respect, its recommendations favour 
the type of safeguard now in practice in Germany. 


VIENNA 
(FROM OUR OWN CORRESPONDENT) 


AGE-GROUPS OF DOCTORS 


In the course of an inquiry into the possibility 
of establishing old age pensions for medical practi- 
tioners, the Austrian Union of Practitioners (Reichs- 
verband der Aerzte) has collected some interesting 
material relating to the age-groups of doctors in 
Vienna, The following Table indicates the general 
position :— 


Age-group. 


Male. | Female. Total. 
90-65 years old .. 550 2 552 
64-45 eg we 1256 90 1346 
44-35 eo 1188 287 1475 
Under 25 years 1 0 1 
— 3898 | 591 4489 


There are 872 (or 15 per cent. of ‘the total) doctors 
aged 60 years and over, and it is proof of the hard 
times the medical profession is experiencing that 
they are nearly all still in practice. During the 
last 20 years either-their savings have been lost or 
their practices and incomes have dwindled. Among 
the recommendations brought forward by the Union 
has been a scheme providing for pensions for all 
practitioners over 65 on condition they retire from 
practice and make way for the younger men. But 
to provide even the very modest pension of 250 
Austrian schillings (about £10) a month a large 


capital fund would have to be collected, and under 


present conditions this is quite out of the question. 
The outlook is therefore not very encouraging. 


TUBERCULOSIS REPORT FOR 1934 


The recently published report of the health depart- 
ment of the Ministry of Social Welfare records that 
its fight against tuberculosis is conducted from 
93 centres working with a staff of 153 doctors, 104 
trained nurses, and 71 follow-up nurses, who advise 
the patients, keep in touch with them, arrange for 


' VIENNA.—-SCOTLAND 


(san. 11, 1936 109 


hospital or sanatorium treatment where necessary, 
and organise preventive work among the contacts. 
In 1934 31,793 new cases were registered, of whom 
44 per cent. were men. Rather more than half were 
over 18 years of age. About 8 per cent., mostly 
from the country districts, were classified as seriously 


ill. The cases reported in Vienna itself were not so 


grave. In 60 per cent. of the cases other members 
of the family were found to be also infected, in 20 per 
cent. seriously. Altogether during 1934 280,740 
patients attended the centres (65 per cent. at the 
clinics in Vienna), and of these 167,144 were kept 
under constant supervision, 8 per cent. being open 
tuberculosis cases. The 169,070 examinations con- 
ducted by the clinics included 11,114 sputum tests, 
15,616 biological tests, and 32,296 radiological 
examinations, The homes of 49,611 patients were 
visited, and 28 per cent. were condemned as un- 
hygienic, while 70 per cent. were found to be over- 
crowded—i.e., more than three people living in one 
room. Of the gravely ill patients only 33 per cent. 
had a room to themselves, and 16 per cent. of them 
had to share even their beds. The amelioration of 
these conditions is the chief aim and work of the 
clinics. | 
RECENT LOSSES IN THE MEDICAL FACULTY 

Prof. Constantin Bucura, the eminent gynco- 
logist, has died suddenly at the age of 62. Prof. 
Bucura, who was of Greek descent, and held the 
position of chief of the department of gynecology 
at the Vienna Polyclinic, where he attracted many 
students from the Balkan cities. He first won recog- 
nition with his work on the theory of conception and 
fertility, but his most recent researches dealt with 
cancer of the uterus and ovaries. The death is also 
reported of Dr. Norbert Dohan who fell a victim to 
an affection of the blood as a result of his work as 
chief radiologist of the “ Krankenkasse.” Dr. Fritz 
Passim, director of the Children’s Hospital of the 
second district of Vienna, has also died at the age 
of 67. He was well known as a bacteriologist and 
for his research work in tuberculosis, especially 
tuberculous meningitis. 


SCOTLAND 


(FROM OUR OWN CORRESPONDENT) 


EDINBURGH ROYAL 


THE ambitious extension and reconstruction 
schemes undertaken by the management of the 
Royal Infirmary of Edinburgh are causing con- 
siderable anxiety to their promoters. In the annual 
report for the year ending Sept. 30th, 1935, the 
managers point out that £150,000 is still required to 
complete the scheme. A further appeal will shortly 
have to be made to the public for the necessary funds. 
The new maternity wing is rapidly taking shape, and 
the foundations of the new nurses’ home have been 
laid. It is hoped that the full scheme will be com- 
pleted by Whitsunday, 1937, when the management 
have promised to take over the functions of the 
Edinburgh Royal Maternity and Simpson Memorial 
Hospital. The large new block near the west gate, 
which is almost finished, is to be used for the treat- 
ment of diseases of the skin and venereal diseases, 
and the wards at present devoted to the treatment of 
these diseases will be converted into surgical wards 
to help relieve the ever-increasing surgical waiting- 
list. Reconstruction of the boiler-house is to cost 
£22,000, and new X ray apparatus will cost over 


INFIRMARY 


‘ 


110 ‘THE LANCET] 


£10,000, for the X ray equipment, which was the best 
obtainable in 1926, is now out of date and will have 
to be scrapped. The number of patients treated 
during the year as in-patients was 20,695 (daily 
average 936), while the 67,583 new out-patients seen 
during the year represented an increase of 791 over 
the previous year’s figure. Motor accident cases 
admitted to the wards numbered 366, and half the 
cost of maintenance of these cases was recovered 
from insurance companies. The managers report a 
satisfactory increase in ordinary income. The deficit 
on the ordinary account amounts to only £28,000, 
but to this must be added the deficiency on auxiliary 
institutions, and sums amounting to nearly £27,000 
which were expended under the heading of extra- 
ordinary expenditure, making a total deficit of over 
£61,000. Fortunately nearly £75,000 was received in 
the form of free legacies during the year, and bequests 
for endowment purposes amounted to over £18,000. 
In conclusion the managers point out that the large 
additions being made to what is already the largest 
voluntary hospital in Britain must lead to a con- 
siderable increase in the annual expenditure, 


IRELAND 


(FROM OUR OWN CORRESPONDENT) 


TUBERCULOSIS IN CATTLE 


A YEAR or two ago Dr. James Ryan, Minister for 
Agriculture in the Irish Free State, held out hope 
that in his work of reducing the number of surplus 
cattle in the country, special attention might be 
given to the elimination of tuberculous stock. Last 
week he informed a congress of the Irish Dairy 
Shorthorn Breeders’ Society that such a scheme was 
impracticable. His reasons are somewhat puzzling. 
On the one hand he maintained that there is no need 
for alarm in regard to tuberculosis, and stated that 
the investigations that had been carried out had 
shown that things were not nearly as bad in their 
herds as they had feared. On the other hand, he 
said that the elimination of tuberculosis would cost 
millions of money, would require more veterinary 
surgeons than they had in the country, and would 
take many years to accomplish. It is difficult to 
reconcile these statements. Dr. Ryan’s opinion 
that there is no need for alarm in regard to tuber- 
culosis will not carry conviction. The thousands of 
tuberculous children in the hospitals throughout 
the country as the result of drinking tuberculous 
milk speak too loudly in reply. 


ee re ar. 


PARIS 
(FROM OUR OWN CORRESPONDENT) 


MEDICAL PRIZES AND AWARDS 


THE French Academy of Medicine is the judge and 
donor of many prizes for the advancement of medical 
science. This year it has awarded 52 such prizes. 
At a meeting of the Academy of Medicine on Dec. 10th, 
a report was presented on the prize-winners for 
1935. It is curious how varied are the conditions 
laid down by the donors for the winning of these 
prizes. The Ernest Guérétin Prize is awarded to 
the authors of works based on clinical observations 
made on the human being, without any sort of vivi- 
section or any experience depending on animals. 
It needs no superhuman insight to fathom the 
donor’s attitude towards vivisection. His prize 
was this time shared, Dr. Antonelli, author of a 
clinical, anatomical, and radiological study of the 


IRELAND.—PARIS.—A QUESTION OF HOSPITAL ADMINISTRATION 


[JaN. 11, 1936 


‘“ poumon cardiaque au cours de l'insuffisance auricu- 
laire gauche ” receiving four-fifths of the prize, and 
Dr. Liège the remainder for his study of the indications, 
results, technique, and accidents of blood trans- 
fusion. The Baron Larrey Prize for the best work 
on medical statistics was also divided last year, 
between Dr. Fricker for his study of the Schick reaction 
and its relation to endemic diphtheria in France, 
and Dr. du Bourguet for his study of penetrating 
wounds of the abdomen. The Lefèvre Prize for the 
best work on melancholia was not awarded, an 
etiological and clinical study of Morel’s melancholia 
being considered worthy of honourable mention, 
but no more. Applicants for such prizes must send 
in their theses to the Secretariat of the Academy of 
Medicine before March Ist of the year in which the 
prize is to be awarded. The text must be in French 
or Latin, and the Academy of Medicine is the sole 
judge. For some prizes the applicants must be 
anonymous; for others, anonymity is optional; 
and for others, again, it is forbidden. For some 
prizes only printed works are considered. With 
certain important exceptions, foreigners as well as 
Frenchmen are eligible. 


A QUESTION OF HOSPITAL 
ADMINISTRATION 


For nearly a year there has been disagreement 
between the hospital authorities and the majority of 
the honorary medical staff of the Bermondsey Medical 
Mission Hospital for Women and Children on a 
matter of principle. The disagreement has now 
culminated in the resignation of the members of 
the honorary staff. We understand that in February, 
1935, six members of this staff sent a letter to the 
hospital committee making a recommendation, con- 
cerning an appointment to the resident medical 
staff, which was disregarded by the hospital com- 
mittee who disapproved of this method of approach. 
After prolonged discussion and correspondence the 


. members of the honorary medical staff came to the 


conclusion that there were certain unsatisfactory 
features in the organisation of the hospital. For 
example, there was no provision for a medical com- 
mittee of members of the active staff, and medical 
appointments to this staff and decisions on medical 
matters were often made without consultation with 
the honorary staff. During the course of the dis- 
cussions it was indicated to the six members of the 
staff that the medical director of the hospital pro- 
posed to close those departments of the hospital 
for which these six members were responsible. Mem bers 
of the honorary medical staff then asked that the 
administration of the hospital should include a 
medical committee formed of the medical director and 
the active members of the honorary staff, for the 
purpose of advising on medical matters, including 
appointments to the staff. It was intimated on 
behalf of the hospital authorities that this suggestion 
was unacceptable. The six members finally resigned 
from the hospital staff in October, 1935, because they 
considered the existence and recognition of a medical 
committee with the usual functions to be essential 
in the interests of the hospital and its patients, and 
they were given the fullsupport of their colleagues 
on the honorary staff. 

The Bermondsey Medical Mission Hospital was 
founded in 1904 and rebuilt in 1928. It is staffed 
entirely by women doctors, and contains 20 beds and 
two private wards for paying patients. 


THE LANCET] 


(san. 11, 1986 111 


OBITUARY 


THOMAS HENNESSY, F.R.C.S.1., D.P.H. 


Dr. Thomas Hennessy, who died suddenly in 
Dublin on Thursday, Jan. 2nd, was well known in 
the political and medical world. He was Irish 
secretary of the British Medical Association and 
arrived at his office as usual in the morning. After 
attending to correspondence he called at a neighbour- 
ing Office where he collapsed and breathing ceased. 
He had suffered for many years from myocardial 
weakness and had long anticipated a sudden end, 
although his general condition recently had. not 
given rise to any immediate anxiety. 

Thomas Hennessy was born 65 years ago in 
Limerick, and received his medical education in Queen’s 
College, Cork, and took the Irish double diploma in 
1894, having as a student distinguished himself as 
a Rugby football player. In 1898 he was admitted 
to the fellowship of the Royal College of Surgeons 
in Ireland, and in 
1902 he obtained 
from the College 
the Diploma in 
Public Health. 
He started as a 
country practi- 
tioner and then 
acted for a long 
period as dispen- 
sary medical officer 
of the Clogheen 
district, Tipperary, 
where he made him- 
self a fine and more 
than local reputa- 
tion. He was an 
able and particu- 
larly sympathetic 
practitioner and as 
a result of his 
strenuous work in 
practice he deve- 
loped the cardiac 
weakness which 
shortened his life. From the time of his entry to the 
profession he became interested in medico-political 
affairs; he was an active member of the council of 
the Irish Medical Association, and in the special 
struggles which lay before the Irish medical profession 
on the introduction of the first National Health 
Insurance Bill, Hennessy was recognised as one of the 
most capable and energetic leaders. When, just 
before the war, the B.M.A. decided to establish a 
secretariat in Ireland Hennessy was offered the 
position of secretary, and though loth to leave practice, 
was influenced by his delicate condition of health 
to accept the post, which he held to the end of last 
year when he took up the duties of medical secretary 
to the Irish Medical Union which replaces both the 
LM.A. and the B.M.A. in the Irish Free State. His 
energy and capacity were notable in his official business 
and undoubtedly his long experience as a country 
doctor fitted him for dealing with the problems which 
came before him, such as, for example, the settlement 
of the dispute between the medical profession and 
the National Health Insurance committees concerning 
the certification of insured persons and their title 
to benefit. The remuneration of the medical pro- 
fession and the conditions of a poor-law medical 
service also presented difficulties in which Hennessy 
proved to be as reasonably conciliatory as he was 


DR. HENNESSY 


strong in advocacy of what he considered right. 
It was mainly owing to his personal influence that 
these struggles terminated satisfactorily, if not 
completely so, for the medical profession. The War 
Office was also indebted to his administrative work 
on the medical war committees, for undoubtedly the 
part that he played at the deliberations of these 
bodies led to considerable recruiting of young Irish 
men to military service of the Crown. It goes without 
saying that to such a man individual practitioners 
in difficulty would often turn for advice, and over and 
above his official work he was hugely occupied in 
giving advice to junior medical men who found 
themselves in difficulties, when it was characteristic 
of him that he gave his assistance without inquiring 
if those who sought it were members of the bodies 
to which he was secretary. . 

All this official work led to no narrow concentration 
on the professional side of the many questions that 
came before him. On the contrary, Hennessy 
always had as his main object the welfare of the 
public, so that it came about that he was not only 
the champion of the medical profession in movements 
for redress of general grievances and the confidential 
adviser to numerous individual medical men, but 
also was the persistent advocate of all movements 
to improve public conditions and promote public 
health service in Ireland. He may be regarded as 
having been the father of modern health reform in the 
Irish Free State. It was mainly through him that 
the Irish public health council was established in 
1919 and all subsequent health reforms may be 
regarded as having been placed in his hands. He 
entered general politics in a noticeable manner, being 
elected to the Dáil in 1927 for South Dublin on the 
vacancy caused by the death of the Countess 
Markieviez. While a member of the Dáil he took a 
prominent part in public affairs. He was a convinced 
Nationalist and gave his support to the Cosgrave 
party on the formation of the Irish Free State, and 
in coöperation with the late Sir James Craig paid 
particular attention in the Irish Parliament to 
matters concerning health. He was twice elected 
to the South Dublin seat and his common sense, 
honesty, and generally sympathetic attitude were 
so manifest that there was general regret when he 
lost his seat some six years later. 


Our Dublin correspondent writes: ‘‘No account 
of Hennessy’s public work will convey to those who 
did not know him a due impression of his winning 
personality. Honourable, broad-minded, far-seeing, 
nothing really roused his anger but intrigue or 
unfairness. He would shock his party colleagues by 
his frank denunciation of policy of which he dis- 
approved. A hearty lover of his own country he had 
no ill-will to any other country. His judgments 
were sometimes impulsive but always independent 
and generous. A strong party-man he would often 
see little good in the other party, in which neverthe- 
less he had invariably many personal friends, and 
even in sharp controversy he would disarm 
hostility by a joke or a smile. A born fighter he 
never fought but in what he held to be a right cause 
and never for himself. In recent years his health 
sometimes gave rise to anxiety and he knew that his 
life was uncertain, but his courage and activity did 
not fail. He died as he would have wished, but his 
sudden leaving is a grave loss to the profession to 
which he gave his best energies and to his country as 
a whole.” 


112 THE LANCET] 


OBITUARY 


[yan. 11, 1936 


GEORGE DOUGLAS MATHEWSON, B.Sc., M.B., 
B.Ch., F.R.C.P. Edin. 

Dr. George Mathewson, who died on New Year’s eve, 
was the son of Mr. James Mathewson, of Dunfermline, 
and received his medical education at the University 
of Edinburgh, where he was Mouat scholar and 
graduated in 1905 as B.Sc., and M.B., Ch.B. He 
acted as house surgeon at the Royal Hospital for 
Sick Children, Edinburgh, and house physician at 
the Royal Infirmary, where he was also clinical 
tutor in medicine. He was appointed assistant 
physician to the Leith Hospital and later filled 
the same post at the Royal Infirmary, while he was 
also physician to the Royal Public Dispensary in 
Edinburgh. Elected F.R.C.P. Edin. in 1912, he 
became lecturer in clinical medicine in the University 
of Edinburgh and full physician at the Leith Hospital 
and at the Royal Infirmary. Both the University 
of Edinburgh and the Royal Infirmary have lost in 
him a distinguished colleague and able teacher, 
while his infrequent writings showed the special 
direction of his studies as a cardiologist, which were 
recognised also when he became responsible for the 
organisation of a cardiological department at Salonika 
during his period of war service. He was a member 
of the Association of Physicians of Great Britain. 


Mr. J. M. Graham, Ch.M., F.R.C.S. Edin., has 
sent the following appreciation of his colleague :— 
“The death of George Mathewson has come as a 
great blow to the medical profession in Edinburgh. 
His friends knew that he had successfully passed the 
crisis of a serious attack of pneumonia. He was 
apparently well on the road to recovery when, on 
the last night of the past year, the blow fell, and it 
was learned that he had suddenly passed away. 
Although only promoted to be one of the senior 
physicians at the Royal Infirmary 18 months ago, 
he had already during his years of service as assistant 
physician, and as physician to Leith Hospital, 
established his reputation as a consultant, and as 
a teacher of clinical medicine. Those of .us who 
knew Mathewson as a student at Edinburgh 
University, felt that he would be successful in what- 
ever branch of professional work he adopted. Even 
as a senior schoolboy he had the ability and character, 
which, without any strong effort on his part, led 
him to the top of his class. His medical work was 
on the same high plane, and it was characteristic 
of him that it should be accomplished easily and with 
no apparent strain. Above all, he enjoyed his 
hospital work, and his contact with students. No 
one could have shown more consideration for the 
feelings of his patients. Mathewson’s first and last 
thought was for the individual he was treating. 
That his patients appreciated his kindly methods 
was obvious to any one who accompanied him during 
a ward visit. The research work which Mathewson 
carried outin the clinical laboratory of the Royal 
Infirmary established his reputation as an authority 
on the physiology and clinical pathology of the heart. 
His special knowledge in this branch of medicine was 
recognised when, during his period of war service, 
he was nominated to organise a cardiological depart- 
ment for the Salonika Army. Although Mathewson 
did not contribute regularly to medical literature, 
what he did write was always original and a definite 
contribution to knowledge. He was the last man to 
‘cultivate’ a reputation. At staff and medical 
meetings he did not speak often, but his remarks 
were always very much to the point. His ideas were 
clear and concise, speaking came easily to him, and 
he had a flair for the ‘right word.’ He had a natural 


gift for teaching, and enjoyed the appreciation of his 
students. In his own student days the teaching 
of clinical medicine in Edinburgh had reached a 
very high standard ; Mathewson had already shown 
that he was well equipped to maintain this fine 
tradition. Nothing gave him greater pleasure than 
the knowledge, just before his last illness, that his 
ward team had reached the final in the Old Residents 
Cup Rugby Competition. | 

“ Mathewson was always on the best of terms with 
his colleagues, and with those working under him. 
He was genuine and loyal in his friendships. He 
looked back with special pleasure on his period of 
war service in Macedonia, where many new friends 
were made and old friendships were confirmed. 
He was at his best as an active member of several 
of the famous Edinburgh medical dining clubs. 
For many years he had been one of the leading spirits 
in the Centenarian Club, and by none will he be missed 
more than by his fellow members. His reputation 
for wit and repartee was acclaimed when he was 
appointed secretary of the Medico-Chirurgical Club. 
His minutes at the biennial dinner were looked forward 
to as the chief entertainment of the evening. It 
was a pleasure to meet Mathewson in his own house. 
He was an ideal host. His intimate friends knew 
how perfectly happy he was in his home life. To 
his widow and to his children, a daughter and a 
son, all will offer heartfelt sympathy.” 


EDMUND VALENTINE GIBSON, M.D. Edin. 

THE death occurred on Dec. 23rd of Dr. E. V. 
Gibson, of Grange, Guernsey, where he had been in 
practice for many years. Born in Derbyshire in 
1865, the son of the Rev. A. A. Gibson, of Stanley, 
he was educated at Trent College and entered the 
University of Edinburgh as a medical student. He 
graduated as M.B., C.M. Edin. in 1890 and in the 
same year. was appointed house surgeon to the 
General Hospital, Birmingham. Thereafter he held 
resident posts at the East London Children’s Hospital, 
at the Devonshire Hospital, Buxton, and was for a 
time resident medical officer to the Victoria Infirmary, 
Glasgow. At different times while holding hospital 
appointments he made interesting clinical com- 
munications to THE LANCET, for he was a very 
competent and well-informed man. He then, some 
forty years ago, established himself in practice at 
Guernsey, was appointed surgeon to St. Peter’s Port 
Hospital and to other institutions on the island, and 
conducted a large practice, latterly in association 
with his nephew, Dr. R. E. Gibson, and his son-in-law, 
Dr. W. B. Fox. During the war he served with the 
rank of surgeon-major in the lst Royal Guernsey 
Light Infantry. Dr. Gibson had been a great athlete 
during his university days, and in later years became 
an enthusiastic horticulturist, possessing at his villa 
“ Paradis? a remarkably beautiful garden. He 
was 70 years of age at his death and was on the eve 
of retirement. 


MARY CHESNEY, M.B., Ch.B. Edin., 
D.P.H. Durh. 

THE death took place at the close of the year in 
Palma de Majorca of Dr. Lilian Chesney, who for a 
time practised in London as a throat and nose 
specialist. She was the youngest daughter of General 
Sir George Chesney, author of the famous skit ‘“‘ The 
Battle of Dorking,” and received her education in 
Edinburgh where she graduated M.B., Ch.B. in 1899, 
afterwards taking out post-graduate courses at 
Vienna. She held clinical and residential appoint - 
ments in various institutions before deciding to 


LILIAN 


THE LANCET] 


PANEL AND CONTRACT PRACTICE 


[yan. 11, 1936 113 


practise as a laryngologist, and obtained the D.P.H. 
Durh. in 1908. On the outbreak of war she went as 


assistant surgeon with the Russian Unit of the - 


Scottish Women’s Hospital and was decorated with 
the orders of St. Anne and St. Sava. Later she acted 
as surgeon to the Serbo-English field hospital and 
recorded her experiences in the Practitioner in 1916, 
especially with regard to typhus fever. In 1920 she 
went to live in Majorca and from there communicated 
her impressions to the Practitioner of the Balearic 
Islands as a health resort. Dr. Lilian Chesney, who 
had many friends in England, promoted that habit 
of visiting the Balearic Islands for health and holiday 
purposes, which seems now to be firmly established. 


JAMES DUNCAN HART, M.C., M.D.,D.P.H.Glasg, 


THE death occurred on Dec. 18th of Dr. James 
Duncan Hart, of North Walsham, Norfolk. A Glasgow 
man, he was educated at Fettes College and the 
University of Glasgow, where he graduated as M.B., 
‘Ch.B. in 1905. After some post-graduate work at 
Bonn he served as medical officer to a group of tea 
. estates in Assam, but at the outbreak of war returned 
to be attached to the 12th Battalion of the London 
Regiment, and for his war service was more than 
once mentioned in despatches and -awarded the 
Military Cross. He then settled at North Walsham 
where he was a member of the staff of the War 
Memorial Cottage Hospital, a keen supporter of the 
St. John Ambulance Brigade, and took a prominent 
part in the social life of the neighbourhood. His 
death, which occurred suddenly at the age of 52, 
was deeply regretted in the neighbourhood as was 
manifested by the large attendance at the funeral. 


ROBERT TURNER, M.D. Aberd., F.R.C.S. Edin. 


THE death is announced of Dr. Robert Turner at 
his residence in Llandudno, where he had retired after 
many years’ practice in Bootle. Born in Banff, Dr. 
Turner received his medical education in Aberdeen 
and Liverpool. He graduated as M.B., C.M. Aberd. 
in 1894 and later proceeded to the M.D. degree, 
acquiring also the diploma of F.R.C.S. Edin. Shortly 
afterwards he started in practice in Bootle, where 
he attained success through his skill and his devotion ` 
to his work. He also took an active interest in the 
civic affairs of the borough and acted as mayor of 
Bootle in 1923-24. He had only recently retired 
from practice and was in good health until a sudden 
illness, necessitating operation, proved fatal, in his 
sixty-sixth year. 


JAMES HARRISON, M.R.C.S. Eng., L.S.A. 


Dr. James Harrison of Garstang died on his seventy- 
eighth birthday on Dec. 28th. He was educated at 


‚Windermere College and proceeded to St. Bartholo- 


mew’s Hospital for his medical training, qualifying in 
1879 as M.R.C.S. Eng., L.S.A. After a short period 
of service at the Blackburn Infirmary he settled in 
Garstang over 50 years ago and took a prominent 
part in the public and social life of North Lancashire 
for nearly half a century. He was a member of the 
Garstang rural council for many years and served as 
a representative on the Lancashire county council. 
Shortly after retiring from practice some 15 years 
ago he was appointed a magistrate for the county, 
sitting on the same bench at Garstang with one of 
his daughters, also a county magistrate. 


PANEL AND CONTRACT PRACTICE 


Light Treatment as Medical Benefit 


As a rule when an insurance practitioner administers 
light therapy he can charge the patient for it and, 
upon submitting form G.P. 45 to the insurance com- 
mittee, no question is raised as to its being a specialist 
treatment. Provided the practitioner satisfies the 
local medical committee that he has the necessary 
qualifications he retains the fee he has charged. 
It may well be argued that the degree of skill required 
for the administration of light treatment is not beyond 
the scope of a general practitioner—it must be 
remembered that the treatment which a practitioner 
is required to give to his patients comprises all proper 
and necessary medical services other than those 
involving the application of special skill and 
experience of a degree or kind which general practi- 
tioners as a class cannot reasonably be expected to 
possess—but it is not every practitioner who possesses, 
orcan reasonably be expected to possess, the apparatus 
for applying light treatment. While too it is a 
truism that every case is dealt with on its merits and 
that a decision on a particular case does not necessarily 
enunciate a principle, it is equally clear that a decision 
on a case may establish a presumption that the 
service is or is not within the scope of a practitioner's 
obligations, as for example the treatment of varicose 
veins by sclerosing fluid, and it is probably this 
reason which has led local medical committees to 
regard light treatment as outside the scope of medical 
benefit. 

The Croydon local medical committee, however, 
are taking rather a different view, and in fact a few 
years ago decided that six cases of electrical treatment 


were not of a specialist character. That committee, 
in respect of two recent cases of sunlight treatment, 
have given their unanimous opinion that the service 
in question was not of a kind which involved the 
application of special skill or experience of a degree 
or kind which general practitioners as a class cannot 
reasonably be expected to possess. The grounds 
upon which their opinion is based are that while in 
certain cases electrotherapy would have to be regarded 
as a specialist service the treatment referred to in 
these cases is not within that category as, with the 
modern apparatus now available, any practitioner 
can reasonably be expected to perform such service. 
The insurance committee have concurred in the view 
of the local medical committee and the insured persons 
concerned will have their fees repaid to them. 

The Insurance Acts Committee have already given 
their view that the general practitioner must be 
expected to keep reasonable pace with advances in 
medical science and, in a letter, they go so far as to 
indicate that ultra-violet ray treatment is not 
necessarily a specialist treatment, but that the 
question whether in particular cases the service is 
within the scope of a practitioner’s agreement can 
only be decided in the full light of all the local 
circumstances. Most committees still hold that light 
treatment is outside the scope of medical benefit. 


More Friendly Guidance 


In another of what he calls his “written chats ” 
the clerk of the London insurance committee 
devotes three paragraphs to the evergreen subject 
of medical records. While congratulating practitioners 
upon the improvement in the return of these 


114 THE LANCET] 


THE SERVICES. 


(san. 11, 1936 


documents he rather cunningly takes advantage of 
the opportunity to indicate that the cases of ten 
particularly bad offenders have had to be referred 
to the medical service subcommittee. Then follows 
a reminder about the immediate transmission of 
records upon the death of insured persons. Practi- 
tioners are required in such circumstances to forward 
the medical record at once, without awaiting a formal 
notification from the committee, but the name of 
the deceased is not removed from their list until the 
fact of the death has been verified by the approved 
society. The action of some practitioners in refraining 
from sending in the records of persons known to be 
dead means in effect that they are claiming credits 
in respect of persons for whose treatment they are 
no longer responsible, and, what is worse, in respect 
of whom the practitioners’ fund is receiving no money. 
But the question may be asked whether a record should 
be sent in if the patient has died while not under the 
care of the practitioner. Certainly it should, even 
if the endorsement has to be ‘‘said to have died in 
hospital’ because, as indicated above, the fact of 


death has to be verified before other action is taken 
by the committee. Sometimes the first intimation 
received by the practitioner is the form G.P. 34, but in 
other cases he will know of the death long before the 
society or the committee does. 

The letter goes on to remind practitioners of the 
desirability of notifying acceptances at frequent 
intervals—the terms of service prescribe ‘“‘ within 
seven days.” The practitioner who sends in no 
acceptances at all during the quarter and then on 
the last day sends over 50 is making things hard for 
himself and putting sand in the mechanism of the 
Act. On prescribing appear two little notes which 
almost deserve to be called wise-cracks: (1) don’t 
issue prescriptions on the committee’s form to persons 
about whose title to benefit you have doubt, and 
(2) if you wonder whether you may properly pre- 
scribe a particular preparation don’t ask the patient 
or the chemist to inquire. ‘‘ We try,” says the clerk, 
“to reply tactfully to inquiries by insured persons, 
but this is a matter which should be dealt with. 
between the doctor and the committee direct.” 


THE SERVICES 


ROYAL NAVAL MEDICAL SERVICE 


Surg. Comdrs. to Surg. Capts.: J. A. O’Flynn, G. V. 
Hobbs, and J. G. Boal. 

Surg. Comdr. (retd.) A. A. Sanders, O.B.E., to rank of 
Surg. Capt. (retd.). 

Surg. Lt. A. K. Stevenson to rank of Surg. Lt.-Comudr. 

Surg. Lt.-Comdrs. (D) to Surg. Comdrs. (D): E.G. Adams, 
F. R. P. Williams, T. E. Brevetor, and J. L. Edwards. 

Surg. Comdrs. K. A. I. Mackenzie to President for 
course, H. L. Douglas to Titania, M. Barton to Apollo 
(on commg.), and J. C. Sinclair to President IV. 

Surg. Lt.-Comdrs. G. Phillips to President for course, 
and A. N. Forsyth to Victory for R.N.B., to Boscawen 
for H.M. Naval Base, Portland, and to Drake for R.N.B., 
addl. 

Surg. Lt. T. McCarthy to President for R.A.F. Medical 
Officers’ course. 


ROYAL NAVAL VOLUNTEER RESERVE 


Surg. Lt.-Comdrs. to Surg. Comdrs.: G. McCoull and 
St. G. B. D. Gray. 

Surg. Lt. A. E. Williams to Royal Sovereign. 

Surg. Sub-Lt. R. V. Jones to Victory for R.N. Hosp., 
Haslar, for training. 


ARMY MEDICAL SERVICES 


Col. C. R. Millar, D.S.O., late R.A.M.C., having attained 
the age for retirement, is placed on ret. pay. 
Lt.-Col. J. C. L. Hingston, from R.A.M.C., to be Col. 


ROYAL ARMY MEDICAL CORPS 


To be Bt. Cols.: Lt.-Cols. J. A. Manifold, D.S.O., 
and B. Biggar. 

Maj. E. A. Sutton, M.C., to be Lt.-Col. 

Short Serv. Commissions: Lts. R. S. Vine and J. E. 
Jameson to be Capts. Capt. L. E. Odlum resigns his 
commn. 

SUPPLEMENTARY RESERVE OF OFFICERS 


Capt. R. W. Agnew resigns his commn. 


TERRITORIAL ARMY 


Col. L. A. Harwood, T.D., from 56th (Ist Lond. Div.), 
is apptd. A.D.M.S., The Lond. Div. 

Maj. J. Melvin, M.C. (late R.A.M.C., Militia), to be Maj. 

Capt. R. W. Agnew (late R.A.M.C., Supp. Res.) to 
be Capt. 

Capt. C. M. Forbes to be Maj. 

To be Bt.-Majs.: Capts. R. W. Gemmell, E. C. Wood- 
head, J. E. McCartney, and T. F. Arnott. 
. Lt. R. M. Allardyce to be Capt. 

Capt. D. R. W. Burbury relinquishes the appt. of 
Divl. Adjt. 47th (2nd Lond.) Div. and Sch. of Instn. 


Capt. D. C. McC. Ettles, from 56th (lst Lond.) Div., 
to be Divl. Adjt., Lond. Div. and Sch. of Instn. 

Supernumerary for service with the O.T.C.: G. E. Gray 
(late Offr. Cadet C.S.M., Queen’s Univ. Belfast Contgt. 
(Med. Unit), Sen. Div., O.T.C.) to be Lt. for duty with the 
Med. Unit of that Contgt. 


ROYAL AIR FORCE 


Wing Comdr. J. Rothwell to R.A.F. Station, Manston, 
for duty as medical officer. 

Flight Lt. L. Freeman is promoted to the rank of 
Squadron Leader. 

Dental Branch.—Flying Ofir. 
promoted to the rank of Flight Lt. 


W. V. A. Denney is 


INDIAN MEDICAL SERVICE 


Col. A. W. M. Harvey to be Maj.-Gen. 

Lt.-Col. S. G. S. Haughton, O.B.E., to be Col. 

Lt.-Col. B. C. Ashton to be Bt. Col. 

The undermentioned officers retire: Col. C. A. Gill and 
Lt.-Col. J. D. Sandes. 


(For New Year Honours in the Services see THE LANCET, 
Jan. 4th, p. 60.) 


COLONIAL MEDICAL SERVICE 


The following have been appointed medical officers, 
West Africa: Dr. G. T. Balean, Dr. D. L. Cran, Dr. C. A. 
McComiskey, Dr. J. L. McLetchie, and Dr. W. R. Phillipps. 
Dr. W. T. C. Berry has been appointed medical officer, 
Nyasaland; Dr. I. T. Dickson, medical officer, Malaya ; 
Dr. J. F. Jarvis, medical officer, Tanganyika; and Dr. 
F. J. Wright, medical officer, Kenya. Dr. H. J. O’D. 
Burke-Gatiney becomes senior pathologist, Tanganyika ; 
Dr. H. Fairbairn, sleoping-sickness oflicer, Tanganyika ; 
Dr. G. Maclean, deputy director of medical services, 
Tanganyika; Dr. A. Rankine, director of medical services, 
Trinidad ; and Dr. H. C. Towell, medical officer, Uganda. 


DEATHS IN THE SERVICES 


The death occurred on Dec. 3lst, at Cacrleon, Mon- 
mouthshire, of Lieut.-Colonel WILLIAM ALBERT MORRIS in 
his 79th year. He was educated at King’s College, London, 
and qualified L.S.A. 1879, L.R.C.P. Edin. 1880. Two years 
later he joined the R.A.M.C., becoming major in 1894 and 
colonel in 1902. He served in Burma in 1886-87, and on 
the North West Frontier (Tirah) in 1897-98. He retired 
in March, 1912, but was re-employed during the European 
war. A frequent contributor to the medical press 
Colonel Morris is best known as editor of the ‘‘ Treatise 
on the Transport of Sick and Wounded Troops,” written 
by Surg.-General Sir Thomas Longmore. | 


THE LANCET] 


[san 11, 1936 115 


CORRESPONDENCE 


HYPERVITAMINOSIS D 
To the Editor of THE LANCET 


Sm,—In connexion with this subject, and Dr. 
Thatcher’s paper thereon in last week’s issue of 
THE LANCET (p. 20), attention may be directed to 
an investigation by L. L. Madsen, C. M. McCay, and 
L. A. Maynard on Synthetic Diets for Herbivora, 
with special reference to the Toxicity of Cod-liver 
Oi, which may not be generally accessible. Sheep, 
goats, rabbits, and guinea-pigs were fed on a “ syn- 
thetic” diet, consisting essentially of regenerated 
cellulose, starch, sucrose, yeast, salts, and lard, with 
cod-liver oil.. Upon it sheep were reared success- 
fully, goats with moderate success, but rabbits and 
guinea-pigs with much less success. Eventual 
failure in the last-named animals, and to a less 
extent in goats, was caused by the development of 
paralysis due to degeneration of the skeletal muscles, 
fatty liver being a constant finding in all species. 
It was demonstrated that the cod-liver oil was the 
chief causative agent in production of the lesions. 
It was found that for sheep and goats a daily intake 
of 0-7 g. of oil per kilo of live weight caused death 
within 93 days, 0°35 g. within 226 days, and only 
when the oil ration was reduced to 0-1 g. was no ill- 
effect produced. 

The authors state that, while furnishing no evidence 
applicable to the human species, the results should 
serve to re-focus attention on the reports of Agdubhr. 
Mouriquand and Michel? have also reported a 
relationship between cod-liver oil intake and the 
development of scurvy, the oil apparently in some 
manner ‘‘antagonising’’ the vitamin C. Cod-liver 
oil may not, therefore, be the entirely innocuous 
substance it is generally supposed to be. 

I am, Sir, yours faithfully, 


Greenwich, S.E., Jan. 4th. R. TANNER HEWLETT. 


‘ MORBUS BRITANNICUS ” 
NEW LABELS AND LARGE TEXT-BOOKS 


To the Editor of THE LANCET 


Sm,—Bearing in mind that text-books of medicine 
now run to a couple of thousand pages, cost a couple 
of pounds, and become “out of date” every three 
or four years, I read with gloom of Dr. Kofoed’s new 
“morbus Britannicus” which he describes in your 
last issue. Surely Dr. Kofoed has only described the 
siens and symptoms of acute vagotonia, which in 
this-case is of occupational origin, occurring in stoke- 
holds and ships’ galleys for the most part. Such a 
well-known syndrome could scarcely be called a new 
specific disease ; nor, in my opinion, can it be termed 
Britannic, since I have seen at least one very acute 
case amongst Chinese firemen, in four voyages to the 
Fast as ship’s surgeon. The etiology -as given in 
the note would seem to be indefinite: in my case 
the weather was calm but very hot, and the men 
were of good physique, neither starved nor given to 
excesses (at sea), and with only their normal lues 
infection. I have yet to learn that a salt-free diet 
can excite such fulminating symptoms, but if this is 
so then this cause did not operate, for these men ate 
plenty of salt meat, and especially salt pork, every 
day. Possibly some sudden deficiency in water 
absorption is a more probable explanation, with 


1 Cornell University Agricultural Experiment Station, 
Memoir 178, June, 1935 (Ithaca, New York). 


3 Compt. rend. Soc. Biol., 1922, Ixxiv., 1170. 


cerebral and medullary stasis. The late Prof. W. E. 
Dixon was wont to remark that the blood was geared 
for albumin, sugar, and salts. It is not, however, 
geared for water, especially during heavy labour in 
stokeholds and galleys, with great loss of body fluid. 

Dr. Kofoed mentions some of the other causes of 
the acute vagotonic syndrome, but others also are 
well known—psychical, inflammatory, reflex, and 
toxic—as in some cases of death in the first stage of 
chloroform ansesthesia, in which the patient may die 
of vagal cardiac inhibition, like a dog. Vagotonia 
varies in degree from the stage fright of the European 
actor or examinee to the ascaris-excited acute 
abdomen of, for example, the North Borneo Murut. 
The ascaris, indeed, is an important cause of the 
acute syndrome in the tropics, a cause which Dr. 
Kofoed does not mention. The syndrome is as 
classical as that of inflammation itself: bradycardia 
followed by tachycardia; colic followed sometimes 
by diarrhea; pallor; sweating; constriction of the 
pupil followed by dilatation ; spasms of voluntary 
muscles with some rigidity of the recti which may 
later become board-like ; nausea and possibly vomit- 
ing. The spasms may be due to an extension of the 
excessive stimulation to the voluntary musculature. 
The diagnosis of the cause is facilitated by giving 
hypodermically a full dose of atropine (gr. 1/50), 
or better by washing atropine into the veins. This 
procedure quickly relieved the acute stokehold cramps 
and colic, but would have less effect when there is 
some continued peripheral stimulation. Hot salt 
baths relieve by the action of heat only, and, of 
course, no salts are absorbed from water through an 
oily epidermis. 

Would it not simplify medicine if certain unneces- 
sary and confusing labels were now discarded, and if 
new labels were reserved for new specific diseases, and 
then only given after a long probationary period ? 
Could one, in conclusion, dare the opposition of 
publishers, and plead for a standard loose-leaf text- 
book of practical medicine, compiled and revised 
annually by the most authoritative committee of 
international expert physicians, to enable us more 
easily and at less expense to see the true growth of 
medicine in its proper perspective ? 

I am, Sir, yours faithfully, 
London Fields, E., Jan. 6th. A. J. COPELAND. 


SYPHILITIC ANÆMIA OF PERNICIOUS TYPE 
To the Editor of THE LANCET 


Sir,—In your last issue (p. 24) Dr. C. R. Box and 
Dr. A. M. Gill report an instance of severe anemia of 
the pernicious type associated with, and apparently 
due to, an active syphilitic infection in an adult ; 
and they remark on the rarity of such cases. It- is 
certainly difficult to understand why, if syphilis 
can produce such a condition, more is not known 
of it. I felt the force of this dilemma some three 
years ago in the case of a child of 5 years old with a 
strongly positive Wassermann reaction and a com- 
paratively severe hypercbromic anwmia. Rapid 
recovery occurred with no medication other than 
mercurial inunction. As there was no evidence to 
sugvést the presence of a hemolytic anemia under- 
going spontaneous recovery, it was tempting to 
presume that the anemia was due to poisoning of 
the bone-marrow by the syphilitic infection. I 
could, however, find no analogous instances in the 
literature, and at a gathering of a dozen pediatric 


116 THE LANCET] 


AGRANULOCYTOSIS.—THE UNDESCENDED TESTICLE 


[JaN. 11, 1936 


physicians no one could recall having seen a similar 
case. The following is a brief account of the case :-— 


A girl, aged 5 years, was brought to the Paddington 
Green Children’s Hospital for pallor which was said to 
have been getting rapidly ‘worse for three weeks. She 
was admitted owing to her anzemic appearance. On the 
day of admission her father gave the information that 
he had had syphilis and that the patient, when an infant, 
had had a short course of treatment for the same disease. 
The girl was well-grown and well-nourished, and showed 
no stigmata of congenital syphilis. Her complexion 
was very pale, showing no bronzing of the skin, and her 
blood-serum showed no icteric tinge. Her blood W.R. 
was strongly positive. The liver and spleen were not 
enlarged. The red blood-cells numbered 2,150,000 ; 
hemoglobin, 50 per cent.; colour-index, 1:16; and the 
white count was 8500 with a roughly normal differential 
count. The film showed marked poikilocytosis, aniso- 
cytosis, and polychromasia; there were a few nucleated 
red cells. 


In this case no treatment was given except the 
inunction of a drachm of blue ointment daily. In 
ten days time the red cells had increased by over a 
million, and the hemoglobin by 30 per cent. Reticulo- 
cytosis amounted to 3-4 per cent. At the end 
of three weeks’ treatment the red cell count was 
4,420,000, and the hemoglobin was 95 per cent. 
The appearances of the blood film were those of 
normal blood. 

I am, Sir, yours faithfully, 
London, W., Jan. 4th. REGINALD MILLER, 


AGRANULOCYTOSIS 
To the Editor of THE LANCET 


Srr,—I am much interested in the article on 
agranulocytosis by Goadby, Worster-Drought, and 
Dickson in THE LANCET of Oct. 26th, 1935. The 
occurrence of meningitic symptoms, with changes 
in the cerebro-spinal fluid in this condition, recalls 
to my mind a similar condition reported four years 
earlier (New Eng. Jour. Med., 1931, cev., 1238) by 
W. Dameshek and myself. This was the first report 
of central nervous system changes in a typical case 
of so-called infectious mononucleosis. Since then 
two other cases of a similar nature have been called 
to my attention: one reported by A. H. Johansen 
(Acta med. Scand., 1931, Fasc. 3, Ixxvi., 269), the 
-other reported to me personally this fall by Dr. 
Edwin M. Cole from the Massachusetts General 
Hospital. 

It was stated in my original communication that 
-changes in: the cerebro-spinal fluid occur simul- 
‘taneously with the cerebral and meningeal symptoms 
of certain internal diseases. Further, it was empha- 
sised that symptoms referable to the central nervous 
system occur in the blood diseases, such as the leukæ- 
mias and infectious mononucleosis. The close 
parallelism between the cellular changes in the 
cerebro-spinal fluid and the changes in the leucocyte 
counts in the latter case was considered to be signi- 
ficant. It was also mentioned that there might be 
a close relationship between this disease and the 
syndrome variously called aseptic, epidemic, and 
acute lymphocytic meningitis. 

During the past few years considerable interest 
has been shown in the literature in lymphocytic 
meningitis, as well as other obscure central nervous 
system infections. This was stimulated by the work 
of Armstrong (Pub. Health Rep., 1934, xlix., 1019), 
and of Rivers and Scott (Science, 1935, lxxxi., 439), 
‘which indicates that a filtrable virus is the causative 
agent of acute lymphocytic meningitis. These 
experimental investigations tend to show that this 
-disease is a clinical entity. 


Whether or not this is a fact remains to be seen. 
However, it was stated in my original article that 
‘the concept of an aseptic meningitis is at best a 
vague one and almost as all-inclusive as the term 
encephalitis.” The concept was emphasised at that 
time that these conditions were symptomatic of 
some generalised systemic disease. The article by 
Goadby and Worster-Drought illustrates again the 
familiar phenomenon of the association of central 
nervous system changes with systemic disease. 
The etiology of agranulocytosis as well as of infec- 
tious mononucleosis is of course unknown. However, 
from the standpoint of the cerebral manifestations, 
which apparently may occur in both diseases, a 
fairly close relationship may be seen. It is conceded: 
nevertheless, that the report concerning the case of 
agranulocytosis is indicative of a chronic infection 
of the central nervous system, whereas my original 
case of infectious mononucleosis dealt with an acute 
cerebral disorder. l 

While it may be true that this report on agranulo- 
cytosis is unique in the literature, it seems to me that 
the crux of the whole situation lies in the larger 
concept of various systemic diseases of known and 
unknown etiology, giving rise to changes in the 
central nervous system. ` 

I am, Sir, yours faithfully, 
SAMUEL H. EPSTEN. 

Harvard University Medical School, Dec. 23rd, 1935. 


THE UNDESCENDED TESTICLE 
To the Editor of THE LANCET 


Sır —We read with interest Mr. Denis Browne's 
letter in your issue of Dec. 28th, in which he sug- 
gested that there are two distinct types of undescended 
testes: (1) those suffering from a delay in develop- 
ment, which would be suitable for hormone treat- 
ment, and (2) those suffering from a congenital 
deformity, in which hormone therapy is contra- 
indicated and which are amenable only to surgery. 
The hormone treatment of undescended testes being 
at present only in the experimental stage, such 
suggestions are indeed of value. 7 

It appears that one of Mr. Browne's criteria for 
classing a case as congenital deformity in which 
hormone treatment should not be undertaken is the 
presence of a hernial sac. Of the 9 cases which he 
quotes from our series as being unsuitable for hor- 
mone treatment for this reason, three (Nos. 14, 17, 
20) had no detectable hernia before treatment and 
the testes descended successfully mto the scrotum. 
Hernias developed during treatment, and operation 
will now be required for their relief. Of the remaining 
6 cases which were unsuccessful, 3 (Nos. 9, 28, 29) ` 
had palpable hernia before treatment and 3 (Nos. 27, 
30, 31) had not; thus the absence of a hernia does 
not necessarily indicate that the result will be sue- 
cessful. Nor is the failure to palpate the testes a 
sien that hormone therapy will be unsuccessful ; in 
three of the cases under discussion (Nos. 27, 28, 29) 
the testes were not palpable and the result was unsuc- 
cessful; but in patient No. 1 both testes were impal- 
pable and a successful descent of both testes was 
obtained. 

It would seem then that Mr. Denis Browne's 
suggestions do not get us much farther. We hope, 
however, that further experience of hormone therapy 
will disclose more definitely the type of case suitable 
and the type unsuitable for the treatment. 

We are, Sir, yours faithfully, 
A. W. SPENCE, 


Dunn Laboratories, St. Bartholomew’s E. F. ScOWEN, 


Hospital and College, E.C., Jan. dth. 


THE LANCET] MEDICAL EDUCATION 


PURKINJE’S EIGHT-RAYED STAR 
To the Editor of THE LANCET 


Smr,—If on awaking in the morning the eyes be 
closed and covered with the hands the centre of the 
field of vision will appear alternately as light or 
dark in accordance with its sensitisation from the 
periphery. If when the disc is light it be observed 
very carefully there will be seen in it a black eight- 
rayed star (Xk) similar to an astigmatic clock. The 
centre of the star is the centre of the field of vision. 
This corresponds to the eight-rayed star seen by that 
minutely accurate observer, Purkinje, by inter- 
mittent light and pressure on the eye. It has been 
very generally neglected, probably because of its 
artificial appearance. One of the main rays is 
vertical and another horizontal. 

I am, Sir, yours faithfully, 
F. W. EDRIDGE-GREEN. 

Board of Trade, S.W., Jan. 2nd. 


MEDICAL EDUCATION AND BLOOD 
EXAMINATION 


To the Editor of THE LANCET 


Sir,—This is an age of mechanisation, the indivi- 
dual is being superseded by the machine, and indi- 
vidualism in medicine is being submerged by specialism 
and team-work. This is no doubt a natural and 
rational development, owing to the great advance in 
medicine and its allied sciences during recent years. 
Jt is impossible for any individual to keep in touch 
with every modern development in its relation to 
medical practice, and the student of the present day 
has come to rely upon a multitude of counsellors— 
the pathologist, the bacteriologist, the biochemist, 
the radiologist, &c.—for a diagnosis. 

The great majority of students however are destined 
for general practice, and many may find themselves 
isolated in country districts, where the props upon 
which they have hitherto relied are not readily 
accessible, and they have to depend upon their own 
resources. Does the clinical training at the medical 
schools supply all the requirements of the general 
practitioner ? The average doctor, when examining 
a medical case, takes the temperature, counts the 
pulse, perhaps looks at the tongue, listens with the 
stethoscope to the heart sounds and the respiration, 
possibly takes the blood pressure, and, if there seems 
to be a special reason, examines the urine for albumin 
or sugar. If any further investigation is required, 
the patient is referred to a specialist. He certainly 
does not examine the blood, and yet the diagnostic 
value of a blood examination cannot be over- 
estimated. Without a satisfactory blood examination 
the diagnosis of the large class of blood diseases, 
which are frequently met with in practice, is impos- 
sible, and in some conditions, which are fortunately 
comparatively rare, such as agranulocytosis and 
pernicious anemia, the patient’s life may depend 
upon early diagnosis and prompt treatment. 

Leucocyte counts, total and differential, are of 
assistance in the diagnosis of acute infections, and 
additional information can be derived from the 
Ameth count, an infection of any kind, whether 
accompanied by leucocytosis or not, being associated 
from its beginning with a “shift to the left.” In 
addition to this, the leucocyte count is a valuable 
cuide in prognosis, and gives an indication of the 
course of the disease and its response to treatment, 
the necessity for operative interference in pyogenic 
infection, and the prospect of recovery. It is no 
exaggeration to say that there is no other method of 


AND BLOOD EXAMINATION 


(Jax. 11, 1936 117 


clinical examination by which so much valuable 
information can be derived. 

The technique of blood examination is simple 
and easily acquired. No elaborate equipment is 
needed : a microscope—preferably with a mechanical 
stage—a hemocytometer, a hemoglobinometer, slides, 
and a few stains, are all that are necessary. The 
process is interesting, even fascinating, and with 
practice a complete examination need not take 
much more than an hour. Why should not students 
be taught to use this method of clinical examination 
as a routine? Clinical clerks might be required to 
supply a record of the blood picture in their notes 
in every case for which they are responsible. 

I am, Sir, yours faithfully, 
Worthing, Jan. Ist. HERBERT H. Brown. 


DUODENAL ULCER TREATED WITH HISTIDINE 
To the Editor of THE LANCET 


Sık, —The following case may be of interest to 
your readers. 


The patient, a Moslem, aged about 30, reported to me 
on Jan. 30th, 1935, with “ chronic dyspepsia,” stated to 
be of six years’ duration. His history was typical of that 
of a duodenal ulcer. I had the patient radiographed for 
a barium-meal series on March 4th, and the duodenal 
cap showed an ulcer crater, which persisted after the 
stomach had emptied. From Jan. 30th to June 7th 
I treated him with alkalis and a gastric diet, without anv 
improvement; if anything his “‘hunger pains” were 
getting worse. On June 8th I started him on a course of 
24 daily intramuscular injections of histidine, using 
Hoffmann-La Roche’s Larostidin, put up in 5 ec.cm. 
ampoules. The injections are practically painless. After 
the fifth injection the patient stated that his hunger pains 
had disappeared, so I told him he could try whatever diet 
he fancied. The next day his gratitude seemed unbounded, 
as he said he was able to have a good square meal for the 
first time without any discomfort whatever. Since then 
he has eaten a normal diet and not had any trouble, 
except some flatulence occasionally. 


In my opinion this case deserves special attention 
in view of the long history, the distinct pathological 
state of his duodenum, as seen in the skiagram, and 
the quick relief obtained, which up to now (nearly 
six months afterwards) seems a permanent cure. 
I had the patient radiographed again by a barium 
meal series on Dec. 4th and there is no evidence 
whatever of the previous ulcer. My thanks are due 
to Dr. P. A. Pierce, radiologist of the Ripon Hospital, 
without whose help I should not have been able to 
obtain the evidence of ulcer and the results of the 
treatment. I am, Sir, yours faithfully, 

Simla, India, Dec. 19th, 1935. A. H. BARTLEY. 


THE BRIGHTNESS OF THE POST OFFICE 
MESSENGER 


To the Editor of THE LANCET 


Sır, —In your leading article of Jan. 4th on the 
Marriage of Public Health and Agriculture you state 
incidentally that “ H. H. Bashford reports that 
Post Ottice messengers get bigger (though not neces- 
sarily brighter) from year to year.” I think it should 
be made clear that the words between parentheses 
are editorial and not mine. [From a long personal 
experience, I have an extremely high opinion of the 
brightness of the average Post Office messenger. 

I am, Sir, yours faithfully, 
H. H. BASHFORD, 

Jan. 4th. Chief Medical Officer, G.P.O. 

* * We have the same opinion, and the inter- 
polated words are no contradiction of it, taken in 
their context.—Eb. L. 


118 THE LANCET] 


AMMONIUM CHLORIDE AS A DIURETIC 
To the Editor of THE LANCET 


Srr,—In their paper on ‘A Mercurial (Novurit) 
Suppository as a Diuretic for Cardiac Œdema ”’ 
(THE LANCET, Jan. 4th) Dr. Parkinson and Dr. 
Thomson also discuss the use of ammonium chloride 
as an adjuvant and mention that “there is difficulty 
in disguising its salty taste.” This difficulty as well 
as the other drawback frequently seen with the use 
of ammonium chloride in the ordinary form—viz., 
the occurrence of digestive disturbances—have been 
overcome by the introduction in 1930 of a preparation 
called Gelamon, which has been prepared by Halpern 
under the auspices of Saxl and Erlsbacher and which 
contains the ammonium chloride in a special form. 
The main features are the adsorption of ammonium 
chloride on gelatin which is then hardened in formalin. 
When given in this form not only is the taste of 
ammonium chloride effectively disguised but also 
there is scarcely any incidence of indigestion, as 
gelamon is not, or only to a negligible extent, decom- 
posed n the stomach. Since its introduction it has 
been used on a large scale in the First Medical Clinic 
of the University of Vienna, and on the ground of 
what I have seen in that hospital as well as in my 
private practice I can recommend it. 

Gelamon is manufactured as pastilles, each con- 
taining 0-4 g. of ammonium chloride; 15 pastilles 
daily and spread over the day should be given 
(preferably after meals) during the 48 hours preceding 
the administration of the mercurial diuretic, during 
the day of the administration, and in some cases 
also during the first day following the administration. 
Our observation has been that not only can a con- 
siderable increase in the diuretic effect be obtained, 
but that also cases which did not respond to the 


administration of a mercurial diuretic or had become 


refractory may become responsive by means of the 
use of gelamon in the way indicated. 

I have been in communication with the makers of 
gelamon for the last few months and understand 
that gelamon will be obtainable in this country 
shortly. I am, Sir, yours faithfully, 


Wimpole-street, W., Jan. 6th. A. SCHOTT. 


AN ALUMINIUM KETTLE 
To the Editor of THE LANCET 


S1r,—Might I suggest to Dr. Elwell, whose letter 


appeared in your issue of Dec. 28th, that he should 
refer to a monograph I wrote in 1931, entitled the 
“Danger of Food Contamination by Aluminium,” 
published by Messrs. John Bale, Sons and Danielsson, 
Ltd. In this he will see that I emphasised “stiffness ” 
as one of the most frequently recurring symptoms of 
aluminium artificially introduced into the system, 
and that I found this specially affected the back of 
the neck and head—similar symptoms, in fact, to 
those he describes in his patient. In the last five 
years, during which I have been working intensively 
on this subject from the clinical point of view, I have 
traced these symptoms in so many patients to 
aluminium that I can definitely assure Dr. Elwell 
that this metal was responsible in his particular case. 
I am, Sir, yours faithfully, 
R. M. LE HUNTE COOPER. 

Harley-street, W., Jan. 6th. 

*,* Dr. Elwell’s patient, who suffered from stiffness 
and pain in the back of the neck and head, had been 
in the habit of drinking daily some eight to ten 
breakfast cups of tea, the water for which was boiled 
in an aluminium kettle; and the symptoms ceased 


BRITISH POSTGRADUATE MEDICAL SCHOOL 


[san. 11, 1936 


when the kettle was no longer used. Dr. Le Hunte 
Cooper is satisfied from similar experience of his own 
that aluminium was responsible in Dr. Elwell’s case, 
and he refers to a monograph which he wrote four 
years ago. At that time we found it difficult to 
attribute the groups of symptoms he described to the 
use of aluminium cooking vessels, especially as the 
work of the American authors whom he quoted in 
support of his deductions was not confirmed either 
in the U.S.A. or in this country. Dr. G. W. Monier- 
Williams, reviewing the subject last year for the 
Ministry of Health, agreed that there may be indi- 
viduals who are susceptible even to small doses of 
aluminium, but found no conclusive evidence that 
this is so.—Ep. L. 


BRITISH POSTGRADUATE MEDICAL 
SCHOOL 


THE organisation of the British Postgraduate Medical 
School provided for a dual teaching staff. There was 
to be a permanent and whole-time staff, usually 
referred to as “ A staff,” and a visiting and part- 
time staff referred to as “‘ B staff.” ‘‘ B staff’’ were 
either to deliver courses of lectures or to take charge 
of wards for such periods as could be arranged. 
With the exception of a few lectures in the refresher 
courses, the whole work of the school since it began 
has been carried on by *“ A stafi.” 

With the beginning of the New Year a start will 
be made with the appointment of members to 
“ B staff.” To some extent the method by which 
the services of ‘‘ B staff ’’ can be utilised is at present 
experimental. It will be extended or altered in the 
light of requirements. 

In the department of medicine Lord Horder has 
agreed to take charge of a ward for a period of ten 
weeks from Feb. Ist. During this period he will 
direct the work of the ward with the assistance of the 
permanent staff, and will conduct two teaching clinics 
weekly. He will be succeeded by Lord Dawson, 
who has consented to take charge of beds from 
May lst to July 15th. These clinics will be held on 
Wednesdays and Fridays from 2—4 P.M. In addition, 
the following courses of lectures have been arranged. 
Commencing on March 2nd Dr. Gordon Holmes, 
F.R.S., will give a course of lectures on cerebro-spinal 
syphilis. Subsequent courses of lectures are to be 
given by Dr. W. S. C. Copeman on arthritis, and 
Dr. R. A. Young on non-tuberculous pulmonary 
diseases. 

In the department of surgery Prof. E. W. Hey 
Groves will commence a series of lectures and demon- 
strations on fractures on Feb. 7th. These lectures 
will be given on Fridays commencing at 2.30 P.M. 
Later in the session Sir James Walton will lecture on 
the surgical treatment of dyspepsia, Sir Henry 
Gauvain on surgical tuberculosis, and Mr. Tudor 
Edwards on thoracic surgery. Each course will 
consist of about six lectures and will include some 
practical work as well as demonstrations of cases 
and of methods of treatment. During the course on 
surgical tuberculosis visits will be paid to Alton and 
Hayling Island. Full details of these courses will 
be published later. 

During the absence of Prof. G. Grey Turner at the 
International Surgical Congress in Cairo Sir Thomas 
Dunhill and Prof. G. E. Gask are in charge of the 
surgical wards and the clinical instruction of the school. 

Colonel L. W. Harrison has been appointed 
honorary consultant in venereal diseases at the school. 


ROYAL INFIRMARY, BRADFORD.— The board of 
management intend in the near future to institute a 
dermatological department at the New Royal Infirmary, 
Bradford, in connexion with which a new appointment 


of dermatologist will be. made, 


THE LANOET] 


INTERNATIONAL SOCIETY OF SURGERY 
CAIRO: DEC. 31ST, 1935, TO JAN. 4TH, 1936 


(FROM A CORRESPONDENT) 


THE eagerly anticipated Tenth Congress really 


began when two large parties of members embarked ' 


on the Champollion and the Mariette Pacha at 
Marseilles on Boxing Day. To make contact with 
friends of other nations, to get to know those whose 
names are notable in surgery, and to discuss informally 
problems of mutual interest, is one of the most useful 
functions of gatherings of this sort; and as sailing 
conditions were ideal, the opportunity was fully used. 
In addition a certain amount of committee work was 
undertaken by the official delegates during the 
voyage. | 

The morning of the 30th found us landing at Alex- 
andria, where the British Fleet lay at anchor in the 
bay. Hereour Egyptian hosts took charge of us, and the 
sight-seeing included a visit to the great new Hôpital 
Roi Fouad I, situated on the confines of the town 
and overlooking the Mediterranean. Built of native 
stone with lavish use of marble, it is after the plan 
of the Martin Luther Hospital in Berlin and provides 
for 450 beds, of which 150 are for paying patients. 
Each of the six floors is painted a different colour 
and all the wards have hot and cold water, telephones, 
and wireless. Each of the ward floors has its operating 
suite with some novel features; but these scarcely 
seemed to compensate for the poor lighting arrange- 
ments. It was interesting to notice that most of 
the sanitary fittings and equipment had been supplied 
by British firms. The nurses are all German and 
everything was spotless. 

At Cairo the arrival of about 340 visitors all at the 
same time rather taxed the resources of some of the 
hotels, but by midnight most troubles had been 
smoothed out, lost luggage was restored to rightful 
owners, and calm reigned once more. Between 
8 and 9 next morning the bureau of the Society at 
the Medical Faculty was besieged and when regis- 
tration was completed it was found that 392 con- 
eressists, not including those from Egypt, were in 
attendance. With the notable exception of Italy 
nearly every country in Europe was represented, and 
there were members from as far afield as Australia, 
South America, Canada, Malaya, Japan, and China. 
The Russian Government sent five interested and 
active members with Dr. Limberg as delegate and 
leader. One of the members from Finland was on 
his way to join a Red Cross unit in Abyssinia. Seven 
members made up the British contingent, while Mr. 
Gordon-Taylor was expected, en passant, on his way 
home from the primary fellowship examination in 
India. Everyone regretted the absence of Prof. 
Anton von Eiselsberg, who had to forego the presi- 
dency for reasons of health. 


AN UNCEREMONIOUS OPENING 


On the morning of Tuesday, Dec. 31st, the Congress 
was otlicially opened in the great hall of the Univer- 
sity at Guizeli. This is situated some little distance 
out of the city and is a beautiful and spacious audi- 
torium which had been finished only the previous 
evening. As one approached the grand entrance it 
was obvious that something unusual was astir, for 
the vicinity was besieged by hundreds of students 
distinguished as much by their excitement and volu- 
bility as by the picturesque tarbush which they all 
wear. <A sort of catafalque, erected to the memory 
of students killed in the recent riots, had been erected 


CAIRO CONGRESS OF SURGERY 


[saAN. 11, 1936 119 


just in front of the entrance, and this was the centre 
of most of the excitement. Early comers reached 
the hall without much trouble, but late arrivals 
were considerably jostled and some of the less 
robust visitors were alarmed. Later the demon- 
stration became noisy; tremendous shouting greeted 
all new-comers ; cars were boarded and the occupants 
harangued with cries of “Down with England,” 
“ Egypt for the Egyptians,” &c. Inside the hall 
while the delegates were assembling on the platform 
there was an extraordinary incident. A student 
carrying a large coloured photograph of the students 
previously killed in the riots mounted the platform 
and holding the photograph at arm’s length called 
for a two minutes’ silence, and then exhorted the 
large body of students inside the hall who shouted 
and cheered. It struck the visitors as remarkable 
that all this was allowed to take place without the 
slightest interference from the police or officials of 
any sort. Eventually Prince Mohamed Aly Hassan 
with his suite arrived and occupied the Royal Box, 
after which the ceremony was allowed to proceed 
without much interruption, although the departing 
guests, and especially those on foot, had to run the 
gauntlet amid a vociferous mob yelling and shouting. 

But these incidents did not upset the Congress 
in any way. As president of the organising com- 
mittee, the Minister of Public Instruction welcomed 
the visitors in an appropriate speech in French, 
which was thoughtfully circulated in that language 
and in Egyptian. ALY IBRAHIM Pasha spoke as the 


dean of the faculty, while Dr. VERHOOGEN (Brussels), 


chairman of the international committee, Prof. 
DE QUERVAIN (Berne), past-president, Dr. MAYER 
(secretary-general of the Society), and Dr. SCHOE- 
MAKER (The Hague), the president, all made speeches 
outlining the work and the activities of the Society. 


SURGERY OF THE PARATHYROIDS 


After the excitement of the morning the first 
scientific session, held at two o’clock in the after- 
noon, was somewhat of a relief. The subject was 
the surgery of the parathyroids, and the reports of 
the openers BiNET (Paris), BAUER (Breslau), and 
BRAINE and CHIFOLIAN (Paris) were succinct and 
admirable. Among the supporters LERICHE (Stras- 
bourg) contrasted operations on the parathyroids 
with those on the sympathetic, and also referred to 
the importance of the possible consequences from 
interference with the blood-supply of the glands. 
His remarks were received with acclamation. JIRASEK 
(Prague) and HABERLAND (Cologne) made suggestive 
contributions, and HUSSEIN (Cairo) focused on the 
difficulty of the subject by comparing the problem 
with that of the nine blind men describing the ele- 
phant! PERERA y PRaTs (Madrid) suggested that 
in Recklinghausen’s disease of bone removal of the 
parathyroid was definitely indicated, in scleroderma 
it was useless, in polyarthritis it was of very doubtful 
value, while in Glénard's disease and muscular 
asthenia it was to be considered on its trial. In this 
discussion PLOTKIN (Moscow) also took part. 


THE SURGICAL SIGHTS OF CAIRO 


On New Year’s morning visits were paid to the 
departments of the medical school and to the 
hospitals. Among the former the anatomical and 
the pathological departments were found most 
interesting. Prof. Bernard Shaw is developing a 
very complete department in pathology with many 
new features. From about 200 autopsies a year he 
is building up complete reports with preservation of 
the naked-eye specimens and histological slides all 


120 


THE LANCET] 


CAIRO CONGRESS OF SURGERY 


[san. 11, 1936 


indexed and filed for subsequent study. The museum 
of the department is already wonderfully complete, 
and the series of case specimens and specimens with 
clinical, X ray, and microscopical records was of 
great teaching value. 

The work in the operating theatres of the Kasr-el- 
Aini Hospital was varied and interesting. Egyptian 
surgeons have a unique experience of splenectomy 
and of the complications of bilharzia. Examples of 
both conditions were dealt with skilfully and with 
proper restraint. The frequency of the Egyptian 
splenomegaly is almost certainly due to intestinal 
infection which is very common in this country. 
The results have much improved since it has become 
the practice to spend three or four weeks in pre- 
liminary treatment and to operate only when the 
enlarged spleen is an encumbrance and danger from 
its size and lability to injury. In one series of 
several hundred operations the mortality was 12 per 
cent., and in a recent consecutive series of 30 cases 
there was no death. One surgeon at another hospital 
carried out six splenectomies the same morning. 
Silk or linen thread is used for the pedicle. Provided 
that concomitant disease has been conquered the 
late results are very encouraging. 

The Kasr-el-Aini Hospital is really a fifteenth 
century building which for many years was the 
palace of the governors. After the conquest of 
Napoleon it was made into a hospital with Baron 
Larrey as chief surgeon. In recent years it has been 
altered and renovated, and with its 1500 beds it 
serves the purposes of a modern hospital very well. 
The wards are clean and bright, and the thick walls 
of the old palace and the wide central corridors help 
to keep them cool in summer. To the visitor 
unaccustomed to Eastern conditions the way in 
which the patients squat on the beds and other 
unusual attitudes are rather remarkable, but they 
seemed wonderfully content and we were informed 
that they make good patients and, generally speaking, 
put up an excellent resistance at least to operations 
and traumatisms. The senior nurses are all British- 
trained, but an additional nursing staff of Egyptian 
girls is being recruited. The new hospital on the 
Island is making rather slow progress, but the new 
out-patient department is now complete and is 
remarkably efficient. It deals with enormous numbers 
and on the day before our visit there were 3457 
attendances of which over 800 were new patients. 

LUMBAR SYMPATHECTOMY 

On Thursday the scientific session began just after 
8 A.M., the subject for discussion being lumbar 
sympathectomy. BRAENCKER (Hamburg) gave an 
excellent presentation of the anatomy, illustrated 
by some beautiful slides. LERICHE (Strasbourg) 
followed, and his well-known interest in this subject 
led him to treat of the related pathology of occlusive 
arterial diseases. GONZALES AGUILAR (Santander) 
suffered from the fact that few of the congressists 
seemed to understand Spanish. Youna (Glasgow) 
made a plea for the consideration of periarterial 
sympathectomy in properly selected cases, and 
LAMBERT ROGERS (Cardiff) made an effective con- 
tribution on clinical and anatomical grounds. Many 
of the speakers quoted experimental work in which 
arteriography had played a useful part. 

There were so many communications that the 
discussion had to be postponed until Saturday 
afternoon. | 

SURGERY OF THE COLON 


Friday’s discussion was opened by CORACHAN 
(Barcelona), GREY TURNER (London), SOUPAULT 


(Paris), and SCHOEMAKER (The Hague). There were 
no less than 52 names down as subsequent speakers, 
but, perhaps fortunately, only 19 actually turned up. 
For the most part the openers gave a general review 
of the subject, reflecting the practice of their several 
countries. There seemed to be unanimity about the 
wisdom of a suitable regimen for uncomplicated 


.diverticulosis, operative treatment being reserved 


for the complications. DE QUERVAIN (Berne) caused 
amusement by suggesting that diverticulosis seemed 
peculiarly liable to occur in diplomats! JIRASEK 
(Prague) spoke in excellent English and made his 
points very clearly. He stated that in non-malignant 
disease a permanent spasm of the distal part of the 
bowel was prone to follow an unphysiological colos- 
tomy. HABERLAND (Cologne), speaking in German, 
was equally explicit, and drew attention to a new 
form of suture for the colon. SHELTON HORSLEY 
(Richmond, Va.) showed some interesting lantern 
slides. He stressed the value of multiple stage 
operations in colonic resection, and spoke of the use 
of continuous intravenous infusions of 5 per cent. 
dextrose in Ringer’s solution and the preliminary 
use of vaccines. LEVEUF (Paris) gave a clear exposi- 
tion of the value of colectomy for aggravated colitis, 
and reported some very good results. FINSTERER 
(Vienna) was listened to with great attention while 
he related the results of a fine series of partial colec- 
tomies which he had carried out for spastic and 
other conditions of the great bowel. The results 
of hemisection, whether right or left, had been most 
satisfactory, but total colectomy had proved dan- 
gerous and unsatisfactory in his hands. One speaker 
(GREY TURNER) hit upon the idea of projecting 
short epitomes in the French language under each 
of his headings—these were interspersed between 
ordinary slides showing specimens, and seemed to 
be a satisfactory method of overcoming some part 
of the language difficulty. 


THE END OF THE CONGRESS 


On Saturday, from 8 to 12, we are promised a 
full programme of lantern demonstrations and the 
like under the auspices of a special meeting of the 
Egyptian Medical Society. The afternoon, from 
2 to 6, is reserved for presentations and reports on 
bilharzia by ALY IBRAHIM Pasha, dean of the medical 
faculty, and Nacuip Makar, both of Cairo, and a 
large number have signified their intention to take 
part in the discussion. As though that were not 
enough any discussion postponed from previous 
sessions is then to be dealt with! 

Our hosts have been most hospitable, and every 
night save one there have been banquets or recep- 
tions. The banquet of closure on Saturday, given 
by the Egyptian surgeons, will really be a welcome 
end to a strenuous though happy and useful week. 

The social side of the Congress has been well 
arranged, and besides the evening functions, like the 
President’s reception at the magnificent Palace 
Hotel in Heliopolis, trips on the Nile to the Barrages 
of the Delta and, of course, an excursion to the 
Pyramids, were thoroughly enjoyable. All the 
“sights ’ of Cairo seemed to be open on presentation 
of the membership card, and we were met by kindness 
and cordiality on every side. All who participated 
in this successful congress must be grateful to Dr. 
Aly Ibrahim Pasha and his able secretaries, Dr. 
M. Khalil Bey and Dr. M. Kamel Hussein. 


WORK OF THE INTERNATIONAL SOCIETY 


There have been long meetings of the international 
committee to discuss several problems connected 


THE LANCET] PUBLIC 


with the future of the Society. The propositions put 
forward were to create associate members with all 
the privileges of the Society but without voting 
power up to 50 per cent. of the titular members of 
each country, and to establish a journal to be 
published every two months in order to keep up the 
interest of the members in the affairs of the Society 
between the triennial meetings. On account of the 
fall in value of the frane the subscription for future 
members is to be raised to 450 Belgian francs. These 
propositions were later brought before the general 
assembly and adopted—but not without some 
opposition regarding the new journal, because many 
members felt that there were already more than 
enough. 


HEALTH 


LJAN. 11, 1936 121 


Invitations for the next congress were received 
from Russia,: Switzerland, and Austria, and it was 
eventually decided to hold the next congress in 
Vienna in 1938 under the presidency of Dr. Rudolph 
Matas of New Orleans. Prof. Sauerbruch (Berlin) 
and Dr. Hybbinette (Stockholm) were elected vice- 
presidents, while the re-election of the treasurer, 
Dr. Lorthioir, and the urbane and indefatigable 
secretary, Dr. L. Mayer, were received with acclama- 
tion. The subjects selected for discussion at the 
next congress were (1) the surgery of arterial hyper- 
tension, (2) bone-grafting, and (3) tumours and cysts 
of the lung. 

The name of Prof. Lambert Rogers, of Cardiff, 
was added to the British committee. 


PUBLIC HEALTH 


Grading of Milk by the Total Bacterial Count 


In the Medical Officer of Dec. 28th Dr. J. B. 
Howell writes of the unreliability of grading milk 
according to the total bacterial count and the test 
for coliform organisms. He finds that if he sends 
identical samples to different laboratories for total 
bacterial counts the reports are often quite different. 
In one extreme case (already quoted in our columns 
1934, ìi., 1074) two identical samples sent to the 
same laboratory produced counts of 147,300 and 
3,400,000 per c.cm., while a different laboratory 
receiving.a third sample reported that the content was 
only 9270 per c.cm. 

Anyone with experience of total bacterial counts 
on milk will not be much surprised at such results ; 
it is common knowledge that the total count tech- 
nique, which is based upon the unwarranted assump- 
tion that every colony originates from a single 
organism, is full of pitfalls. But Dr. Howell is hardly 
being fair when he assumes that variations in count 
are due to the failure of bacteriologists to “‘ faithfully 
and carefully carry out the suggested procedure.” 
The factor which probably has most effect on the 
bacterial content of milk is the state of the weather, 
which is altogether outside the bacteriologist’s 
control. In hot weather bacteria grow extremely 
rapidly in milk, and unless samples are transported 
from the sampler to the laboratory packed in an 
efficient ice-box there may be big variations in 
bacterial growth within a short period of transit, 
depending upon the different temperatures attained. 
Apart from considerations of temperature, it 1s 
extremely hard to standardise a test of this type. 
There are mechanical faults such as errors in the 
graduation of pipettes to be controlled; there are 
the difficulties of standardising culture medium 
prepared from such variable constituents as meat 
and peptone; and there is a difficulty to which 
Dr. Howell draws attention—that of breaking up 
cell aggregates in the milk. This is attempted by 
shaking the sample in a bottle; but it is impossible 
to disintegrate all clumps and chains of organisms 
suspended in milk, and any endeavour to standardise 
the degree of disintegration by standardising the 
amount and method of shaking will achieve but shght 
success. Finally, in preparing total counts the 
failure of the human element plays an important 
part, both during the various manipulations and in the 
final counting. However well-trained and con- 
scientious laboratory technicians may be, their errors 
cannot be reduced to a level at which they can be 
ignored. 

Undoubtedly there are strong grounds for agreeing 


with Dr. Howell that little reliance can be placed 
upon a report of the bacterial content of a milk 
when judging the grade or quality of a sample. 
Comparison of a series of counts made at frequent 
intervals enable one to form a reasonable estimate of 
the standard of cleanliness under which the milk has 
been produced, but the results of a single test are 
usually worthless. j 

Generally speaking, two fundamental objections 
can be levelled against the present method of grading 
milk. The one is based upon the inherent inaccuracies 
of the total count; the other is that owing to the 
laboratory accommodation necessary, and the high 
degree of technical skill required, for performing the 
count a very definite economic limit is set to the 
number of times an individual milk-supply can be 
tested in the course of a year. Obviously, therefore, 
an improved method of grading milk depends not 
upon improving or elaborating the technique of the 
total count, but rather upon devising a test simple 
and cheap enough to be applied to an individual 
supply of milk—daily if need be—and one which 


eliminates some of the above inaccuracies. 


We may look for some further light on choice of 
technique when Prof. G. S. Wilson’s expected 
report is issued. In the meantime reference should 
be made to the method of judging the quality of 
milk for pasteurisation, which was first suggested 
by Anderson and Meanwell,! and is also advocated 
in a report by Scott and Wright? which has just 
reached us. Bacterial counts are made of the milk 
before and after pasteurisation and the results are 
correlated, attention being chiefly paid to the post- 
pasteurisation count. It has been shown that while 
the pre-pasteurisation count is largely influenced by 
weather conditions and may be a very unreliable 
index of the hygienic conditions of the farm, the post- 
pasteurisation count of heat-resistant organisms 
depends largely upon the cleanliness of production, 
these organisms coming mainly from badly sterilised 
apparatus, 


INFECTIOUS DISEASE 
IN ENGLAND AND WALES DURING THE WEEK ENDED 
DEC. 28TH, 1935 


Noltifications.—The following cases of infectious 
disease were notified during the week: Small-pox, 0 ; 
scarlet fever, 2052; diphtheria, 997; enteric fever, 
20; acute pneumonia (primary or influenzal), 1076 ; 
puerperal fever, 35 ; puerperal pyrexia, 72 ; cerebro- 
spinal fever, 14; acute poliomyelitis, 8; encephalitis 


1 Anderson, E. B., and Meanwell, L. J.: 
1933, iv., 213. 

7 Scott, A. W., and Wright, N. C.: 
Inst. Bull., No. 6, 1935. 


Jour. Dairy Research, 


Hannah Dairy Research 


122 THE LANCET] 


lethargica, 5; dysentery, 33; ophthalmia neona- 
torum, 42. No case of cholera, plague, or typhus 
fever was notified during the week. 


The number of cases in the Infectious Hospitals of the London 
County Council on Jan. 3rd. 1936, was 3728, which included: 
Scarlet fever, 1164; diphtheria, 1212; measles, 315; whoop- 
ing-cough, 165; puerperal fever, 19 mothers (plus 14 babies) ; 
encephalitis lethargica, 279; poliomyelitis, 3. At St. Margaret’s 
Hospital there were 14 babies (plus 5 mothers) with ophthalmia 
neonatorum. 

Deaths.—In 121 great towns, including London, 
there was no death from small-pox or enteric fever, 
39 (3) from measles, 4 (1) from scarlet fever, 26 (7) 
from whooping-cough, 40 (6) from diphtheria, 59 (20) 
from diarrhoea and enteritis under two years, and 
SO (14) from influenza. The figures in parentheses 
are those for London itself. 

The mortality from influenza. of which the total has begun 
to rise, is scattered over 47 great towns, Liverpool reporting 5, 
Manchester 4, Bolton and Leicester each 3, no other great town 
more than 2. Liverpool reported 15 deaths from measles, 
Manchester 7, Warrington 3. Liverpool also had 5 deaths from 
whooping-cough. The deaths from diphtheria were reported 
from 24 great towns: Liverpool 5., Darlington, Manchester, 
Newcastle-on-Tyne, Sheflicld, Wallasey, Warrington, and 
Birmingbam each 2 
The number of stillbirths notified during the week 
was 233 (corresponding to a rate of 60 per 1000 total 
births), including 31 in London. 


Medical Diary 


Information to be included in this column should reach us 
in proper form on Tuesday, and cannot appear if it reaches 
us later than the first post on Wednesday morning. 


SOCIETIES 
ROYAL SOCIETY OF MEDICINE; 1, Wimpole-street, W. 


TUESDAY, Jan. 
Pathology. 8.30 P.M. (Middlesex Hospital, W.). J. 
P. Fildes, 


McIntosh: Some Centrifuge Experiments. 
B. C M. Richardson, and G. P. 


J. G; Knight, G. 
Metabolism of Staphylococcus aureus. 


Gladstone : 

L. E. H. Whitby and M. Ilynes: Supravital Staining 

of Leukemic Leucocytes. An Apparatus for Rapid 

Red Cell Measurement. R.W. Scart! and M. McGeorge : 

Blood Pressure in Experimental Renal Lesions. 

W. H. Mason: Pathogen-sclective Cultures. L. C. 

Bousfield: Findings in Joint Fluids from Cases of 

Rheumatoid Arthritis. K. M. Eisenberg: Microscopy 

of Living Virus Material. A. C. Counsell and L. C. 
Martin: Pathological Specimens. 

WEDNESDAY. 

History of Medicine. 5 P.M. Mr. T. B. Layton: History 

the Knowledge of tho Anatomy of the Nose. Dr. 

T. Wilson Parry will read a paper by the late Dr. Dan 

McKenzie entitled Surgical Perforation in a Mediæval 

Skull with Reference to Neolithic Holing. 

THURSDAY. 

Dermatology. 5 P.M. (Cases at 4 P.M.) Cases: 

Thomson: 1-2. Cases for Diagnosis. 3. 

Serpiginosum. 4. Complete Leukonychia. 


Dr. M.S 
Angioma 
Mr. H. 


ye 5. Pigmented Hairy Mole developing in an 
ult. 
Neurology. 8.30 P.M. Prof. B. Brouwer (Amsterdam): 


The Spleen, the Liver, and the Brain. 

(FRIDAY. 

Obstetrics and Gynecology, Radiology. 
Dougal and Dr. R. E. Roberts: Radiology tn Relation 
to Obstetrics. Dr. L. N. Reece, Dr. H. C. H. Bull, 
a W. i Mackay, and Dr. Archibald Durward will 

also speak. 
MEDICAL SOCIETY OF LONDON, 11, Chandos-street, W. 

MONDAY, Jan. 13th.—8 P.M., Pathological Meeting. 

ROYAL SOCIETY OF TROPICAL MEDICINE AND 
HYGIENE, Manson House, 26, Portland-place, W. 

Toorspay, Jan. 16th.—8.15 P.M., Col. ©. A. Gill: 
Points in the Epidemiology of Malaria, 
of the Malaria Epidemic in Ceylon. 

PADDINGTON MEDICAL SOCIETY. 

TUESDAY, Jan. 14th.—9 P.M. (Great Western Royal Hotel, 
W.) Mr. G. G. Turner: Income-tax in Medical 
Practice. 

TUBERCULOSIS ASSOCIATION. 

FriDAay, Jan. l7th.—5.15 P.M. (Manson House, 26, Port- 
Jand-place, W.), Dr. Noel Bardswell, Dr. J. G. Jobn- 
stone, and Miss M. C. Marx: After-care of the Tuber- 
culous in London. 8.30 P.M., Dr. Jumes Maxwell: 
Intestinal Tuberculosis. 

BRITISH INSTITUTE OF RADIOLOGY, 
street, W. 

THURSDAY, Jan. 16th.—7.45 P.M., Special General Meeting. 
7.45 P.M., Dr. J. F. Brailsford: Radiological Demon- 
stration of Developmental Abnormalities of the 
Skeleton. 

FRIDAY.—l11 A.M., Visit to the X Ray Department of St. 
Mary’s Hospital. 5 P.M., Case Demonstration and 
Discussion. (Medical Meeting.) 


8 P.M. Prof. D. 


Some 
arising out 


32, Welbeck- 


MEDICAL DIARY.— APPOINTMENTS 


[JaN. 11, 1936 


NORTH LONDON MEDICAL AND CHIRURGICAL 
SOCIETY, Royal Northern Hospital. N. 

WEDNESDAY, Jan. I5th.—9 P.M., Dr. Bellingham Smith: 
Continued Fever. 

SOCIETY FOR THE STUDY OF INEBRIETY. 

TUESDAY, Jan l4th.—4 P.M. (11, Chandos-street. W.), 
Dr. W. Norwood East and Dr. H. J. Norman: The 
eae of Alcoholism and Crime to Manic-depressive 

isorder. 


BIOCHEMICAL SOCIETY. 


FRIDAY, Jan. 17th.—3 P.M. (United Dairies Research 
FA DOTOLORICS, Wood-lane, W.1), Short Communica- 
ons. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 


ROYAL COLLEGE OF SURGEONS. Lincoln’s Inn-fields, W.C. 
FRIDAY, Jan. 17th.—5 P.M., Prof. A. F. MacCallan: The 
Surgery and Pathology of Trachomatous Conjuncti- 
vitis. (Hunterian Lecture.) 
UNIVERSITY COLLEGE, LONDON. 
THURSDAY, Jan. 16th.—5 P.M.. Mr. F. G. Young, Ph.D.: 
Glycogen and the Metabolism of Carbohydrates. First 
of four lectures. 


Me TEAL FOR SICK CHILDREN, Great Ormond-street, 


Dr. R. Frew: Cough. 
Prophylaxis of N ON 


WEDNESDAY, Jan. 15th.—? P.M., 
3 P.M. Dr. A. Signy: 
and Measles. 

Out-patient Clinics daily at 10 a.m. and ward visits (except 
on Wednesday) at 2 P.M. 


a SCHOOL OF DERMATOLOGY, 5, 


een Jan. 14th.—5 P.M., Dr. G. 
riasic Dermatitis. 

WEDNESDAY.—9S P.M.. Dr. I. Muende: 
Some Common Skin Diseases. 


FELLOWSHIP OF MEDICINE AND POST-GRADUATE 
MEDICAL ASSOCIATION, 1, Wimpole-street, W. 

Monpay, Jan. 13th, to SUNDAY, Jan. 19th.—ST. JOHN’S 
HospITatL, 5, Lisle-street, Leicester-square, W.C. 
Afternoon Course in Dermatology. (Open to non- 
memwbers.)—NATIONAL HOSPITAL FOR DISEASES OF 

THE HEART, Westtnoreland-street, W. All-day Course 

in Cardiology. (Open to non- -members. )—NATIONAL 
TEMPERANCE HOSPITAL, Hampstead-road, N.W. Tues., 

8.30 P.M., Mr. McNeill Love : Hernive. Thurs., 8.30 P.M., 

Mr. A. Lawrence Abel: The Surgery of the Sympa- 
thetic Nervous System.— ROYAL CHEST HOSPITAL, 
City-road, E.C. Sat. and Sun., Course in Diseases of 

the Heart and Lungs. (Open to non-members.)— 
(Courses arranged by the Fellowship are open only to 


Lisle-street, 
B. Dowling: Pity- 


Histopathology of 


Members.) 
LEEDS GENERAL INFIRMARY. 
TUESDAY, Jan. 1l4th.—3.30 P.M., Dr. MacAdam: Some 
Cases of Minor Invalidism. 
LEEDS PUBLIC DISPENSARY AND HOSPITAL. 
WEDNESDAY, Jan. 15th.—4 P.M., Mr. L. N. Pyrab : Injec- 


tion Therapy in the Treatment of Hemorrhoids, 
Varicose Veins, and Hydrocele. 
UNIVERSITY OF DURHAM. 
SUNDAY, Jan. 19th.—10.30 A.M. (Newcastle General 
Hospital), Prof. T. Beattie : Medical Ward Visit. 
GLASGOW POST-GRADUATE ASSOCIATION. 
WEDNESDAY, Jan L5oth.—4.15 P.M. (Royal Maternity and 
Women’s Hospital), Prof. James Hendry: Hemor- 
rhage at the End of Pregnancy. 


Appointments 


ATLEF, C. N., M.D. Durh., M.R.C.P. Lond., D.P.H., D.P.M., 
has been appointed Divisional Medical QOticer to the 
London County Council. 

BALDWIN, E. J.. M.B. Oxon., D.O.M.S., Hon. Ophthalmic 
Surgeon to the Essex County Hospital, Colchester. 

LAURENT, L. P. EB., M.D., M.R.C.P. Lond., Medical Registrar 
at the West London Hospital. 

MITMAN, M., M.D., M. R.C.P. Lond.. D.P.H., D.M.R.E., Medical 
Superintendent, Eastern Hospital. 

PEET, E. W., M.B. Durb., F.R.C.S. Eng.. Bernhard Baron 
Research Student at the Ferens Institute of Otology at 
the Middlesex Hospital Medical School. 

Sykes, Rupert, M.D.. M.R.C.P. Lond., Resident Medical 
Otlicer at the Mane hester Royal Intirmary. 

TALBOT, G. G., M.B. N.Z., F.R.CS. Eng., Second Ophthalmic 
Surgeon to the Royal Northern Hospital, N.7. 

TuomMpson, H. R.. M.B. Camb., BLR.C.S. Eng., Surgical First. 
Assistant and Registrar at the London Hospital. 

WALTON, W. 5., M.D. Dur. B.Hy.. D.P.H.. Medical OMeer of 
Health and school Medical Otlicer for W est Bromwich. 
WYATT, WALTER, M.B. Edin., L.D.S., D.P.M., Assistant School 

Medical Otlicer in Leeds. 


Princess Alice Memorial Tospital, Lastbourne.—The following 
appointments are announced :— 

ILSON, F.R.C.S. Edin., Hon. Surgeon ; 

SHERWOOD, G. D.. M.B. Camb., Hon. Surgeon ; 

Crook, A. H., M.Chir. Camb., F.R.C.5. Eng., Surgeon in 


Charge of Frac ture Clinic 
Estrcourr, H. G., M.B. Lond., Ñ. R.C.S. Edin., Hon. Assistant 
F R.C.S 


Surgeon :; 
WILSON, T. H., M.B. Lond., 


Surgeon. 


HALL, E. WILSON, 


. Eng., Hon. Assistant 


THE LANOET] 


[yan. 11, 1936 123 


MEDICAL NEWS 


University of Cambridge 

The Rockefeller Foundation have made an annual 
grant of not more than £1200 for five years for research 
in cellular physiology at the Molteno Institute under the 
direction of Prof. Keilin. 

The title of the degree of M.B. has been conferred on 
Mrs. M. H. D. Gunther. 


University of London 
At recent examinations the following candidates were 
successful :— 
M.D. 


Branch I. (Medicine).—W. H. P. Cant, a of Birm. 
P. ©. L. Carrier, Charing Cross Hosp. ; Iris M . Cullum, Rosai 


Free Hosp.; M. E. Disney, London Hosp., T. J. Evans, 
Univ. Coll., Cardiff, and Middlesex Hosp. ; `T. Falla, London 
Hosp. ; F. M. Finzel, Univ. of i Clifford James, 


Middlesex Hosp.; D. B. vV. Jones, King’s Coll. Hosp.; H.M.R. 
Jones, Middlesex Hosp. ; Herbert Kirman, King’s Coll. Hosp. ; 
Beatrice Lewis, Univ. Coll. Hosp.; R. J. G. Morrison, St. 
Bart.’s Hosp.; Ivor Whittington, St. George’s Hosp.; J. C. 
Aaa King’s Coll. Hosp.; and Tamsin M. Wynter, Royal 
ree Hosp. 

Branch II. (Pathology).—Ronald Hare, St. Mary’s Hosp. ; 
W A. E. Karunaratne, Univ. Coll. Hosp.; D. M. Pryce, 
St. Mary’s Hosp. ; and R. S. Wale, King’s Coll. Hosp 


‘ monn III. (Psychological Medicine)—H. A: Cooper: King’s 
oll. Hosp. 
Branch IV. (Midwifery and Diseases of Women). —R. E. 


Bowes, Univ. of Liverp. and St. Thomas’s Hosp.; J. O. F. 
Davies, Middlesex Hosp.; Mary Evans, King’s Coll. Hosp. ; 
and Margaret M. White and Honor E. C. Wilkins, Royal Free 


osp. 

Branch V. (Hygiene).—D. M. Connan, King’s Coll. Hosp. and 
Westminster Hosp.; David Erskine, Guy’ s Hosp. and London 
School of Hygiene and Tropical Medicine; J. T. R. Lewis, 
Middlesex Hosp.; and F. J. G. Lishinan, Univ. Coll. Hosp. and 
London School of Hygiene and Tropical Medicine. 


University of Birmingham. 
At recent examinations the ene mInS candidates were 
successful :— 
FINAL EXAMINATION FOR M.B., B.S. 


ph: M. Barker, Dorothy M. Braddock, N. R. Chan- -Pong, 
. W. F. Craig, F. J. Fowler, R. J. Ing ham, E. E. K. kilvert, 
i A. Singer, Aileen M. Sutcliffe, and L. ate Thompson. 


B.D.S. , 
C. G. Hails. 


Royal College of Surgeons of England 

The following lectures will be given at the college on 
Mondays, Wednesdays, and Fridays from Jan. 17th to 
Feb. 21st: Jan. 17th, Mr. A. F. MacCallan, the surgery 
and pathology of trachomatous conjunctivitis ; Jan. 20th, 
Dr. E. W. Twining, a radiological study of the third 
ventricle; Jan. 22nd, Mr. Arthur Bulleid, the assessment 
of dental sepsis as a factor affecting medical and surgical 
procedures; Jan. 24th, Mr. John Gilmour, adolescent 
deformities of the acetabulum; Jan. 27th, Mr. E. P. 


Stibbe, the anatomy and surgery of the subtentorial 
angle; Jan. 29th, Mr. R. T. Payne, pyogenic infections of 


the parotid; Jan. 3lst, Mr. G. A. Mason, extirpation of 
the lung; Feb. 3rd, Mr. A. M. Boyd, the investigation of 
peripheral vascular disease; Feb. 5th, Mr. H. Osmonde 
Clarke, injuries of the carpal bones; Feb. 7th, Mr. F. H. 
Bentley , wound healing in vitro and the interrelation of 
epithelial and fibrous tissue growth; Feb. 10th, Mr. 
G. C. Knight, intestinal strangulation; and Feb. 12th, 
Mr. G. F. Rowbotham, a series of tumours of the skull. 
On Feb. 17th, 19th, and 2lst Dr. John Beattie will give 
three lectures on temperature regulation. All the lectures 
will take place at 5 P.M. 


Order of St. John of Jerusalem 


The following promotions in and appointments to the 
Venerable Order of the Hospital of St. John of Jerusalem 
have been sanctioned by the King :— 

As Knight of Grace.—Lieut.-Colonel R. E. Wodehouse, 
0.B.E., M.D. 

As Commander.—James Cairns, O.B.E., 
Lieut.-General Sir James Andrew Hartigan, 
C.M.G., D.S.O., M.B. 

As Oficer.—Dr. N. M. Goodman, Major C. G. H. Morse, 
M.R.C.S.: Major R. F. Walker, M.C., M.B., R.A.M.C. ; 
Dr. A. Tetreault, Lieut.-Colonel J. N. Gunn, D.S.O.. 
M.D., M.R.C.S.; and Mrs. Constance E. M. Berridge, M.B. 


M.B., and 
K.C.B., 


Royal Society of Arts 

On Wednesday, Jan. 15th, at 8 P.M., Mr. L. H. Lampitt, 
D.Sc., chairman of the food group of the Society of Chemical 
Industry, will speak on Food and the World. 


Guild of Hospital Librarians 

The first international meeting of this guild will be held 
in Paris from May 8th to llth. The speakers will include 
Dr. René Sand, Madame Getting, Mademoiselle Oddon, 
Mr. C. E. A. Bedwell, Mrs. M. E. Roberts, and Mr. 
A. D. Power. The hon. secretary may be addressed at 
48, Queen’s-gardens, London, W. 2. 


Hunterian Society 

The Hunterian lecture of this society will be delivered 
at the Mansion House, London, E.C., at 9 p.m. on Monday, 
Jan. 20th, by Dr. Sven Ingvar, professor of medicine at 
the University of Lund, Sweden. He will speak on the 
physical basis of psychoneurosis. | | 

The annual dinner of the society will be held on 
Thursday, Feb. 13th, at the May Fair Hotel. 


Post-graduate Work in Newcastle 

Under the auspices of the University of Durham classes 
will meet at the Babies’ Hospital and Royal Victoria 
Infirmary, Newcastle, during the months of January, 
February, and March on Thursday afternoons. Till 
March 22nd there will be lecture demonstrations in medicine 
and surgery every Sunday at 10.30 a.m. Further 
particulars may be had from the Registrar, College of 
Medicine, Newcastle-upon-Tyne. 


The late Dr. Haydn Brown 

The death occurred on Jan. 3rd of Dr. Haydn Brown 
at his house in Bedford-square. He came prominently 
before the public as on two occasions the General Medical 
Council felt constrained to remove his name from the 
Medical Register for ethical reasons, which led to 
journalistic comment. He wrote profusely on many 
subjects which, generally speaking, fall within the province 
of the neurologist, but he was unable to convince his 
medical colleagues of the scientific soundness of his 
theories, in which he himself was, however, an implicit 
believer. 


German Society for Internal Medicine 

The Deutsche Gesellschaft für Innere Medizin is holding 
its forty-eighth meeting from March 23rd to 26th at 
Wiesbaden under the presidency of Prof. Schwenken- 
becher of Marburg. A joint meeting will be held with 
the Reichsarbeitsgemeinschaft für eine neue deutsche 
Heilkunde when the internal treatment of thyrotoxicosis 
will be discussed. Other subjects for discussion will be 
the electrocardiographic diagnosis of myocarditis and 
diseases of the lung caused by inhalation of dust. The 
last two sessions will be devoted to joint meetings with the 
Deutsche Rontgengesellschaft when the subjects of dis- 
cussion will be inflammatory diseases of the large intestine, 
the diagnosis of cavities, and the radiotherapy of malignant 
tumours of the internal organs. Dr. A. Géronne, of 
Wiesbaden, is the secretary of the congress. 


The Medical Society of London 

The second half of the 1935-36 session of this society 
will open on Jan. 13th with a pathological meeting. On 
Jan. 27th Mr. Zachary Cope will open a discussion on the 
treatment of acute appendicitis, and other discussions 
and their openers will be: Mr. C. 8. Lane-Roberts on 
the treatment of sterility (Feb. 10th), Lord Horder on the 
etiology and treatment of B. coli infections of the urinary 
tract (Feb. 24th), Mr. A. Dickson Wright on phlebitis and 
its treatment (March 9th), and Prof. G. Grey Turner on 
surgery of the cessophagus (March 23rd). The Lettsomian 
lectures will be given on Feb. 10th and 26th and March 2nd 
by Dr. Philip Manson-Bahr, who has chosen as his subject 
the differential diagnosis of diseases of the colon (dysentery 
and colitis) and their complications, with special reference 
to treatment. Sir James Walton will deliver the annual 
oration on May llth, when he will speak on carcinoma of 
the stomach. The annual dinner of the society will be 
held at Claridge’s on Thursday, Feb. 27th. 


124 THE LANCET] 


MEDICAL NEWS.—VACANCIES 


[JaN. 11, 1936 


Pharmaceutical Society of Great Britain 


On Tuesday, Jan. 14th, Mr. H. Berry will give a lecture 
on sterilisation technique. The meeting will be held at 
8.30 P.M. at the house of the society, 17, Bloomsbury- 
square, London, W.C. 


Tenth British Congress of Obstetrics and Gynez- 
cology 


This Congress will be held at Belfast from April Ist 
to 3rd under the presidency of Prof. R. J. Johnstone. 
One of the chief subjects of discussion will be the con- 
servative treatment (operative or otherwise) of patho- 
logical conditions of the ovaries, tubes, and uterus, and 
there will be communications from several sources on 
radiotherapy of uterine diseases, on the use of sex hormone3 
in gynecology, and on sepsis and other complications of 
pregnancy and labour. . The secretaries are Mr. C. H. G. 
Macafee and Dr. F. M. B. Allen, and the address of the 
former is 18, University-square, Belfast. 


A Drowning Tragedy 


Further details are to hand of the death of Dr. A. B. 
Aitken, which occurred on Dec. 8th at Lagos, as a result 
of a drowning accident. Dr. Aitken, who received his 
medical education at the University of Glasgow and the 
London Hospital, graduated as M.B.. Ch.B. Glasg. in 
1905 and took the diploma of F.R.C.S. Eng. in 1909. 
He served as house surgeon to the Royal Hospital for 
Sick Children, Glasgow, and at the outbreak of war, with 
the rank of temporary captain, was attached to the 
R.A.M.C. as a surgical specialist. Later he became con- 
sulting surgeon to the African hospital at Lagos and 
established a reputation throughout the whole district 
as a surgeon. He was out swimming with a party at 
Lagos when he got into difficulties. A brave attempt to 
rescue him was made by Sir Walter Johnson, director 
of medical and sanitary services in Nigeria, who himself 
was only saved by means of a rope of towels knotted 
together by other members of the party. 


B.M.A. Scholarships and ‘Grants in Aid of Research 


The Council of the British Medical Association is 
prepared to receive applications for research scholar- 
ships and grants for the assistance of research in connexion 
with disease. 

Scholarships.—An Ernest Hart Memorial Scholarship, value 
£200 per annum. a Walter Dixon Scholarship, vahie £200 
per annum, and three Research Scholarships, each of the value 
of £150 per annum. These scholarships are given to candidates 
whom the Science Committee of the Association recommends 
as qualified to undertake research in any subject (including 
State medicine) relating to the causation, prevention, or treat- 
ment of disease. Each scholarship is tenable for one year, 
commencing on Oct. Ist, 1936. A scholar may be reappointed 
for not more than two additional terms and is not necessarily 
required to devote whole time to the work, but may hold a 
junior appointment at a university, medical school, or hospital, 
provided the duties of such appointment do not interfere with 
the work as a scholar. 

Grants for the assistance of research into the causation, 
treatment, or prevention of disease will be made to applicants 
who propose as subjects of investigation problems directly 
related to practical medicine. 


In making awards preference will be given to mem- 
bers of the medical profession, and applications must 
be made not later than May 9th on the prescribed 
form, a copy of which will be supplied on application to 
the medical secretary of the Association, B.M.A. House, 
Tavistock-square, London, W.C.1. Applicants are 
required to furnish the names of three referees who aro 
competent to speak as to their capacity for the research 
contemplated. 


e 
y ACANCI1eS 
For further information refer to the advertisement columns 

Aberdeen City District Mental Ifospital.—Jun. Asst. M.O. £300. 
Barry Surgical Hospital.— Res. Surg. O. £350. 
Bedford County Hospital.—second U.S. At rate of £150. 
Birmingham City Mental Hospital.mJun. Asst. M.O. £350. 
Birmingham and Midland Hye Hospital.—Res. Surg. O. £200. 
Bes Selly Oak Hospital—Jun. M.O.’s. Each at rate 

o 
Birmingham United Hospital.—Bactcriologist and Clin. Patho- 

logist. £500 


Boling broke Hospital, Wandsworth Common, S.1V.—H.P. At rate 
of £ 


Bootle General Hospital.—H.P., two H.S 
at rate of £150. 

Brighton, Sussex Eye Hospital.—Hon. 

Bristol Royal Infirmary.—H.P.’s, H.S.’s, &ce. Each at rate of 
£80. Also Sen. Obstet. Surg. At rate of £100. 

British Postgraduate Medical School, Ducane-road, W.—H.P. 

Cn pee Queen Mary's Hospital for Children.— Asst. 
M.O. £25 

Charing Cross Hosnital, W.C.—Hon. Anesthetist. 

Chelsea Hospital for Wonen, Arthur-street, SAV -—Pathologist. £40. 

Colchester, Essex County Hospital. —Agst. H.S. £120 

Colindale Hospital, Colindale, N.W .—Asst. iLO. £35). 

County Hall, Westminster Bridge, S.E.—Asst. M.O. £600. 
Also Asst. M.O.’s for School Medical Work. 30s. a session. 

Coventry and Warwickshire Hospital.—H.S. to Aural and Ophth. 
Depts. At rate of £125. 

Croydon, Mayday Hospital.—Jun. Res. Asst. M.O. £300. 

Doncaster koyal Infirmary.—H.S. £175 

Dorset County Council.—Asst. County M.O. £500. 

Eastern Fever Hospital, Homerton-grove, k.—Asst. M.O. £250. 

Kast Riding Mental Hospital, Beverley.—Jun. Asst. M.O. £250. 

Elizabeth Garrett Anderson Hospital, Fuston-road, N.UF.—Cltin. 
oe Pane Nose, and Throat Dept. Also Asst. Radio- 
Ogis (yt 

Evelina Hospital for Sick Children, Southwark, S.E.—Dental 


Also Cas. O. Each 
Asst. Surgeon. 


Surgeon. 50 guineas. 

Glasgow Victoria Infirmary.—Asst. Radiologist. Also two 
additional Visiting Anwsthetists. Each £400, 

Grimsby and District Hospital.—sen. H.S. £200. Also Jun. 


H.S. and H.P. Each £150. 

Halifax General Hospital.—Jun. Res. M.O. £250. 

Hampstead General and N.W. London Hospital, Haverstock Hill, 

L.P. At rate of £100. 

Hertford County Hospital. —H.P. At rate of £150. 

Huddersfield County Borough.—Asst. School M.O. £500. 

Ipswich, East Suffolk and Ipswich Hospital.—H.P. £144. 

Isleworth, West Middlesex County Hospital.—Res. Anesthetist. 
£400. Also Cas. M.O. £350 

Kettering and District General oeni: —Second Res. M.O. At 
rate of £125. 

Leeds General Infirmary.—Res. Aural Officer. £149. 

Liverpool and District Ifospital for Diseases of Heart.—H.P. 
At rate of £100. 

Liverpool, Royal Children’s Hospital.—Med. Reg. and Tutor. £50. 

Liverpool, Stanley Hospital.—H.s., H.P., and Gynecological 
H.S. Each at rate of £100. 

L.C.C. Group Laboratory, Archway Hospital, Archway-road, N.— 
Asst. Pathologist. £65. 

London County Council.—aAsst. M.O.’s for Mental Hospital. 
Each £470. 


London Homeopathic Hospital, Great Ormond-street, W.C.— 
Asst. Physician for Diseases of Women. 

London Hosvital, E.— Asst. in X Ray Dept. £100. Also Hon. 
Asst. Surgeon. 

London School of Clinical Medicine, Dreadnought Hospital, 
Greenwich, S.E.—Jun. Pathologist. £4100, 


Manchester, Aneoats Hospital.—Two H.S.’s. Each at rate of 
£100, Also Med. Reg. £50. 

Manchester Victoria Memorial Jewish Hospital, 
Res. H.S. £150. 

Marie Curie Hospital, 2, Fitzjohns-arenue, N.W.—Res. M.O. At 
rate of £100. 

Metropolitan Hospital, Kingsland-road, E.—Res. Cas. O. £100. 

National Dental Hospital.—Hon,. Asst. Anesthetist. 

NE UO TYNE, Barrasford Sanatorium.—Res. Med. Asst. 
£250 


Cheetham.— 


Newcastle-upon-Tyne, Citu Hospital for Infectious Diseases.— 
Res. Med. Asst. £350. 

Newcastle- -Upon-T yne, Hospital for Sick Children.—Res. Surg. O. 
£250. Also H.P. and H.S Each at rate of £100. 

Notlingham General Hospital. aks At rate of £150. 

Oswestry, Robert Jones and Agnes Hunt Orthopadic Hospital.— 
H.S. At rato of £200. 

Pinewood Sanatorium, Wokingham, Berks.—Asst. M.O. £250. 

Plymouth, Mount Gold Orthopadic and Tuberculosis Hospital.— 
Asst. Res. M.O. £3650. 

Preston, Biddulph Grange Orthopadic Hospital.—Sen. H.S. At 


rate of £250, 
M.O. At rate 


Pulney Hospital, 
of £100. 

Queen's Hospital for Children, Hackney-road, E.—Three Anws- 
thetists. One guinea per attendance. 

Reading, Roual Berkshire Hospital.—Cas. O. At rate of £125. 

Royal Eye Hospital, St, George's-circus, Southwark, S.E.— Hon. 
Asst. Surgeon, 

Royal Masonic Hospital, Ravenscourt Park, W.—Surgeon. 

St. Bartholomew’s Hospital, E.C.—Asst. Physician. Also Asst. 
Physician and Asst. Director to Medical Professorial Clinic. 

St. Mary's Hospital, W.—Cas. H.S. At rate of £100. 

Salford Royal Val Oro dii Reg. £100. 


Lower Common, S.W .— Jun. 


Smethwick, St. Chad's Hospital.—Res. Obstet. Officer. £350 
Also Jun. Res. M.O. At rate of £150. 

i j Res. M.O. £200. 

South London Hospital for Women, Clapham Common, S.W .— 


Out-patient M.O. £100, 
Stockport Infirmary.—Res. Surg. O. £250. 
Stoke-on-Trent, Longton Hospital. —1H.S £160, 
Swindon eM North Wilts Victoria H spital. —second Res. M.O. 


€12 
Vitoria ‘Hospital for Children, Tite-strect, Chelsea, S.W .— 
Cas. O. At rate of £200. Also H.P. and H.S. Each at 


rate of £100. f OET 
West End Hospital for Nervous Diseases, Gloucester-gate, N.W .— 


Res. H.P. £125. , 

Westminster Hospital, Broad Sanctuary, S.W.— Asst. Obstet. 
Surgeon. 

Woreester Royal Infirmary.—Jun. H.S. £120. 

Worksop, Victoria Hospital.—msSen,. and Jun. Resident. At rate 


of £150 and £120 respectively. 


THE LANCET] 


[sAN. 11, 1936 125 


NOTES, COMMENTS, AND ABSTRACTS 


SCHOOL PRESSURE IN WORK AND PLAY 


_THAT the stress of modern education and examina- 
tions in schools is shown by a loss of weight during 
term, the weight being made up in holidays. was the 
contention of Dr. G. O. Barber, M.O., of Felsted, who 
opened a discussion at a meeting of the Society of 
Medical Officers of Schools, held at University 
College on Jan. 3rd. The fact that this rhythm 
occurred in day- as well as in boarding-schools showed 
that it was not due to school food. It was, moreover, 
general experience that a boy admitted to the 
sanatorium with some minor physical injury slept 
solidly, waking only for food, for the first 24 hours. 
Similarly children slept a lot at the beginning of the 
holidays before they came to take an interest in 
hobbies or games. The three ways of dealing with 
the problem were: (1) distribution of the strain by 
reducing work periods and providing a midday 
pause of half an hour when the child could do exactly 
what it liked; (2) free time—rightly used (at Felsted 
the hobbies and clubs were housed in a big country 
house, with a warden to help boys out of difficulties, 
where each could follow his bent); (3) morning and 
evening chapel which provided ten minutes of detach- 
ment at each end of the day.—Dr. Alice Sanderson 
Clow (Cheltenham), who followed, held that children 
needed protection against their own energies rather 
than stimulation. Great responsibility rested on the 
parent and head of a boarding-house in detecting the 
early signs of fatigue. By the time the doctor was 
consulted the symptoms were anxiety, diminished 
concentration, stooping, loss of appetite, and broken 
sleep, and the only remedy was prolonged absence 
from school. A brain once impaired by prolonged 
fatigue rarely, if ever, recovered completely. The 
greatest feature in modern strain seemed to be the 
external examination taken too young. The morning 
session should be from 9 to 12.40, with 5-minute 
intervals of complete relaxation between the 40-minute 
lessons and a 30-minute break in the middle of the 
morning. Children found essay writing a great 
strain, and the homework set was usually too long for 
all but the brightest. Some homework was good in 
that it could be done in the evening, allowing the 
child to get out in the afternoon sun. A tired child 
sought rest rather than play, and might be overdone 
by organised games, especially with the element of 
competition. <A little girl of 12 who had recently 
gone to her first boarding-school had said, ‘‘ Oh, 
everything is lovely—but there’s no time to play.” 
“ But don’t you have games?” “ Oh, yes, we have 
lots of games and they’re glorious. But they’re not 
play. Dr. Clow contrasted the white limbs of 
school-children on the beach early in the holidays 
with the bronze of their parents and baby brothers ; 
school-children were often kept in high collars, in 
order to display thc school tie, and in gloves and long 
black stockings which were unhygienic from every 
point of view.—Mr. A. J. R. Roberts (head of Mill Hill 
junior school) had known in many years’ experience 
only one breakdown, which had taken place during 
holiday time. The régime of his school included most of 
the desiderata mentioned. Boys who spent themselves 
in nervous energy must be given a day in bed now 
and then.—Mr. Lee-Browne (head master of Rendcomb 
College) also outlined his time-table ; teaching periods 
had been reduced to 28 and preparation to 74 hours 
for boys up to 15 and 10$ hours over that age. These 
hours included music, drawing. and manual work ; 
and there had been no falling off in scholastic success 
as a result. His boys got about 20 hours of spare 
time a week, with 8 on Sunday, on which day 
l hour must be spent in compulsory quiet. Value 
had been obtained from a brief exercise before break- 
fast followed by a cold bath. Recently they had 
instituted, with great success, one completely free 
afternoon a week when boys could do exactly what 
they liked—work or play. There was a very rea 
problem of holiday pressure—the pressure of the carl 


the cinema, or even the organised camp. The time 
for character training had been squeezed almost out 
by new subjects in the curriculum, If the number 
of teaching hours could not be reduced the period 
of school life would have to be lengthened.—Dr. 
Jessie White thought strain would be greatly lessened 
if children were allowed to move about freely while 
being taught, instead of being obliged to sit for long 
periods in cramped positions. 


THE SELECTION OF AN ANZSTHETIC 


. “« Who pays the piper...” 

But the patient would generally be very ill served 
if he were allowed to call the tune. The wise doctor 
will not categorically refuse his right to call it, but 
while appearing to concede the request he will do 
what he knows to be best for his patient. A few 
days ago a hospital visitor handed on to the executive 
committee a complaint by patients who had been 
given a local anesthetic as a preparation for a major 
operation. Some persons, she said, had come to 
hospital expecting to have a general anesthetic and 
had been shocked to find themselves conscious on 
the operating table. It may safely be assumed that 
the local anzsthetic was preferred for some good 
reason. There are occasions when, in some form or 
another, it is so much the safer method to adopt 
that the surgeon has no choice in the matter. 
There are others when the advantage is less decisive 
and when the patient may reasonably be given 
his choice. Perhaps when the inquiry suggested at 
the Manchester Medical Society (see p. 89) has been 
made there may be less room for such choice. 
But to put the pros and cons before the patient 
would generally be to ask him to answer a question 
the full bearings of which he cannot possibly realise. 
When as a result of previous experiences of his own 
he holds definite views as to the anesthetic which 
suits him the anesthetist will weigh these before 
he makes up his own mind. What anesthetist has 
not met the patient who ‘ cannot take ether; they 
tried to give it to me but it’s no good ”? And what 
anesthetist has not in those circumstances started 
the administration with something else and then 
gone on to give ether without a hitch? The same 
thing is true of almost any anesthetic. But every 
anesthetist knows the importance of a quiet mind 
in the subject for operation; it is half the battle 
that the patient should believe from the start that 
what is being done is suitable to him and in accord- 
ance with his desire—if he has expressed one. 


THE KEEP FIT ADVENTURE IN SUNDERLAND 


THE development of the Keep Fit movement in 
Sunderland ought to dispel any doubts whether 
youths and men and girls and women of this country 
are ready to respond to opportunities of organised 
physical training when they are offered by an 
organiser of inspiring zeal. Chapter II. of the report 
of the C.M.O. of the Board of Education, to which 
reference hzs already been made, relates the history 
of the movement. To the very first class, held in 
the winter of 1929, there came 127 girls. and on the 
evening of May 8th, 1935, no fewer than 1450 women 
and girls took the field in a mass demonstration. 
A ten-fold increase in six years clearly proves the 
case for such an *‘adventure.” Throughout the 
25 weeks of that first winter season, two classes 
were held, one for girls under 16 years of age and 
one for older women. The organiser took both these 
classes herself, but as the numbers increased it was 
found-necessary to appeal for voluntary leaders to 
take extra classes. In response to this appeal, 
17 elementary school teachers and three trained 
gymnasts came forward to offer their help. 

From 1930 onwards demonstrations have been 
given in various parts of the counties of Northumber- 
land and Durham, and it has been found that this is 


126 THE LANCET] 


one of the most effective means of spreading the work 
and of arousing enthusiasm. Through the coöperation 
of the chief education officer and of headmasters and 
mistresses of schools with good halls, arrangements 
were made whereby halls became available to the 
movement at the cost of paying each caretaker the 
fee of ls. per class. In 1930 there were nine classes 
running in different parts of the town, with an 
average attendance of 500 a week, but by the end 
of 1934 there were 18 classes, with an average 
attendance of 1000. At the beginning all classes 
were for anybody and everybody, but soon there 
sprang into being one special class for mothers only, 
provided with'a nursery, and two classes for women 
over 40. The leaders are now sufficiently trained to 
give courses of lessons. 

As far back as 1931 Sunderland leaders of classes 
were taking classes outside the Sunderland area. 
Then organisers in Northumberland and in New- 
castle began to train leaders, and so the work spread 
to various districts, each district supporting itself. 
Sunderland is very proud of its “ keep fit ’’ adventure, 
and the officers of the local education authority have 
had the reward of seeing those for whom they have 
worked reaping the full benefit of their efforts. The 
movement is spreading to Huddersfield, Halifax, and 
other northern towns. 


THE ‘‘ REALITY ” OF PAIN AND DISEASE 


Mr. CHARLES W. J. TENNANT, district manager 
of the Christian Science Committees on Publication 
for Great Britain and Ireland, writes: In his lecture 
on Medicine and Faith published in your issue of 
Dec. 28th, 1935, Dr. Louis Leipoldt, quoting from 
the fifth chapter of the Epistle of St. James, infers 
that pain and disease must be regarded as realities, 
“and not,as the Christian Scientists would have us 
believe, as mere figments in a perfect world.” Toa 
Christian Scientist ‘‘reality ° means that which is 
“ spiritual, harmonious, immutable, immortal, divine, 
eternal” (“ Science and Health with Key to the 
Scriptures,” by Mary Baker Eddy, p. 335). If disease 
were a reality in the above sense, it could never be 
cured. God is the creator of all that is real, eternal, 
immutable, and immortal. Therefore sin, disease, 
and death, which do not proceed from God, are 
unreal, and can only be the erroneous conceptions 
of a false material sense. Christian Scientists, in the 
measure of their spiritual understanding, are daily 
proving the unreality of evil by healing the sick and 
reforming the sinner through spiritual means alone 
in fulfilment of our Master’s command. 


NEW PREPARATIONS 


‘“ KALDROX ’? ABSORBENT COMPOUND is described 
as a palatable emulsoid of colloidal kaolin and alumi- 
nium hydroxide gel, the formula being kaolin 20, 
aluminium hydroxide 2°5, aromatics 0'008, aqua 
destill. to 100. It is used to remove excess acid from 
the stomach by adsorption and provide a protective 
covering for. irritated mucous membrane, thus 
relieving the pain or discomfort often associated 
with peptic ulceration ; it is also recommended for 
diarrhoea and conditions designated ‘‘colitis’’ or 
“unstable bowel.” The makers are Petrolagar 
Laboratories Ltd., Braydon-road, London, N.16. 

BELLERGAL.—Each tablet contains 0°001g. of 
Bellafoline (lavorotatory alkaloids of belladonna), 
0:0003 g. of Femergin (ergotamine tartrate), and 
0°02 g. of phenobarbital. It is designed to overcome 
excessive autonomic nervous tone; the belladonna 
restrains over-activity of the sympathetic, while the 
ergotamine inhibits the parasympathetic—the two 
forms of hypertonus being often associated though 
one of them may predominate. Experiments are held 
to show that the individual actions of belladonna and 
ergotamine are not impaired by mixing them in 
Bellergal and that the central sedative action of 
phenobarbital is increased. 'The remedy is prepared 
by Sandoz Products (134, Wigmore-street, London, 
W.1), and is recommended especially for the preven- 
tion of migraine and asthma, and the treatment of 


"BIRTHS, MARRIAGES, AND DEATHS 


[san. 11, 1936 


Graves’s disease, urticaria, pruritus, night-sweats, and 
functional nervous disorders. The dose proposed is 
3-4 tablets daily, or sometimes more. 3 


“ TABLOID ” BLAUD PILL AND CoPPER.—It has 
been suggested that the therapeutic action of iron is 
enhanced by the addition of minute quantities of 
copper. Quoting work by M. S. Rose (1932), Prof. 
L. J. Witts stated in our last issue that ‘‘in experi- 
mental animals iron can be absorbed and stored in 
the liver but cannot be converted into hæmoglobin 
unless copper is also present.” How far a physio- 
logical deficiency of copper can occur in the human 
beings is open to question, but the use of this metal 
in conjunction with iron may perhaps be effective 
in some cases where iron alone has failed. For the 
convenience of those physicians who favour its 
administration Messrs. Burroughs Wellcome and Co. 
(Snow-hill Buildings, London, E.C. 1) are now issuing 
Blaud Pill (pil. ferri carb. B.P.) and Copper in the 
form of Tabloids. Each contains 10 grains of the pill 
and 1/100 grain of copper sulphate. 


APONDON “ DiwaG’”’ is a preparation of thyroid 
recommended for use in obesity. The objection 
to using thyroid by itself is that it gives rise to 
symptoms such as tachycardia and restlessness, and 
in Apondon this obstacle is overcome, it is claimed, 
by the addition of a sympathetic depressant, Ergo- 
cholin ‘‘ Diwag,”’ made by the same firm, Dr. Joachim 
Wiernik A.-G., Berlin-Waidmannslust. Each pill 
includes 5'25 mg. of the Ergocholin and 114 mg. of 
standardised thyroid gland (= 0:5 mg. iodine) and 
the suggested dose is 1-2 pills daily at first and 2-4 
later. The preparation is distributed in this country 
by Messrs. Coates and Cooper Ltd. (94, Clerkenwell- 
road, London, 12.C.1). 


WE have received from the MARMITE Food Extract 
Company a booklet which sets out clearly under three 
main headings evidence of the potency of the product 
in the vitamin-B complex, of its efficacy in the treat- 
ment of certain anzemias, and of its value in tropical 
medicine. Some 70 recent references to medical 
literature are quoted in support of the claims made, 
and a dosage table and details as to administration 
are appended. 


Births, Marriages, and Deaths 


BIRTHS 


ANDERSON.—On Jan. 3rd, to Margaret (née Hutton), wife of 
Dr. E. W. Anderson. a son. ' 

BULL.—On Jan. Ist, at Devonshire-place, the wife of Dr. Cecil 
Bull, of a daughter. 

Dicks.—On Jan. 6th, at Blackheath, the wife of Henry V. 
Dicks, M.D. Camb., of a son. 

Macutay.—On Jan. 4th, at Kensington-square, W., the wife of 
the Hon. W. S. Maclay, M.D. Camb., of a daughter. 


MARRIAGES 


OWEN—CHIOZZA MONEY.—On Dec, 31st, 1935, at Caxton Hall, 
Thomas Owens, M.R.C.S. Eng. (Camb. and St. Bart.’s), to 
Gwendolen Doris, only child of Sir Leo and Lady Chiozza 
Money, of Bramley, Surrey. 

REWCASTLE-WOODS—LESTER.—On Nov, 30th, 1935, at Hong- 
kong, Dr. T. G. Reweastle-Woods to Bertha Iris Lester. 
(Address, Methodist Mission, Hankow, Hupeh, China.) 


DEATHS 


BrRowN.—On Jan. 3rd, at Bedford-square, W.C., Haydn Brown, 
L.R.C.S. Edin. 

COULDREY.—On Jan. Sth, at Scunthorpe, 
Reginald Couldrey, M.R.C.S. Eng. 

GIBSON.—On Dee. 27th, 1935, at Paradis, Grange, Guernsey, 
Kdmund Valentine Gibson, M.D. 

GRaY.—On Jan. dth, at Glasgow, Albert Alexander Gray, 
M.D. Glasg. 

Mornis.—On Dec. 31st, 1935, at Caerleon, Monmouthshire, 
Lieut.-Col. William Albert Morris, L.R.C.P. Edin., 
R.A.M.C. (retd.), in his 79th year. 

ORLEBAR.—On Jan. 2nd, at Hove, of acute pneumonia, Jeffery 
Alexander Amherst Orlebar, M.B. Camb, 

READ.—On Jan. 2ud, Mabyn Read, M.D. Camb., D.P.H., 
Medical Otlicer of Health for Worcester, 1891 to 1929, 
aged 81. 

WHITHK.—On Jan. 5th, at St. Bartholomew’s Hospital, Rochester, 
Clement John Goodhugh White, M.B. Camb., aged 27 years. 

N.B.—<A fee of Ts. 6d. is charged for thé insertion of Notices of 

Births, Marriages, and Deaths, 


Lincs, Thomas 


THE LANCET] 


JAN. 18, 1936 


ADDRESSES AND ORIGINAL ARTICLES 


DIABETES MELLITUS 


ITS DIFFERENTIATION INTO INSULIN-SENSITIVE 
AND INSULIN-INSENSITIVE TYPES * 


By H. P. Hrwswortu, M.D., M.R.C.P. Lond. 


DEPUTY DIRECTOR OF THE MEDICAL UNIT, UNIVERSITY 
COLLEGE HOSPITAL MEDICAL SCHOOL, LONDON 


IN previous publications! > it has been shown that 
the efficiency with which insulin acts in the body 
is governed by an unknown factor or condition 
which renders the body sensitive both to injected 
and pancreatic insulin. When this sensitising factor 
is limited the efficiency with which each unit of 
insulin depresses the blood-sugar is decreased, and 
when it is abundant the efficiency of each unit is 
correspondingly increased. It can easily be seen that 
if this sensitising factor is limited below a certain 
degree, then the insulin in the body will be relatively 
powerless and the symptoms and signs of hypo- 
insulinism, clinically recognisable as diabetes mellitus, 
will appear. This consideration led me to suggest 4 ë 
that a type of diabetes mellitus might exist which 
was due, not to lack of insulin, but rather to lack of 
this sensitising factor. An investigation of cases of 
diabetic patients from this point of view was 
therefore commenced. 

At first sight the simplest method of testing this 
hypothesis would appear to be by comparing in 
different diabetic subjects the rate and extent of fall 
of the blood-sugar after a standard dose of insulin. 
Such comparison of insulin depression curves from 
diabetic patients is, however, impossible. Insulin 
depression curves are only comparable when obtained 
from one and the same subject and, even then, only 
if the initial blood-sugar values of the different 
curves are within a few mg. per 100 c.cm. of the 
same level.’ <A new test was therefore sought and 
found in the application of an observation previously 
made on animals.* If glucose and insulin are given 
simultaneously to a normal animal, then the extent 
to which the injected insulin suppresses the hyper- 
glyczemia, consequent upon the administration of 
glucose, is determined by the sensitivity of the 
animal to insulin. This test has two great advantages 
over the insulin depression curve. Greater changes 
of the blood-sugar occur, and therefore minor variations 
consequent upon differences of the fasting blood- 
sugar level of the order of 50 mg. per 100 ¢.cm., may 
be disregarded ; the effect of insulin in suppressing 
hyperglycemia can be gauged by comparing the 
blood-sugar curve resulting from glucose alone with 

the curve resulting from glucose plus insulin. 


_ THE TEST 

The patient receives no food or insulin after supper 
the previous evening and the test is carried out next 
morning. Blood-sugar estimations are performed on 
capillary blood. Three resting samples are taken. 
The patient is given the appropriate dose of insulin 
intravenously and immediately afterwards the appro- 
priate dose of glucose to drink. A blood sample is 
taken 5 minutes after the insulin injection, the next 
at 10 minutes, and subsequent samples at intervals 
of 10 minutes until the hour is reached, and then 
two more samples at 15 minute intervals. Tho test 
is thus completed in 90 minutes. 


s Part of this work was done during the tenure of a Beit 
memorial research fellowship. 


5564 


The doses of insulin and of glucose can conveniently 
be based on the surface area of the patient. The 
patient’s height and weight being known this is 
determined from the appropriate nomogram.’ . In 
our tests 30 grammes of glucose and 5 units of insulin 
per square metre of body surface were allowed. The 
glucose was given dissolved in half a pint of cold 
water and flavoured with citric acid and essence of 
lemon ; the insulin used, for which I am indebted to 
Dr. J. W. Trevan of the Wellcome Physiological 
Research Laboratories, was a sterile solution of 
crystalline insulin assayed at 10 units per c.cm. 

Various precautions are necessary to obtain satis- 
factory results. Firstly, the test must not be carried 
out if the patient shows signs of nausea or faintness. 
In these cases absorption from the stomach is delayed 
and a fallacious result obtained. Secondly, if it is 
desired to compare a series of curves, the patients 
must all be receiving diets containing approximately 
the same amount of carbohydrate, as I have previously 
shown that the insulin sensitivity of a normal subject 
is determined by the amount of carbohydrate 


utilised. In the case of diabetics care sho be 
taken that sugar is not being excreted in tk@‘irthe 
in such amounts as to reduce materially thé. carbo 


hydrate supply of the body. Thirdly, conditi 
exercise will very probably affect the testez 


were hospital in-patients and advantage ye 
this fact to perform the test under ‘‘ basa} ê 


RESULTS 


clear that by means of this test diabet ay 
differentiated into two types: those in whem : 
injected insulin produces an immediate suppression 
of the hyperglycemia which normally follows ingestiom 
of glucose alone ; and those in whom the insulin has. 
little or no eflect in suppressing this hyperglycemia. 
In Fig. 1 a typical curve from each type of patient. 
is shown. In patient I. the insulin has had little 
effect, whilst in patient II. not only has the hyper- 
glycemia been suppressed but an actual depression of 
the blood-sugar level has been produced. Patient I. 
is insulin-insensitive ; patient II. is insulin-sensitive.. 
Point is lent to these results when it is noted that. 
patient I. passed only small amounts of sugar when 
receiving 20 units of insulin a day, whilst patient IT. 
required 95 units of insulin a day to keep her sugar- 
free. Reference to the curves marked “‘ capillary 
blood ”? in Fig. 2 show that in patient III., who is 
insulin-insensitive, there is very little difference 
between the curve after glucose alone (III. a) and the 
curve after giving the same dose of glucose and in 
addition insulin (III.B), whilst the capillary blood 
curves for the insulin-sensitive patient IV. differ 
widely when in one case only glucose is administered 
(IV. A), and in the second glucose and insulin (IV. B). 

It may here be noted that the curve in healthy 
subjects approximates to that of the insulin-sensitive 
diabetics.” The curve obtained in this type of 
patient (II. and IV.) thus appears capable of easy 
explanation as being the result of normal insulin 
action. 

The curve in the insulin-insensitive patients 
(I. and III.) is more diflticult to explain. Three 
distinct possibilities offer themselves: (i) the liver 
may be pouring so much sugar into the blood that 
the effect of the injected insulin is swamped ; (ii) the 
liver may be incapable of storing the ingested sugar ; 
(ii) the characteristic action of insulin in promoting 

o 


128 THE LANCET] 


DR. H. P. HIMSWORTH: TWO TYPES OF DIABETES MELLITUS 


[JAN. 18, 1936 


storage of blood-sugar in the peripheral tissues may 
be unable to manifest itself. The first two possibilities 
involve the portal system, the third the peripheral 
tissues. If now it is possible to compare the removal 
of sugar by the peripheral tissues, firstly, when 
slucose is given alone, and secondly, when glucose 
is given along with insulin, the site of the functional 
derangement can be localised either to the periphery 
or to the portal system. This can be done by measur- 
ing the sugar content of the blood entering a hmb 
and the sugar content of the blood leaving the limb. 
I have shown that capillary blood taken from the 
warm ear has approximately the same sugar content 
as arterial blood, and also that venous blood specimens 
taken under identical conditions from the same half 
inch of vein in all tests on the same subject give 
a reliable if only relative indication of the sugar 
content of the blood leaving the limb.? By per- 
forming simultaneous curves on capillary and venous 
blood (A.V. curves) after ingestion of glucose and 
after glucose and insulin, and comparing the size of 
the capillary venous blood difference (A.V. difference), 
a’ rough estimation can be made of the extent to 
which insulin promotes peripheral storage in a 
particular case. In the normal subject the giving of 
insulin along with glucose results in a tremendous 
increase in the A.V. difference as compared with the 
increase of A.V. difference after glucose alone.? This 
increase is so great as to be quite outside the limits 
of experi- 
mental error. 
A.V. curves 
were, there- 
fore, per- 
formed on 
both insulin - 
sensitive and 
insulin-insensi - 
tive diabetics. 
The results 
are shown in 
Fig. 2. 

In the insu- 
lin-sensitive 
patient IV. 
insulin had the 
normal elfect 
of greatly aug- 
menting the 
A.V. diference 
after glucose. 
Up to 60 min- 
utes the area 
enclosed be- 
tween the 
capillary and 
venous blood- 
sugar cnrves of 

. curve IV.B, as 
compared with 
curve IV.a, in- 
creased by 120 
per cent. 

In the insu- 
lin - insensitive 
patient the 
effect is quite 
different. On 
comparing 
curve III.a 
(glucose alone) 
with curve 
III.B (glucose 


CLUCOSE + 
INSULIN 


Blood Sugar mgf/00 cem. 


O 10 30 50 70 90 110 
Time in Minutes 


FIG. 1.—Simullancous glucose and insulin 

test. Capillary blood-sugar curves. 

Patient I.—Insulin-insensitive. Woman, 
aged 60, on a dict of 1500 calories 
containing carbohydrate 150 g., protein 
80 g., fat 66 g., and 35 units of in- 
sulin daily. Passing small amounts of 
sugar. 

Received 73 units of insulin intra- 

venously and 4378 g. of glucose orally. 

Fasting blood-sugar 208 mg./100 c.em. 

Patient 11,—Insulin-sensitive. Woman, 
aged 21, on a dict of 2000 calories 
containing carbohydrate 208 gœ., protein 
80 g., fat 94 g., and 95 units of insulin 
daily. Sugar-free. No hypoglycemic 
attacks. 

Received 7 units of insulin intravenously 

and 41 g. of glucose orally. Fasting 

blood-sugar 244 mg./I00 c.cm. 

The curves have been charted so as to 

ota at the same resting blood-sugar 

evel. 


+ insulin), it will be seen that the insulin has resulted 
in little or no increase of A.V. difference. By actual 
measurement of the areas enclosed between the 
capillary and venous blood-sugar curves the increase 
is found to be the negligible figure of 9 per cent. 

It may thus be seen that, in the insulin-insensitive 
diabetic, insulin is unable to exert its characteristic 
action of effecting the transference of sugar from the 
blood to the peripheral tissues; that even if the 
insulin-insensitive patient possessed a normal supply 
of pancreatic insulin such insulin would be unable to 
act efficiently and the patient would be diabetic. On 
the other hand, it is seen that in the insulin-sensitive 
diabetic insulin is able to act, that the giving of this 
substance produces a normal reaction, and that, 
therefore, if these diabetics had a greater supply of 
pancreatic insulin, they would show no signs of 
diabetes mellitus. 

It therefore appears that in insulin-sensitive 
diabetics the disease is due to deficiency of insulin, 
whilst in insulin-insensitive patients diabetes mellitus 
results, not from lack of insulin, but from lack of an 
unknown factor which renders the body sensitive to 
insulin. 

CLINICAL OBSERVATIONS 

Sufficient data have not yet been accumulated to 
permit a precise correlation between the clinical 
findings and the type of diabetes mellitus as revealed 
by the glucose-insulin test. But enough observations 
have been made to allow certain tentative opinions 
to be expressed. 

A general relationship appears to exist between the 
type of onset of the disease and the type of diabetes. 
The onset in insulin-sensitive patients is as a rule 
acute; the onset in insulin-insensitive patients is 
insidious. For example, in the _ insulin-sensitive 
patient II. (a girl aged 21), the diabetes mellitus 
appeared with intense symptoms, and within 48 hours 
the patient was in coma; in the insulin-sensitive 
patient IV., a man aged 48, the disease came on 
suddenly in December, 1930 ; in the insulin-insensitive 
patient I., a woman aged 60, the patient developed 
vulvitis without symptoms of thirst or polyuria, the 
urine was tested and sugar was found; and in the 
insulin-insensitive patient III., a man aged 60, 
sugar was discovered fortuitously at a life insurance 
examination seven years ago, but none of the classical 
symptoms of diabetes mellitus have ever been noted 
and no therapeutic measures were taken until he 
developed first an external rectus and later a facial 
nerve palsy. The insulin-insensitive type is more 
common in but not confined to the elderly, whilst 
the insulin-sensitive type is commoner in the young. 
As diabetes mellitus becomes more frequent with 
increasing age it would appear probable—and my 
experience so far supports this deduction—that the 
commonest type of diabetes mellitus will eventually 
prove to be that which is not essentially due to 
insulin deficiency. 

A further observation concerns the diflerent reaction 
of the two types to change in the carbohydrate 
content of the diet. When high carbohydrate diets 
were first introduced the claim was made that the 
carbohydrate content of the diabetic’s diet could be 
raised from the 50g., then orthodox, to 200¢., 
without necessitating any increase in insulin dosage. 7-9 
It has been my experience that in many cases this 
claim is true, but it has been denied by other observers. 
The differentiation of diabetics into Insulin-sensitive 
and insulin-insensitive types seems to provide the 
key to the discrepancy. In the cases examined so far 
it appears that insulin-sensitive diabetics will tolerate 
large increases of carbohydrate in the diet with little 


‘ 


THE LANCET] 


[JaN. 18, 1936 129 


DR. H. P. HIMSWORTH: TWO TYPES OF DIABETES MELLITUS 


or no increase in the amount of insulin required to 


keep the urine sugar-free ; insulin-insensitive patients, 


on the other hand, pass sugar after only small 
increases in dietetic carbohydrate. For example, 
patient I. was always sugar-free when taking a diet 
containing 67g. of carbohydrate and 20 units of 
insulin a day. Increase of the carbohydrate to 148 g., 
whilst keeping the calorie value of the diet the same, 
resulted in profuse glycosuria which was not controlled 
by 35 units of insulin a day. On admission, 
patient II., who was insulin-sensitive, was receiving 
a diet containing 65g. of carbohydrate and was 
taking 45 units of insulin a day. Her physician had 
been quite unable to balance her, she was extremely 
wasted, and her urine contained sugar and ketones 
in large quantities. She was given a diet containing 
200 g. of carbohydrate a day and rendered sugar- 
free with 95 units of insulin daily. After ten days of 
complete control, in which no hypoglycemic attacks 
occurred, she was given an equicaloric diet containing 
320 g. of carbohydrate. Glycosuria did not appear 
and some days later the insulin dose had to be 
reduced because of hypoglycemic attacks. 

It thus appears that the differentiation of diabetics 
into insulin-sensitive and insulin-insensitive types by 
means of the insulin-glucose test may prove to be of 
considerable practical importance as offering a means 
by which the appropriate diet can be chosen for the 
particular case. It is hoped that other- observers 
will attempt to arrive at an opinion on this point. 
One thing, however, I would make clear. The 
observation that on a low carbohydrate diet a 
particular diabetic requires least insulin is no proof 
that the diet is the optimum from the point of view 
of the preservation of his health. 


DISCUSSION 


I have said that I think it probable that in those 
cases of diabetes mellitus which are insulin-sensitive 
the cause of the disease is deficiency of insulin, whilst 
in those cases which are insulin-insensitive the 
cause of the disease is not lack of insulin, but the 
restriction, to a greater or less degree, of an unknown 
sensitising factor. In previous publications I have 
communicated the results of work on healthy men 
and animals which demonstrated the existence of a 
factor rendering the body sensitive to insulin.‘ 5 
It is of interest to inquire whether it is the restriction 
of this same factor demonstrable in healthy subjects 
which is responsible for the insulin insensitivity of 
a type of diabetes. 

A characteristic of the insulin-sensitising factor 
of normal people is that the quantity of it present 
in the tissues at any time is determined by the amount 
of carbohydrate in the diet. When more carbo- 
hydrate is given to a healthy subject the body reacts 
by rendering itself more sensitive to insulin. Now 
it has been shown in the previous section that when 
more carbohydrate is given to an insulin-sensitive 
diabetic the insulin requirement does not increase 
and glycosuria does not appear. I have shown 
elsewhere * that this apparent increase in efficiency 
of the injected insulin can satisfactorily be explained 
on the basis that these patients react to the increased 
amount of dietary carbohydrate by becoming more 
sensitive to the injected insulin. But in the case of 
the insulin-insensitive diabetic increased intake of 
carbohydrate results in glycosuria and consequent 
increased insulin requirement. Thus, these patients 
are abnormal in being unable to react to increase in 
dietary carbohydrate by increase in their sensitivity 
toinsulin. It appears, therefore, justifiable to regard 
the insulin-insensitive type of diabetes as being due 


Blood Sugar mg [100 ccm. 


CLUCOSE 
INSULIN 


0 20 40 60 0 20 40 60 
Time in Minutes 


FIG. 2.—Simultanecous glucose and insulin test. Simultaneous 
capillary and venous blood-sugar curves (A.V. curves). 
Patient IJI.—Insulin-insensitive. Man, aged 61. 

Curve IIIa.—53 g. of glucose by mouth. Resting 
capillary blood-sugar 149 mg./100 c.cm., venous 
blood-sugar 147 mg. 

Curve IIIb.—53 g. of glucose by mouth immediately 
preceded by 88 units of insulin intravenously. 
Resting capillary blood-sugar 141 mg., venous 
blood-sugar 139 mg. 

Receiving a diet of 1570 calories containing carbohydrate 
210 g., protein 70 g., fat 60 g. forthe previous ten months. 
Insulin dosage raised steadily until, on admission to hos- 
pital, was receiving 85 units of insulin. This was inade- 
quate. Every specimen of urine passed gave a complete 
reduction of Benedict’s solution, and no hypoglycemic 
attacks occurred. i 
Patient IV.—Insulin-sensitive. Man aged 48. 

Curve IVa.—*50 g. of glucose by mouth. 
capillary blood-sugar 152 
147 mg. 

Curve 1Vb.—50 gœ. of glucose by mouth and 5 units 
of insulin intravenously. Resting capillary blood- 
sugar 171 mg., venous blood-sugar 169 mg. 

Receiving a diet of 2493 calories containing carbohydrate 
238 g., protein 102 g., fat 115 g., and 20 units of insulin 
aday. Consistently sugar-free. 


* These doses of insulin and glucose were chosen before the 
scheme of dosage based on surface area was adopted. The dose 
on surface area would have been 58 g. of glucose and 9°7 units 
of insulin. 


Resting 
mg., Venous blood-sugar 


to lack of that same unknown factor which in the 
normal subject produces sensitivity to insulin. 

On the balance of the evidence available I have 
suggested that this insulin-sensitising factor is an 
activator of insulin,} ? but as yet there is no incon- 
trovertible evidence whether the unknown is a factor, 
in the sense of being a definite substance, or a condi- 
tion of the tissues in general which facilitates the 
action of insulin. -It will be seen, however, that the 
nature of the unknown “ insulin-sensitising factor ” 
must be such that it is intimately concerned with the 
action of insulin and that its restriction will result 
in rendering a proportionate amount of the available 


insulin powerless. 


The term insulin insensitivity has been used in 
preference to the term insulin resistance for two 


130 
reasons. Firstly, because in my investigations into 
the variations of insulin sensitivity in normal subjects 
I have seen no evidence of any factor which 
antagonises or resists the action of insulin itself, but 
only evidence indicating the presence of a factor which 
is complementary to insulin. Secondly, because 
the term insulin resistance has already been used 
with two different meanings.!° In one sense it 
appears to mean simply that the patient requires 
more insulin to produce hypoglycemic symptoms 
than the physician expected. In the other sense 
it refers to those rare cases in which enormous doses 
of insulin, such as 1600 units a day, are insufficient 
to prevent the patient developing and dying in diabetic 
coma.14 12 These latter cases cannot be explained 
on the basis of lack of insulin, but I would suggest 
that they can be explained on the basis of extreme 
deficiency of the insulin-sensitising factor. 


THE LANCET] 


SUMMARY 


It is shown that two different types of disease 
can be distinguished as causing the symptom-complex 
of diabetes mellitus. One, the insulin-sensitive type, 
appears to be caused by deficiency of insulin; the 
other, the insulin-insensitive type, is apparently due 
not to lack of insulin, but to lack of an unknown factor 
which sensitises the body to insulin. A test for 
distinguishing these two types of diabetes mellitus 
is described. The appropriate dietetic treatment 
of the two diseases may differ. 


“ADDENDUM 


Since this paper was written I have read a publi- 
cation by Boller and Uiberrack in the Falta-festschrift 
(Wien. Arch. f. inn.: Med., 1935, xxvii., 75) which 
bears on these results, These workers chose diabetics 
of two types: those who required less insulin than 
was estimated to produce hypoglycemic attacks, the 
‘‘insnlin-sensitive’’ group, and those who required 
more insulin than was expected, the ‘“insulin- 
resistant” group. Amongst the different experiments 
performed one series is relevant to this paper. 
Insulin was injected and some hours later when 
hypoglycemic symptoms appeared glucose was given 
by mouth. In the “insulin-sensitive’’ group the 
oral glucose resulted in a smaller hyperglycemia 
than in the “ insulin-resistant ”’ group. The authors 
explain their results by the varying sensitivity, in the 
two types of case, of the mechanism which causes 
liberation of sugar into the blood stream. As my 
results show, this cannot be the explanation ; for 
the difference is due not to swamping of insulin 
action by pouring of sugar into the blood, but to 
deficient. removal of blood- -sugar due to inefficient 
insulin action. Their results, however, are of 
importance as showing that the type I have called 
insulin-sensitive easily “develops hypoglycæmic symp- 
toms, whilst the type named insulin-insensitive 
develops these symptoms with difficulty. 


REFERENCES 


»- Himsworth, H. P.: THE BASOEI ha li., 935. 

. Same author: Clinical Sci., 1933, 

. Same author: Jour. of Physiol., 1934, Ixxxi., 29. 

. Same author: Brit. Med. Jour., 1934, ii., 57. 

. Same author: Clinical Sci., 1935, ii., 

Peters, J. P., and van Slyke, D. ae : 

Chemistry, ‘London, 1931, vol.i., p. 21. 

Richardson, R.: : Amer. Jour. Med. Sci., 1929, clxxvii., 

; Rabinowiteh, Í, M.: Diabetes Mellitus, Toronto, 

xiii 

A Adler bere, D., and Porges, O.: Die Behandlung der 
Zuckerkrankbeit mit fettarmer Kost, Berlin, 1929. 

10. Joslin, E. P.: The Treatment of Diabetes Mellitus, Phil- 

adelphia, 1 1935, p. 294. . 
11. Root, H. F.: New Eng. Jour. Med., 1929, cci., 201. 
12. Tannhauser, S. J., and Fuld, H.: Klin. Woch., 1933, i., 252. 


r` 
ad 


7. 
Quantitative Clinical 


426, 
1933, 


O ON GON es dO pi 


PROF. G. GREY TURNER : CARCINOMA OF THE ŒSOFHAGUS 


[JaN. 18, 1936 


CARCINOMA OF THE ŒSOPHAGUS 


THE QUESTION OF ITS TREATMENT BY 
SURGERY 


By G. GREY TURNER, M.S., F.R.C.S.. 
(Bradshaw Lecture concluded from p. 72) 


Œsophagectomy 

It may be taken as an axiom that it is not practical 
to excise a sufficient length of the cesophagus for 
cancer and to make a union in situ, for the ends 
cannot be opposed without tension if more than 
4cm. is removed. This amount would not be 
sufficient for the eradication of any malignant 
neoplasm likely to be met with. A study of cancer 
of the esophagus and its mode of spread shows that 
we must excise not only a sufficiency of healthy 
tube on either side of the growth, but as much extra 
cesophageal tissue as possible. Most growths are 
from 1 to 3 in. in length and because of the tendency 
to spread up and down under the mucosa, at least 
14 in. and better 2 in. should be removed beyond the 
margin of the growth on either side. In other words, 
it is essential to remove a large section of the œso- 
phagus if the ablation is to hold out any prospect of 
eradicating the disease. Many growths are of such 
longitudinal length that nothing short of removal of 
the whole wsophagus can hold out any chance of 
success and any more limited excision is bound to 
be attended by recurrence. If these requirements 
are admitted, then it can only be in a few cases of 
carcinoma of the lower end that a direct anastomosis 
can be made between the mobilised stomach or the 
small bowel by the abdominal or abdomino-pleural] 
route. Even if it is justifiable to contemplate this 
plan, it must be realised that the actual junction will 
have to be made to that part of the cesophagus 
where its blood-supply is the most precarious. In 
most cases when this has been attempted there has 
been leakage at the suture line. 

Some of the operations for excision of the œso- 
phagus which have been recommended and which 
are freely illustrated in books must be looked upon 
as largely armchair exploits and doomed to failure 
in practice. This especially applies to those methods 
which must rely for their success on the isolation 
of a considerable area of the esophagus, which is 
thus denuded of its blood-supply at the part which 
is to be anastomosed to the stomach. Similarly 
those procedures which depend for their success on 
the displacement of a large part of the stomach into 
the chest have not been successful, largely because 
of the failure of the blood-supply of the displaced 
viscus, After all, the one essential is to remove the 
growth as completely and widely as possible and 
without reference to the repair of the csophagus. 
If the patient can be safely piloted over this ordeal, 
the restoration of the power of swallowing need not 
present an insuperable problem. 

There can be no doubt that in many cases in the 
past the real difficulty has been that associated with 
the exposure of such a deep-seated organ. In recent 
times however, since the practical methods of 
approach have been better understood, I think one 
may say that what has defeated our efforts on most 
occasions has been the comparatively advanced 
Stage at which the patients reach us. As a rule it 
is possible to determine the presence of distant 
dissemination, but our methods of assessing the 
local extension of many of the growths have not 
been sufficiently helpful and definite to enable us 


THE LANCET] 


to say at what stage local fixation by extension of 
the growth has gone too far for possible removal. 

Another great difficulty has been the question of 
infection of the cellular tissue. In my own cases 
some of the deaths have been due to technical errors 
which could be avoided. When I first contemplated 
the possibility of removing growths by the *‘ pull- 
through ” method, my principal concern was the 
question of hæmorrhage, and that still remains a 
main consideration. Though it may not be serious 
as borne out by several cases, including the one 
completely successful issue, one must admit that 
in those that have died this factor has sometimes 
played a considerable part. 


CHOICE OF METHOD 


As the result of the considerations which I have 
put before you I have formulated certain definite 
though admittedly tentative conclusions for my own 
guidance. If in a case of known cancer of this tube 
there is no evidence to show that there is already 
dissemination and nothing to suggest that local 
fixation is well marked, then I would undertake 
operative measures for its removal. 

There are many successful cases on record of exci- 
sion of malignant growths of the cervical csophagus 
with restoration by plastic reconstruction with skin 
flaps. Most of these have really been growths of the 
lowest part of the pharynx and commencement of 
the csophagus. The results have sometimes been 
very wonderful and encouraging, and the methods 
employed are now established surgical procedures, 
But I have only in mind growths which are strictly 
in the csophagus at the root of the neck. In such 
cases the growth usually extends below the level 
of the manubrium in such a way that it is not pos- 
sible to remove it with a sufficient margin of healthy 
tissue on either side and at the same time to make 
a plastic restoration. The problem is therefore the 
Same as in connexion with the growths in the posterior 
mediastinum. When the growth is in the upper 2 or 
3 inches the approach should be from the neck in 
the firstinstance. Ifit can be separated all round with 
the finger, then I should be prepared to pursue this 
as far down as it could be conveniently reached from 
the neck. If it were possible to ligature or to clamp 
the esophagus well below the growth, then I should 
cut it across and bring the upper end out on to the 
chest wall as I have already described. If divided 
by the cautery or divided and thoroughly carbolised 
and bipped, the lower end of the wsophagus may be 
relied upon to look after itself and probably the 
upper part of its bed would become safely obliterated. 

If the growth is situated in the lower 2 or 3 inches, 
then the approach should be from the abdomen. 
If the growth could be separated all round and the 
lower part of the wsophagus mobilised, then I would 
suggest that the case is worth the complete “‘ pull- 
through ” operation, and I would endeavour to carry 
out extirpation by that means. If, on the other 
hand, the growth was situated in the middle of the 
thoracic csophagus, then my present view would 
be in favour of either the ‘“ pull-through’’ method 
or a combined posterior mediastinal and transpleural 
exposure, completing the procedure as in the successful 
case operated upon by Torek. The lower part of the 
csophagus divided not less than two inches below the 
growth is left behind. 

In deciding the route to be employed in any con- 
templated excision the type and build of the patient 
must be taken into consideration. Those of short 
stature, even though the chest is voluminous, have 
shorter cesophageal tunnels than others, and condi- 


PROF. G. GREY TURNER: CARCINOMA OF THE GSOPHAGUS 


(yan. 18, 1936 131 


tions are still more favourable if there is marked 
kyphosis. In such subjects it is possible to make 
the fingers meet in the tunnel when passed from 
the neck and the abdomen. For the same sort of 
reason those who are rather tall and slight present 
a much easier problem for the transpleural approach. 
The type of costal angle gives a very good indication 
of these anatomical differences. 


SELECTION AND PREPARATION OF PATIENTS 


It will be well in considering this matter to be 
guided more by the vigour, physique, and especially 
courage of the patients, than merely by terms of 
years, It is most important that these patients 
should have a great desire for food and an ardent 
wish to have the power of swallowing restored. 
Above all, I think it is important that they should 
have proved that they are suffering from a mechanical 
disability rather than absorption or cachexia, as 
shown by the fact of their great and striking improve- 
ment after gastrostomy or jejunostomy. I should 
just like to say that I believe the majority of patients 
with gastrostomy will recover better in their own 
homes. In hospitals the routine of feeding may be 
quite in keeping with physiological requirements, but 
it takes little note of those psychological factors 
concerned in digestion and nutrition. At their own 
homes the patients may find it easier to establish 
a régime which will satisfy both requirements, and 
as a result it is often found that they do better in 
these circumstances. 

The question of the preliminary collapse of one or 
other lung is very important, but so far as this step 
is concerned I am prepared to occupy a position of 
suspense. In my completely successful case I con- 
templated collapsing the left lung, thinking that any 
injury to the pleura was most likely to occur on that 
side. As a matter of fact it was well that J did not 
do so, for it was the right pleura which happened to 
be opened at the operation. At the same time I 
certainly think that if it is proposed to adopt the 
transthoracic route, then it would probably be wise 
to have the corresponding lung collapsed as a pre- 
liminary. The mere opening of the pleura need not 
in itself be serious, and, in fact, I know from actual 
experience that both sacs may be opened without 
any positive pressure arrangements and the patient 
may easily survive the accident. But there is another 
reason why it is most important that the pleura 
should be preserved intact if possible, and that is so 
that hemorrhage may be circumscribed by the intact 
esophageal tunnel. I believe that when the pleura 
is opened it is much more likely that bleeding will 
continue after the cesophagus has been separated 
from its bed, and in several cases J have been struck 
by the amount of blood which may be found in the 
pleural sacs in these circumstances. 


Operative Details 

“ There is a time and a way in which all things can be 
done; none shorter—none smoother. For all noble 
things, the time is long and the way rude... .”—John 
Ruskin. l 

The story of the introduction of the ‘‘ pull-through ” 
or collo-abdominal method was related in my Bigelow 
lecture in 1931, and it is not necessary to repeat it 
here. Suffice it to say that the first ‘‘ pull-through ” 
operation was completed in December, 1927. Having 
been fortunate enough to carry the method to a 
successful issue in one case and to have come very 
near success in others, one feels that it may now 
be looked upon as a surgical procedure which is, at 
least, provocative of serious consideration. When 


132 THE LANCET] 


called upon to repeat that operation, I would incor- 
porate the folowing modifications :— 


(a) A better approach from the neck to be obtained by 
the excision of the inner half of the clavicle. 

(6) Taking much more care to distend the cellular 
tissue by injection and to carry out the enucleation with 
especial gentleness and deliberation. 

(c) The completion of the removal by drawing the 
cesophagus up into the neck, rather than downwards into 
the abdomen. . 

(d) Allowing the œsophagus, withdrawn from its bed, 
to lie free on the front of the chest until such time as the 
cellular tissue spaces of the neck and thorax are safely 


shut off. 
(e) Taking more active steps to combat hæmorrhage 


and delayed shock. 


To gain access to the upper mediastinum the removal 
of the inner half of the clavicle is of great assistance. 
This step was suggested by a study of a preparation 
of the inlet of the thorax given me by Sir James 
Berry. I first employed the method in carrying out 
exploration of a growth of the upper part of the 
esophagus, and it proved so helpful that I have 
continued to use it. Still further room may be 
obtained by cutting away the upper left corner of 
the manubrium sterni, but I have not usually found 
this to be necessary. The removal of so much of the 
clavicle does not appear to interfere materially with 
the usefulness of the arm. The idea underlying the 
second modification has been mentioned in the 
section on anatomy, and J feel sure it has been helpful. 
The withdrawal of the esophagus upwards seems to 
have the advantage that it is but retracing the steps 
imposed upon it in the process of development, 
and, moreover, vessels and nerve-fibres are more 
likely to separate easily and tear, if pulled against 
the direction in which they normally grow. Further, 
this upward withdrawal greatly facilitates the next 
modification of importance, for it is desirable to 
have as long a portion of esophagus as possible to 
bring out of the wound. The idea of allowing the 
esophagus to lie well out of the wound until such 
time as the cellular tissue is shut off is thoroughly 
sound and practical; moreover it is in keeping 
with the known success of the two-stage method 
of dealing with pharyngeal diverticula. I first 
thought of and noted this plan in January of 1931 
and yet, so treacherous is memory, that it was 
subsequently overlooked in two cases which I always 
believe would very probably have recovered had it 
been adopted. 


The last modification is almost self-evident, but I 
- venture to think it is of first moment. There is so 
great a risk of reactionary or recurrent hemorrhage 
that every means possible should be taken to anti- 
cipate its onset, and for this purpose most careful 
hemostasis at the time of operation and early hemo- 
static blood transfusion are essential. If it is not 
justifiable to regard the growth as early and probably 
free from fixation, it would be wiser to adopt Torek’s 
approach so that the exact condition could be inves- 
tigated under the guidance of the eye before any 
attempt was made at removal. By this plan even 
pleura adherent to the growth might be excised, and 
very careful and deliberate separation can be carried 
out and more care exercised in the control of bleeding. 
In these operations the hemorrhage is mostly venous 
and can be controlled by very light pressure, and if 
the pleura is not opened there is much likelihood of 
it being spontaneously arrested. Should it be too 
free, as shown by its escape from the tunnel into 
the abdomen or the neck, it may be controlled by 
temporarily inserting a gauze strand, taking the 


PROF. G. GREY TURNER: CARCINOMA OF THE CGSOPHAGUS 


. to be good condition, 


Se ee 


[yan. 18, 1936 


greatest of care not to damage the pleura during 
its introduction. Snake venom as a hemostatic may 
also prove valuable; I have not as yet employed 
it. Another plan, which I have contemplated, 
is to introduce a rubber tampon made of the large 
size colotomy tubing. This could be drawn into 
the abdomen from the neck or vice versa, a stiff 
oesophagus tube being used as a pilot. The colotomy 
tubing would be introduced in the collapsed state 
and inflated with air or hot fluid when in situ. 
Having served its purpose, the tampon could be 
gradually deflated and withdrawn a little at a time 
in order to allow the empty tunnel to collapse. 


Review of Lessons Learnt 


It is very surprising how few of the patients have 
actually died as the immediate result of the opera- 
tion. This has only been the case in one patient, an 
example of a posterior mediastinal removal in which 
the patient succumbed before leaving the theatre, 
but that was an advance case in which the growth 
was very adherent and had to be peeled off the aorta. 
As a rule the patients have left the operating table 
in wonderfully good condition, and in many of them 
the condition for several hours, that is to say until 
some other and secondary changes have taken place, 
has not given rise to anxiety. Some of the opera- 
tions have really been of great magnitude, and one 
would have expected them to be attended or followed 
by great shock. In the patient who completely 
recovered the operation took 1 hour and 40 minutes, 
and was very well borne. In a recent case, a not 
robust old lady of 75, the operation lasted the same 
length of time. The csophagus was exposed by the 
transthoracic route and the growth removed (Fig. 3), 
but both the neck and the abdomen had to be opened 
to remove either end. 
In spite of so severe an 
ordeal the general con- 
dition was wonderful 
throughout, and she 
returned to the ward 
in what was considered 


| 

| 

j 

Any operation des- 
tined to remove an 
organ like the œsopha- 
gus is in itself a very 
major proceeding which 
must be a severe tax | 
on elderly people whose 
nutrition has been seri- 
ously imperiled before 
the operation is under- 
taken. Most deaths 
have occurred within | 
12 to 24 hours, and the 
inchnation is to put 
them down to delayed 
shock, but the autopsy 3 
usually furnishes | 
another explanation, 
In four cases of collo- 
abdominal removal, in 
which a post-mortem 
examination was made, 
the pleura was torn on 
both sides in one and 
on the left in the others, i 
with hæmorrhage into 
the pleural cavity in all. 
This bleeding was of 


— 


FIG. 3.—Well-developed carci- 
noma, with only four months’ 
history, removed by trans- 
thoracic route, 


THE LANCET] 


variable quantity and was undoubtedly often 
exaggerated in amount by admixture with pleural 
exudation, but in each case I was satisfied that the 
amount was enough to contribute largely to, if not 
to explain, the fatal result. Bleeding has never been 
alarming at the time of the operation, but it probably 
slowly continues for some hours after the inter- 
ference, so that the 
patients may be ...- .--~-- 
said to run the risk 
of bleeding to death 
into their own 
pleural cavities. , In | 
the cases in which | 
a transpleural | 
approach has been 
used there was also 
bleeding into the 
pleural cavities, 
despite the fact that 
in these patients the 
operation was con- 
ducted under the 
guidance of the eye 
and no obviously 
bleeding points were 
left unattended. 
One can only con- 
clude that there is 
a risk of continued 
oozing, and that 
when the pleura 
remains intact it is 
restrained by the 
confines of the tun- 
nel. Even when the 
pleura is not torn 
there is usually 
some retropleural .. 
hemorrhage, but it — 
has never been 
great in amount and 
I have never seen 
anything more than 
a localised hema- 
toma. In no case 
has there been any 
considerable hæmor- 
rhage into the peri- 
toneal cavity, prob- 
ably because of the 
close of the abdomi- 
nal hiatus. This is 
brought about by stitching the left lobe of the liver 
over the aperture or packing the lower end of the 
tunnel with omentum. 

In an endeavour to guard against injury to the pleura 
I have injected quantities of weak local anesthetic into 
the cellular tissue surrounding the csophagus with the 
idea that the bulk of fluid would push aside the serous 
membrane and would also open up the cellular spaces, 
thus making separation easier and facilitating the removal 
of the cesophagus, while reducing traumatism to the 
minimum, If it was known to have occurred, then the 
most important factor in reducing any evil results is 
probably the complete expansion of the lung. 


In those cases that survived the first 24 hours, 
death was due to sepsis in some form. In no case 
was there an acute spreading mediastinitis, but in 
two there was a low form of infection. The three 
cases that lived 7 days, 8 weeks, and 9 days respec- 
tively were most instructive, for in each there was 
the most wonderful evidence of repair of the media- 


trouble. 


PROF. G. GREY TURNER: CARCINOMA OF THE CESOPHAGUS 


FIG. 4.—The parts removed from a patient who died nine days after excision 
of the cesophagus by the ‘ pull-through ” method. 
beautifully demarcated, and there is no evidence of spreading inflammatory 

The inset shows the upper aperture from the front. 


é 
[zan. 18, 1936 133 


stinal tunnel. The main features of the first two of 


these cases were described in a discussion at the 
Royal Society of Medicine in December, 1933.4 A 
more recent case operated upon at the Hammersmith 
Hospital was equally instructive and encouraging 
and for our purpose more useful, as I am able to 
show you the parts (Fig. 4). 


The patient was a 
man, 60 years of age, 
who was admitted to 
hospital with only 
two months’ history 
of difficulty in swal- 
lowing. Investigation 
disclosed an occluding 
growth opposite the 
fourth dorsal verte- 
bra. It was removed 
by the collo-abdo- 
minal method with- 
. out any special diffi- 
| culty. By a most 
' unhappy mischance 

which I shall always 
regret the œsophagus 
was cut too short in 
the neck. As a result 
its lower edge separ- 
ated from the skin 
and retracted expos- 
ing the cellular tissue 
deep in the neck to 
infection from saliva, 
&c. All our efforts to 
i control the ravages 
| of this disaster were 
' of no avail. The 
| wound in the neck 
further separated and 
left the entrance to 
the mediastinum 
widely exposed. 
Saliva and discharge 
found their way into 
the cesophageal bed, 
and some ounces of 
infected fluid were 
sucked up from this 
pocket several times 
a day. As a result 
his condition deteri- 
orated and the gas- 
trostomy began to 
leak. This was re- 
paired, but nutrition 
was too much under- 
mined and death oc- 
curred on the ninth 
day following’ the 
operation. An examination after death showed bilateral | 
broncho-pneumonia with old healed fibrocaseous tubercle 
of the right lung. The bed from which the cesophagus 
had been removed was safely sealed at its lower end, and 
for the rest was beautifully shut off by organisation of 
its wall. The latter was smooth and regular and covered 
with small healthy granulations. It was an example of 
perfect preparation for healing and a wonderful exhibition 
of what nature can do. Although the cavity had been 
flooded with infected material for at least a week there 
was no evidence of any active infection whatever, and on 
microscopical examination very few organisms could be 
found. 


The naked-eve appearances were confirmed by the 
microscope, and sections made from the upper end of the 
cesophageal tunnel showed a typical layer of granulation 
tissue with fibroblastic proliferation and an infiltration 
with macrophages, but very few polynuclears. One 
vessel in the deeper part showed endarteritis. Staining 
showed some Gram-negative cocci limited to the surface 


— ~ . : 4 


The *‘ tunnel ” is 


“Proc. Roy. Soc. co 1934, xxvii., 355. 
C b 


134 THE LANCET] - 


PROF. G. GREY TURNER: CARCINOMA OF THE CSOPHAGUS 


[yan. 18, 1936 


layer. At the lower end of the tunnel the section showed 
an essentially similar picture, only here the tissue was 
looser and the limits of the area of granulations- less 
distinct. The surface also showed a thick layer of fibrin 
but no organisms were seen. 


This risk of infection of the upper part of the 
esophageal tunnel can 
probably be avoided by 
deferring the actual ex- 
cision of the esophagus 
until some days after 
its enucleation, The 
use of B.I.P.P. may also 
be of some little help ; 
it is smeared over the 
end of the cut csopha- 
gus before it is with- 
drawn and is rubbed 
into the walls of either 
end of the tunnel. 

During the process 
of separation of the 
csophagus and during 
its actual removal, great 
care must be taken not 
to tear it, and complete 
mobilisation must pre- 
cede any traction. In- 
stead of pulling on the 
extremity of the cso- 
phagus, it should be 
grasped with sponge 
handles, the surgeon 
changing the hold of 
the forceps in order to 
get nearer and nearer 
to the site of any 
‘remaining attachment. 
“When the time for the 
attempt at removal of 
the csophagus arrives, 
the presence of the 
gastrostomy is often an 
embarrassment, and in 
two of the cases it 
undoubtedly contri- 
buted to the fatal result. 
In order to expose the 
diaphragmatic hiatus it 
is essential that the 
- stomach should be free, 
so that it can be drawn 
down and to the right 
in order to put the 
abdominal part of the 
esophagus on the 
stretch. In order to per- 
mit of the free handling 
of the stomach it has 
sometimes been neces- 
sary to separate it from the parietes and to re-attach 
the gastrostomy opening as a last stage in the 
operation or to remake the gastrostomy. 

Although I do not think that patients thrive as 
well on jejunostomy feeding as when fed directly 
into the stomach, still I am persuaded that jejuno- 
stomy would be an advantage in many ways. It was 
very satisfactory in the case in which I had to remove 
the whole stomach with the asophagus and in 
another case of total gastrectomy. Iam hoping that 
some day we will get these cases at so early a 
stage that neither preliminary gastrostomy nor 
jejunostomy will be necessary. 


months (see text). 
the small bowel is well seen. 
the dermal tube. 


FIG. 5.—Antethoracic csophagus which had functioned for eleven 


The junction between the dermal tube and 


The only area of recurrent growth is shown 
on the back of the curdiac part of the stomach. 


An Improvised (sophagus 
“ Nothin’s finished till it’s done.”—Mrs. Jorrocks. 


As a commentary on the subject will you forgive 
me if I merely mention the case in which I was able 
to complete the excision by the ‘‘ pull-through ” 
method and to restore 
the function of swallow- 
ing by the construction 
of a new esophagus. 
A short account of this 
case has already been 
published. This man 
went along quite hap- 
pily until eighteen 
mouths after the prim- 
ary operation when he 
commenced to lose 
ground until he died a 
month later from ne- 
phritis. An examination 
of the body did not 
disclose any very ob- 
vious signs of recurrence 
of the growth. There 
was a small mass in 
the cardiac end of the 
stomach about two 
inches away from the 
situation of the normal 
esophageal opening, 
and on section this 
showed histological 
characters of a type 
similar to the original 
growth. The new œso- 
phagus shows a beauti- 
ful wide tube with an 
average diameter of one 
inch (Fig. 5). The wall 
of the new cesophagus 
is smooth, and there is 
no sign of irritation or 
suspicion of ulceration. 
The junction between 
the skin and the intes- 
tine is almost imper- 
ceptible and just as 
smooth and nice as in 
an old gastro-enteros- 
tomy. The interior of 
the dermal tube has a 
curious ringed appear- 
a2 ance, rather suggestive 
of the inside of the 
trachea. There are a 
few long hairs growing 
into the lumen but 
certainly not in excess. 
Histological examina- 
tion reveals no striking changes in the skin in spite 
of its adaptation to a new function. 


Inset shows the inner aspect of 


Iam glad to have this opportunity of acknowledging 
the help of my colleagues of the British Postgraduate 
Medical School and ths Hammersmith Hospital. 


THe LANCET, 1933, ii., 1315, and 1934, ii., 1293. 
Roy. Soc. Med., 1934, xxvii., 350. 


Proc, 


N 


Kina EDWARD’S HOSPITAL FUND FOR LONDON .— 
The King has sent £1000 and the Queen 100 guineas 
to King Isdward’s Hospital Fund as their annual 
subscriptions. 


THE LANCET] 


DR. S. ZUCKERMAN : ESTROGENS & THE MALE REPRODUCTIVE TRACT [yan. 18, 1936 135 


AN EMBRYOLOGICAL INTERPRETATION OF 
CHANGES INDUCED BY CSTROGENS 
IN THE MALE REPRODUCTIVE TRACT 
By S. Zuckerman, D.Sc. Lond., M.R.C.S. Eng. 


BEIT MEMORIAL RESEARCH FELLOW 
(From the Department of Human Anatomy, Oxford) 


RECENT investigations on rats, mice, and monkeys 
indicate that changes induced by cstrone in the 
epithelium of the male reproductive tract may throw 
light on the etiology of senile enlargement of the 
prostate in.man. The morphological basis of the 
experimental response is thus a matter of the highest 
importance. Burrows,! following Lacassagne,? sug- 
gests that Millerian epithelium enters into the forma- 
tion of those organs (in particular the different 
lobes of the prostate) which in the male rodent respond 
to ostrone. This hypothesis, which immediately 
relates the effects of œstrone in the male to those 
produced by the hormone in the female (whose 
‘definitive reproductive tract is generally assumed to 
derive entirely from the Millerian ducts) fails to 
account, however, for changes which .cestrone occa- 
sions in parts of the male reproductive tract that 
undoubtedly are not related embryologically to the 
Millerian ducts—e.g., in the rat, the entire urethra.! 
Unfortunately, too little is known of the develop- 
ment of rats and mice to allow even moderate 
certainty to embryological interpretations of the 
responses of the male to cestrone, while the homo- 
logical relations of the rodent and human repro- 
ductive tracts are too speculative for comparative 
anatomical interpretations. 

Facts derived from corresponding studies of 
monkeys are not subject to as many limitations, 
and they point to a more fruitful hypothesis, the 
gist of which is that cstrogens act specifically not 
only on Millerian epithelium, but also on epithelium 
of the urogenital sinus. Many of the responses of the 
male become understandable in terms of this latter fact. 

OBSERVATIONS ON MONKEYS 

Apart from general fibromuscular growth in the 
stroma of both the prostate and the seminal vesicles, 
a response which can reasonably be regarded as an 
undifferentiated effect of cestrogens on tissues derived 
from .the mesoderm of the genital cord, the-con- 
spicuous internal changes produced by estrone in 
the reproductive tract of male monkeys are limited 
to the epithelium of the urethra and of the uterus 
masculinus (utriculus prostaticus). Of nine monkeys 
thus far tested,? two (Cebus fatuellus and Hapale 
jacchus) showed no utricular response ; one (Presbytis 
entellus) showed disorganised glandular hyperplasia 
of a utricle which normally comprises a regular 
system of tubular glands; and the remaining six, 
of which the best known is Macaca mulatta, the rhesus 
monkey, presented a utricular response essentially 
the same as that of the vagina to cstrone, the utricle 
becoming greatly distended and lined by a much 
stratified and desquamating epithelium, This type 
of utricular response is identical with the urethral 
response in those species in which the urethra is 
affected. In no case was the upper urethra respon- 
sive to cestrone; the sensitive region under the 
conditions of the present scries of experiments 
extended from the region of the utricular opening 
to the urethral meatus. The upper insensitive 
section of the urethra arises with the bladder from 
the part of the ventral division of the entodermal 
cloaca lying above the opening of the Müllerian ducts, 
and it may include some epithelial remnants of the 


Wolffian ducts, whose definitive openings are at the 
same level as the Millerian.4 

The uterus masculinus, like the vagina, is com- 
monly believed to develop from the terminal part 
of the Miullerian ducts; histological difficulties, 
however, have obscured the picture of the actual 
embryological process. The view that unchanged 
Millerian epithelium is responsible for the vaginal 
epithelium in man is not generally accepted. Alter- 
native descriptions are that epithelium of the primi- 
tive urogenital sinus, into which the Miillerian ducts 
open, either partly,’ or entirely, replaces that of 
the Miullerian primordium of the vagina. It is 
reasonable to suppose that a corresponding process 
could occur in the male homologue derived from the 
distal part of the Millerian ducts—i.e., the uterus 
masculinus—and histological evidence provided by 
some anomalous prostates from rhesus monkeys, 
that will be presented in detail elsewhere, favours the 
view that in this species sinus epithelium does in 
fact extend along and replace the Millerian epithe- 
lium that forms the groundwork of the utricle. Far 
stronger support for this interpretation is provided 
by endocrinological evidence, not only from the 
rhesus but also from other species of monkey, for 
in them the vaginal and utricular response to cestrone 
is essentially similar to that of tissue undoubtedly 
derived from the epithelium of the urogenital sinus— 
i.e., in the female the epithelium of the vestibule, 
and in the male that of the urethra as far up as the 
opening of the utricle (which represents the external 
opening of the primitive Millerian ducts). The 
facts thus suggest that in these species of monkey, 
the male cestrogenetic responses under consideration 
do not fundamentally represent the responses to 
oestrogens of Miillerian epithelium, but of epithelium 
derived from the primitive urogenital sinus. Sinus 
epithelium reacts in essentially the same way as 


.true ectodermal epithelium (see below), and although 


the epithelium of the urogenital sinus is generally 
regarded as being entodermal in origin, there is an 
alternative view, which has not been disproved, that 
ectoderm plays a large part in its formation (see. 
Frazer,’ p. 432). The embryological topographical 
connexion between the urogenital sinus (as part of 
the original cloaca) and the primitive streak, the 
sinus’s great sensitivity to oestrogens, and the primi- 
tive streak’s capacity to elaborate organising sub- 
stances, are facts which assume a related interest in 
view of the presumed chemical relationship between 
organising substances and oestrogens.§ 

The cestrogen-sensitive epithelium of the monkey 
is not limited to tissues derived from the urogenital 
sinus, but in many species extends for varying dis- 
tances from the external genitalia to form a “ sexual 
skin,” a circumgenital area of surface skin which 
becomes highly coloured, thickens, and may even 
swell in response to estrone. Although not so pro- 
nounced, the external epidermal growth is funda- 
mentally the same, and may be regarded as part 
of the same process, as the more centrally occurring 
stratification of sinus epithelium; the external 
reactive area is the peripheral part of the total 
estrogen-sensitive epithelial zone. If the extent of 
this zone in the female of a species is regarded as a 
species index of epithelial sensitivity to oestrone, an 
explanation is forthcoming for the fact that strati- 
fication of the male urethral epithelium in response 
to oestrone failed to occur in all species tested. In 
males, in which stratification did not occur, the 
corresponding females have no external sexual skin ; 
in species in which the female has a sexual skin, 
stratification of the male urethral epithelium occurred. 


136 


THE LANCET] 


IMPLICATIONS 


The general hypothesis outlined here suggests that 
epithelial structures in whose development cestrogen- 
sensitive sinus epithelium has played a part should 
be expected to react when adequately exposed to 
the action of cestrogens. In the rhesus monkey, the 
urethral openings of the prostatic glands, which 
presumably give the topographical relations of the 
embryonic prostatic tubules, are placed almost 
entirely in the uppermost part of the region of the 
urethra which responds to estrone. Nevertheless, 
only the proximal parts of the collecting tubules, 
and not the glands themselves, reacted in two monkeys 
of this species which were injected for 70 and 90 days 
respectively. It is possible that the glandular epi- 
thelium and the sinus epithelium, from which the 
glands arise, react differently owing to differential 
specialisation during development. On the other 
hand, it should be noted that the prostatic tubules 
of the mouse react only after very prolonged cestrone 
administration,’ and it may also be remarked that 
true prostatic epithelium did show signs of reacting 
in two other species of monkey (Cercopithecus mona 
and C. e@thiops sabeus) after as little as two weeks’ 
treatment.? It is also of interest that one part of 
the human prostate, the posterior lobe, arises entirely 
from tubules which develop distal to the openings 
of the Millerian and Wolffian ducts,® and by analog 
with the rhesus monkey, from the region of the 
urethra most sensitive to oestrogens. In view of the 
prevailing belief in the close chemical relationship of 
estrogens and some carcinogens,!® it is therefore 
significant that although primary carcinoma may 
occasionally begin anywhere in an otherwise normal 
prostate,!! it commonly starts in the posterior lobe. 

A useful extension of the present hypothesis which 
should be mentioned here is that in species in which 
the uterus masculinus is an organ composed of a 
system of tubular glands only—e.g., man and Pres- 
bylis entellus—and in which it does not respond to 
estrogens by epithelial stratification such as occurs 
in the rhesus monkey, the utricular epithelium 
represents Millerian epithelium unchanged by epithe- 
lium of the urogenital sinus. There is some evidence, 
as yet unpublished, that the small columnar-celled 
glands occasionally found in the hydatid of Morgagni, 
the male rudiment of the cranial end of the Millerian 
duct, develop and become distended in monkeys 
under the influence of oestrone; whether or not 
tubular glands derived from the terminal part of 
the duct would behave as uterine glands under the 
same conditions is at present a matter for conjecture. 
This problem has been considered elsewhere from 
the point of view of its possible bearing on the 
wtiology of senile hyperplasia of the prostate.!? 

The detailed data supporting the working hypo- 
thesis put forward here will be submitted for 
publication in the near future. 


REFERENCES 

1. Burrows, H.: Nature, 1934, cxxxiv., 570; Amer. Jour. 
Cancer, 1935, xxiii., 490. 

i Lacassagne, A.: Compt. rend. Soc. de Biol., 1933, cxiii., 
590. 

. Zuckerman, S., and Parkes, A. S.: Jour. of Anat., 1936, 
lxx. (in the press), 

. Frazer, J. E.: Ibid., 1935, Ixix., 455. 

. Kotf, K. A.: Contr. Embryol. Carneg. Instit., 1933, xxiv., 


O Om o N 


; Vilas, E.: Zeits. f. Anat. u. Entwicklungsgesch., 1932, xeviii., 
263 


. Frazer, J. E.: A Manual of Embryology, London, 1931. 

. Waddington, C. H., and Needham, D. M.: Proc. Roy. 
Soc. B., 1935, cxvii., 310. 

. Lowsicy, O. S5.: Amer. Jour. Anat., 1912, xiii., 299. 

- Dodds, kk. C.: Ergeb. d. Physiol. u. exper. Pharm., 1935, 
xxxvii., 264. 

. Ferguson, R. S.: Amer. Jour. Cancer, 1932, xvi., 783. 

3 es A S., and Parkes, A. 5.: Jour. of Anat., 1935, 
xix., 484. 


pd 
Ne Se ON 


bat fant 


MR. H. H. RAYNER: CARCINOMA OF THE COLON 


{[yan. 18, 1936 


THE TREATMENT OF 
CARCINOMA OF THE COLON * 


By H. H. Rayner, M.B. Vict., F.R.C.S. Eng. 


SURGEON TO THE MANCHESTER ROYAL INFIRMARY AND CONSULTING 
SURGEON TO THE MANCHESTER CHILDREN’S HOSPITAL 


THE factors which govern our treatment of this 
grave disease are so numerous, yet so variable in 
their incidence and importance, that the problem 
of treatment differs greatly between one case and 
another. Personal experience then is apt to be an 
imperfect guide to the surgeon, and for that reason 
there are few subjects so worthy of discussion at a 
meeting of surgeons. 


Preliminary Treatment of the Intestinal 
Obstruction 


The large majority of patients when first seen by 
the surgeon are suffering from some degree of intes- 
tinal obstruction, and in a considerable proportion 
of these the obstruction is complete or acute and of 
several days’ duration. It is one of the axioms of 
abdominal surgery that complete obstruction caused 
by colonic cancer must be relieved by simple drainage 
of the colon above the obstruction and that no 
attempt must be made to deal with the causative 
disease until the obstruction has been relieved and 
the patient has received the full benefit of preliminary 
drainage of the colon. The operation of cxcostomy 
has for many years been that most commonly em- 
ployed for this purpose, for it has the merit of being 
applicable to every case irrespective of the site of 
the growth if we exclude the cecum and ileocecal 
orifice. It is clear that cxcostomy is not the ideal 
operation for the relief of obstruction in the distal 
colon; but it works sufliciently well, for it can be 
depended upon to save the patient’s life from the 
immediate threat of death from intestinal obstruc- 
tion, and it is easy and safe to perform considering 
the circumstances. Above all, it leaves the field for 
the later operation of resection undisturbed and the 
surgeon unhampered. The choice of operation for 
this preliminary drainage is of the greatest import- 
ance; if the surgeon in his desire to achieve the 
ideal performs a colostomy near the obstruction he 
may later bitterly regret his choice. There is some 
divergence of opinion whether, in these cases of com- 
plete obstruction, the surgeon should proceed at 
once to perform a c:ecostomy through an incision 
directly over the viscus, or whether he should first 
explore the abdomen through a paramedian Incision 
and then, unless the information he has thus obtained 
suggests a more etiective operation, go on to perform 
a c.ecostomy. 

There is room for both procedures, but personally 
I have a strong preference for an exploratory laparo- 
tomy unless the condition of the patient is desperate 
and makes the use of local anesthesia highly desirable. 
If a spinal aniesthetic is to be employed—and this I 
believe to be the best for the great majority of these 
patients—then the duration of the anesthesia will 
suflice for exploration and cæcostomy and the com- 
plete relaxation obtained by this method will allow 
a gentle but efficient exploration and an easy closure 
of the incision. 

The advantages of the exploratory incision are 
several. (1) The diagnosis of colonic obstruction can 


* A paper read before the Manchester Surgical Society on 
Dec. 3rd, 1935. 


THE LANCET] 


MR. H. H. RAYNER: CARCINOMA OF THE COLON 


[san, 18, 1936 137 


be verified; there can be no risk of overlooking 
obstruction in the lower small intestine. (2) The 
information to be obtained about the site of the 
growth, its extent and connexions, the presence of 
metastases in the liver, enables one to decide whether 
cecostomy is the best operation under the parti- 
cular circumstances and on one’s plans for the resection 
of the growth at a later date. An opaque enema 
examination, after recovery from the preliminary 


operation, will not give us all this necessary informa- ` 


tion. (3) If caecostomy is decided upon the explora- 
tory incision will often help us to perform this opera- 
tion much more easily than could be done through a 
limited incision directly over the cecum for blind 
cecostomy is sometimes a very diflicult operation. 


Czcostomy was performed on 28 of my patients 
and in 20 of these at the close of an exploratory 
laparotomy. Of these 20 one died; in this patient 
compression of the cecal pouch (the cecum had 
been brought up to the skin) by the parietal muscles 
obstructed the outlet and the recognition of this 
was too tardy to save life. In one of the 20 blind 
eecostomy had been attempted, but an exploratory 
incision was necessary to expose and deliver the 
cecum through the iliac incision. In the other 
8 patients a blind cecostomy was performed, and 
of these also one died ; strictly speaking, this death 
did not follow a blind cæcostomy, but was due to 
my inability to perform it owing to the high position 
of the cecum and extreme distension of small intes- 
tine. Rather than make an exploratory incision 
which would have allowed me the valuable alternative 
of a colostomy of the transverse colon (always an 
operation to keep in mind in the presence of pelvic 
colon obstruction—the site of the disease in this 
patient) I performed a Witzel’s enterostomy of the 
terminal ileum which failed to give the patient more 
than very temporary relief. 


Removal of the Growth and Adjacent Portions 
of the Colon 


The patient should by preparatory treatment be 
made as fit as the circumstances allow to undergo 
this. Sometimes much can be done to reduce the 
degree of chronic intestinal obstruction, from which 
the patient in great probability suffers, by a fluid but 
nourishing diet, the judicious administration of 
liquid paraffin, Epsom salts, and small doses of 
morphia. During this preparatory treatment a 
systematic examination, including an opaque enema 
examination, will have revealed the position of the 
growth. If the patient has had complete obstruction 
then his preparatory treatment will have been 
facilitated by the drainage of the colon which the 
cecostomy has secured, and by irrigation of the colon 
through the czcostomy during the three or four days 
preceding the operation of resection. At this opera- 
tion, presuming there is no contra-indication to 
resection, there are in principle two methods open 
to us: (a) resection and immediate union of the two 
ends by suture anastomosis, and (b) resection without 
immediate union. The bowel ends are brought up 
to the surface of the abdominal wound and continuity 
between these is later established by the enterotome 
as in Pauls operation and its modern counterpart, 
obstructive resection. 


RESECTION WITH IMMEDIATE UNION 


Probably most of us have performed resection 
and immediate anastomosis of the ends of the colon, 
even in the presence of a moderate degree of intes- 
tinal obstruction, without the safeguard provided 


by a preliminary cecostomy, and have had many 
gratifying successes from this procedure; but col- 
lective experience shows that such a method entails 
an unnecessary degree of risk and it should therefore 
only be practised under very exceptional conditions, 
including that of great skill and experience on the 
part of the surgeon. Resection and suture anasto- 
mosis should only be practised after a preliminary 
czcostomy or some other type of proximal drainage, 
even though the growth may have caused little or 
no obstruction in the colon. The cæcostomy may 
be performed at the same time as the resection 
operation, but to me this does not seem as sound a 
proceeding as the performance of a cecostomy two 
weeks before the resection. When the growth to be 
resected is in the pelvic colon then an additional 
safeguard is the passage of a wide-bore rubber tube 
up the anus to a point in the colon several inches 
above the anastomosis. 


This principle of proximal] drainage before resection - 


and anastomosis is modified in the treatment of 
growths in the cecum and proximal colon. 
the orthodox method of operation in two stages, 
first lateral anastomosis between terminal ileum and 
transverse colon, or, as advised by Rankin,! implan- 
tation of the end of ileum into the side of the colon, 
and then, some two weeks later, resection of the 
short-circuited bowel holding the growth, gives 
excellent results. Wakeley and Rutherford ? recorded 
14 such operations in series without a death. My 
only criticisms of the procedure are that both stages 
of the operation are serious ones, for in both the 
colonic lumen is opened and sutured, and then the 
second stage may be troublesome on account of 
plastic adhesions around the anastomosis. 


RESECTION WITHOUT IMMEDIATE UNION 


The second method, that in which after resection 
of the growth the bowel ends are brought up to the 
abdominal wound for restoration of continuity at a 
later date, was first described by F. T. Paul ® forty 
years ago. During the past twenty-five years the 
great improvements in technique of intestinal surgery 
have led to the pretty general adoption of resection 
and immediate suture anastomosis as the method 
of choice, and Paul’s method has taken a place 
second to this and as one to be employed under 
exceptional circumstances. In recent years, however, 
there has been a distinct movement to revive Paul's 
method with improvements in technique under the 
term ‘obstructive resection.” For those who may 
not be familiar with this method the following brief 
description is intended. 

The length of colon to be resected is determined ; 
its mesenteric attachments are divided so as to 
allow removal of a maximum amount of mesenteric 
tissue ; above and below the colon must be exten- 
sively mobilised so as to allow the bowel ends to 
be brought up to the abdominal wound without 
tension, yet without sacrificing the thoroughness of 
the resection. Two crushing clamps (Schoemaker 
pattern) are then applied, about 3 inch apart across 
the upper limit of the loop to be resected and two 
across the lower limit. (Fig. 1.) The resection is 
now completed by dividing the bowel with the 
cautery between each pair of clamps. The posterior 
peritoneal gap is repaired, and then the two limbs 
of the bowel are tacked together by the finest catgut 
sutures over a length of 3—4 inches from the clamps 
so as to produce the familiar double-barrelled gun 
arrangement. The bowel ends each firmly in the 
grasp of a crushing clamp are brought out through 
the abdominal wound which is closed snugly around 


Here . 


' 


138 THE LANCET] MR. H. H. RAYNER: CARCINOMA OF THE COLON [san. 18, 1936 


them. The skin edges around the emerging bowel 
should be sutured to the bowel wall at a few points 
in order to cover over the raw area and to prevent 


premature retraction. (Fig. 2.) The crushing’ 


clamps are removed on the third day and an entero- 
tome is introduced then or on the following day to 
a depth corresponding to the length of coaptation 
of the two limbs of bowel. (Fig. 3.) The enterotome 
should at first be screwed just tightly enough to 
afford a firm grip of the partition, and is gradually 
tightened up during the next two days. A lengthy 
communication between the two limbs of*the colon 
is crushed out in six or seven days and usually a 
natural bowel action through the rectum follows 
within a day or two. The fæcal fistula that remains 
tends to shrink and the amount of fæcal discharge 
to diminish ; the operator may close the fistula by 
an extraperitoneal operation at his own discretion. 

This method may be employed for the resection 
.of any part of the colon except of course the lower 
pelvic colon, for here the lower stump of bowel is 
too short to allow of its being brought up to the 
abdominal wound. Difficulty too will be experienced 
at the upper end of the pelvic colon, particularly in 
stout patients, for the absence of a proper mesentery 
to the iliac and descending colon may limit the length 
of the upper stump and tension or insufficient length 
of resection must not be tolerated as a means of 
securing coaptation of the two limbs of bowel. Under 
these circumstances either the ends of the bowel 
should be brought out of the wound without attempt- 
ting to coapt them, and later, when the bowel is 
healthy and the patient is in good condition, the 
ends can be united by intraperitoneal suture, or the 
abdominal wound should be prolonged to allow of 
resection of the descending colon and splenic flexure 
in order that the transverse colon may be utilised 
as the upper hmb in the wound. Obstructive resec- 
tion can be used very satisfactorily for cancer in the 
proximal colon. 7 

I have performed by this method right hemi- 
colectomy in 8 patients without a death or serious 
complication ; the discharge of ileal contents on to 
the abdominal wall for some two weeks after the 
operation may seem a serious objection to the method 
in this situation but in practice I have seen no harm 
result from this and the inconvenience is no greater 
than that after an open cxcostomy. Obviously this 
method should not be practised on a patient 
suffering from a complete or acute obstruction, 
but it may properly .be performed after a pre- 
liminary cecostomy, distasteful as it may seem to 
inflict for a time two separate fecal fistule on the 
patient. It may be employed in patients suffering 
from chronic intestinal obstruction without pre- 
liminary cæcostomy, and in these the colonic contents 
should be displaced from above downwards into the 
loop to be resected before the application of the 
upper crushing clamps, or, if this is insullicient to 
relieve the loaded colon, then after completion of 
the operation and protection of the wound the clamp 
can be removed from the upper limb of bowel and a 
tube tied into the end. ‘To facilitate this the upper 
limb should be arranged to project 2 or 3 inches 
beyond the surface of the abdomen; this Joop with 
its attached tube can then pass through the dressings 
and fastenings. Lahey? applies this method of 
securing immediate drainage of the proximal intes- 
tine to resection of the right colon in the presence 
of intestinal obstruction and I am satisfied that the 
method is a valuable one under these conditions, 
and is always practicable because the upper limb is 
obtained from the terminal ileum, 


The following advantages of obstructive resection 
will be readily appreciated. 


1. The operation is much shorter in duration and easier. 
This is a substantial merit if the patient is a stout person 
whose colon is difficult of access and whose mesenteries 
are heavily fat laden. Under such conditions resection 
and anastomosis is a long and laborious operation and is 
often followed by severe shock ; the operator too is tempted - 
to hurry over the resection stage because of the amount 
of work that still remains to be done. In the obstructive 
method, as Devine ê points out, almost the whole of the 
operator’s time and care are spent on the essential part 
of the operation—the complete removal of the malignant 
growth and its connexions. For these reasons the method 
should always be employed when the resection is a 
complicated one involving other viscera or the parietes. 

2. The operation with ordinary care is an aseptic one, 
and the operator cannot fail to be struck by the clinical 
evidence of this. 


THE METHODS COMPARED 


Ilow do these methods compare, and why has 
Pauls method in a modified form been revived ? 
Resection and suture anastomosis at its best gives 
a very good result with a shorter and pleasanter 
convalescence than the obstructive method with its 
fecal fistula and the secondary operation for the 
closure of this. The fundamental objection to suture 
anastomosis after resection is the high mortality 
and morbidity-rate which it entails in the hands of 
most surgeons. To quote from my own experience— 
in 39 operations of resection and anastomosis there 
were 9 deaths (21 per cent.), and amongst the patients 
who recovered there were several whose convalescence 
was marred and protracted by wound suppuration, 
feeal fistula, and illnesses arising from these com- 
plications. In 30 consecutive resections performed 
by obstructive resection there were 3 deaths (10 per 
cent.), and very few complications of any kind 
amongst the patients who recovered. 

I do not attach much importance just to the 
contrast between the two mortality-rates for each 
series is a Small one; but a consideration of the 
modes of death and of the difference in the con- 
valescence after the two methods, in conjunction 
with the contrast in mortality-rate, does suggest 


“in “ay 


oT LO IHR A a 


FIG. 1.—Obstructive resection. Division of colon with cautery 
between crushing clamps. 


that obstructive resection is a valuable method, and 
one always to keep in mind at least as an alternative 
to resection anastomosis. 


Of the 9 deaths in the resection anastomosis series, 2 
occurred within two days of the operation and were plainly 
duo to the severity of this; both patients wero stout and 
had deep abdomens and in 1 a previous colostomy near the 
growth increased the magnitude of the operation. The 
other 7 all made good recoveries from tho operation and 


made satisfactory progress for at least four days; after 


THE LANCET] 


MR. H. H. RAYNER: CARCINOMA OF THE COLON 


[JAN. 18, 1936 139° 


that time relapses occurred, sometimes sudden in onset 
with severe abdominal pain and rapid collapse—plainly 
due to gross leakage at the anastomosis—in others less 
sudden with rise of pulse-rate and temperature, abdominal 
discomfort evidence of wound infection, and later fecal 
discharge and progressive cardiac muscle failure. 

Of the 3 deaths after the obstructive method 2 were 
caused by acute intestinal obstruction beginning three or 
four days after operation ; in one of these a large portion 
of the anterior abdominal wall had been removed with the 
growth and probably the small intestine became adherent 
to the raw area which inevitably resulted; in the other, 
obstruction was due to the small intestine becoming 
trapped in the foramen created by bringing up the stumps 
of the pelvic colon to a left iliac incision. The third death 
was due to faulty application of the enterotome which 
was screwed up much too tightly when first inserted. 
Severe abdominal pain and collapse followed in a few 
hours, but as the patient was known to have gross 
metastases in the liver no further operative interference 
was attempted. 


The 3 deaths after Paul’s operation do not seem 
to me to be due to defects inherent in the method, 
whereas the 9 deaths and the protracted con- 
valescences in some of the survivors after suture 


NOA; 7 Sra SS 
` "is ae wD Ss 
FESS I ` sT 


acta | 


“MT UM 


FIG. 2 —Obstructive resection. Coaptation of terminal limbs 
of colon by sutures : ends of colon, each in grasp of a crushing 
clamp, fixed in abdominal wound. 


anastomosis can hardly be dismissed as due to avoid- 
able or very unusual causes. Seven of these deaths were 
unmistakably due to leakage or gross infection at 
the anastomosis, and in view of the interval of time 
(four days at least) between the operation and the 
onset of the first symptom, it may be inferred that 
the infection originated within the bowel and travelled 
through anastomotic margins devitalised by suturing. 

The risk of infection and leakage at the anasto- 
mosis, after the mechanical support of the sutures 
has ceased to be effective, remains inherent in all 
suture anastomoses of a functioning colon ; parti- 
cularly so in cancerous obstruction, for here the 
bowel wall in the vicinity of the growth is infected 
and the stagnant fecal contents are abnormally 
virulent in their toxicity. A proximal fistula (czecos- 
tomy) will by diverting a portion of the fecal stream 
and flatus relieve the anastomosis of some of the 
strain to which otherwise it would be subject, and 
by allowing the means for a previous cleansing of 
the colon will have reduced the toxicity of the con- 
tents, but the extent of this relief in any particular 
case is uncertain and cannot be depended upon to 
abolish the risk of infection and breakdown of the 
anastomosis 


Resection of Growths in the Lower Pelvic 
Colon 


In the lower pelvic colon, after an adequate resec- 
tion of the growth, the lower stump is too short to 
permit of a reliable suture anastomosis and obstruc- 


SAA aa as | , Bo PORES 
NT Mn hr, “MU 


yr 3 ae 


~ 
_ 
= 


—— 
a 


FIG. 3.—Obstructive resection. Re-establishment of continuity 
of colon by crushing intervening bowel walls with enterotome. 


tive resection is still less practicable. A large number 
of operations have been devised to meet the problem ; 
some of these are chiefly noteworthy as tributes to 
the endurance of the human species. I shall mention 
four : the first two are suitable for growths at or 
near the pelvirectal junction, one of them entailing 
a permanent colostomy, while the other does not ; 
the second two are suitable for. growths a few inches 
above the pelvirectal junction, and of these again 
only one entails a permanent colostomy. 


1. Abdomino-perineal excision of the rectum.—A well- 
established operation e merits of which it is unnecessary 
to describe. 


2. Abdomino-anal excision of the rectum in which the 
stump of the pelvic colon is pulled through the anal 
sphincters—after removal of the rectum and the mucosa 
of the anal canal—to the site of the anal orifice. A 
description of this operation, as performed by Prof. 
Sebrecht, of Bruges, was given by me at a recent meeting 
of the proctological section of the Royal Society of Medicine® 
and was severely criticised on the ground that it entailed 
a serious risk of sloughing in the transplanted colon. 


3. Anterior or intraperitoneal resection of the rectum.— 
In this operation after the necessary resection of bowel 
the stump of the rectum is invaginated, dropped into the 
bottom of the pelvis, and is covered over by suturing the 
gap in the peritoneal floor of the pelvis. The end of the 
pelvic colon is brought out through a small left iliac 
incision as a terminal colostomy. This operation, though 
a very safe one, is open to the criticism that the patient 
is left with an intact but functionless sphincter mechanism 
around the anal canal. | 

4. The Rutherford Morison type of operation in which a 
direct union between the open ends of the pelvic colon 
and the stump of the rectum is effected over a wide bore 
tube. One end of the tube must be secured in the end of 
the pelvic colon by a transfixion ligature and the other 
end is passed into the rectum through the anus, where it is 
drawn down by an assistant. Continuity of the bowel 
ends can now be restored by invagination and sutures. 


Before undertaking either of the two operations which 
aim at reconstruction of the rectum—the abdomino- 
anal and the Rutherford Morison types—the surgeon 
will be well advised to carry out a colostomy of the 
transverse colon some three or four weeks previously. 
The colostomy should be of the Sistrunk type, in 
which the ends of the colon are completely separated 
by a bridge of skin. I began to perform such a 
colostomy in this connexion 3} years ago and have 
never since omitted to do it before attempting recon- 
structive operations on the lower pelvic colon and 


140 THE LANCET] 


rectum. Devine’ has described and advocated a 
colostomy of the transverse colon as an essential 
preparatory measure to all anastomosis operations 


on the lower pelvic colon, and the surgeon who is. 


unaware of the value of this step should acquaint 
himself with Devine’s convincing article on the 
subject. A colostomy of the transverse colon in 
which the ends are effectively divorced prevents 
fecal material entering the colon distal to the colos- 
tomy; by daily irrigation it allows the removal of 
feecal material already present and the cleansing of 
the colonic mucosa; further, it puts the distal 
colon entirely out of action until complete healing 
of the transplanted bowel has taken place. It can 
be easily closed afterwards by the enterotome. 

The danger of all anastomosis operations in this 
region is that of sloughing of the bowel, and this is 
due to the combined effects of infection from the 
fecal traffic and impairment of blood-supply from 
suturing and encroachments on the mesentery ; 
remove the infective element entirely and the impair- 
ment of blood-supply loses most, if not all, of its 
terrors for the surgeon. 


REFERENCES 
1. Rankin, F. W.: Surg., Gyn., and Obst., 1934, lix., 410. 
2. Wakeley, C.P. G., a Rutherford, R.: Brit. Jour. Surg., 
1932, XX., 91. 
3. Paul, F. T.: Brit. Med. Jour., 1895, i., 1139. 
4. Lahey, F. H.: Surg., Gyn., and Obst., oho? liv., 923. 
5. Devine, H .: THE "LANCET, 1931, i. V 627 
6. Proc. Roy. Soc. Med., 1935, xxviii. ? 1559. 
7. Devine, H. B.: Austral. and N.Z. Jour. Surg., 1934, iii., 211. 


THE PRODUCTION OF A 
NEUROTROPIC STRAIN OF RIFT 
VALLEY FEVER VIRUS 


By R. D. MACKENZIE, M.B., F.R.C.P. Edin. 
AND 


G. M. Finptay, C.B.E., M.D., D.Sc. Edin. 


(From the Wellcome Bureau of Scientific Research, London) 


\ 


Since Pasteur first showed that the street virus of 
rabies can be altered by continued passage in the 
brain of the rabbit, much evidence has accumulated 
to show that other viruses may be experimentally 
modified by changing the substrate on which they 
grow. Thus, Theiler (1930) found that the virus 
of yellow fever was modified by passage in the brains 
of mice, and that eventually its capacity to produce 
viscerotropic lesions in rhesus monkeys was practically 
abolished. Nieschulz (1932) and Alexander (1933) 
similarly produced a neurotropic strain of horse- 
sickness virus by repeated mouse brain passage. 
These efforts at modifying the characteristics of 
viruses involved the use of an animal which is not 
normally susceptible to the ordinary strain of the 
virus. Recently, however, Findlay and Stern (1935) 
have shown that it: is possible temporarily to inhibit 
certain virus activities by means of the protective 
action of immune serum. When rhesus monkeys 
were injected intraperitoneally with yellow fever 
immune serum, before inoculating the ordinary 
yellow fever virus intracerebrally, it was found that 
the animals died, not with necrosis of the liver, but 
from encephalomyelitis, thus demonstrating the 
essential neurotropism of the yellow fever virus. 
In view of the result obtained in yellow fever, it 
appeared not improbable that a similar method might 
reveal a neurotropic activity in certain viruses, which 


DRS. MACKENZIE & FINDLAY : NEUROTROPIC STRAIN OF FEVER VIRUS 


[yan. 18, 1986 


so far had shown only viscerotropic characters. 
Further, it seemed possible that intensive passage 
under these conditions might result in the production 
of a neurotropic fixed virus variant. 

In the present communication the results are 
recorded of applying this experimental procedure 
to the virus of Rift Valley fever. 


THE VIRUS 


Before describing the production of a neurotropic 
strain of Rift Valley fever virus, it may be of interest 
very briefly to recall the main facts in regard to the 
ordinary or viscerotropic strain. The virus was 
first isolated by Daubney, Hudson, and Garnham 
(1931) in Kenya where it caused a great mortality 
of ewes and lambs; it was also found to be patho- — 
genic for man, producing a dengue-like disease, but 
without any rash, Findlay and Daubney (1931) 
showed that mice and other small rodents are 
particularly susceptible to the virus, since they die 
with widespread necrosis of the liver a few days after 
inoculation, while rhesus and other monkeys develop 
a non-fatal febrile reaction, not unlike that seen in 
man, associated with focal necrosis of the liver 
(Findlay 1931-32 and 1932-33). The. virus has 
now been maintained for nearly five years under 
laboratory conditions, and during this period has 
never shown any signs of neurotropic activity ; it 
has maintained unimpaired its pathogenicity both 
for men and mice. In the latter species, an intra- 
peritoneal inoculation of 0-2 c.cm. of a liver suspension 
diluted 10°° or 101° is almost always fatal. Death 
with liver necrosis also follows intracerebral or 
intranasal inoculation. 


THE NEUROTROPIC STRAIN 


Despite the great susceptibility of mice to the 
ordinary or viscerotropic strain of the virus, it bas 
proved comparatively easy to produce a neurotropic 
strain in this species, the technique employed being 
based on that used by Findlay and Stern (1935) 
in the case of the yellow fever virus. Mice were first 
injected intraperitoneally with human immune serum 
derived from a recent laboratory infection. Fifteen 
minutes later they were inoculated intracerebrally 
with 0-03¢.cm. of blood from a mouse dying of 
Rift Valley fever. In the case of the first transfers 
the mice were killed 2-3 days after inoculation when 
the infected brain tissue was passaged. Later the 
mice were allowed to develop nervous symptoms, 
which usually came on 3-5 days after intracerebral 
inoculation and consisted of paresis of the hind and 
fore legs, circular turning movements and epileptiform 
crises. One strain which has passed through more 
than thirty intracerebral passages shows all the 
features of a fixed neurotropic variant. The symptoms 
exhibited by the mice have all been referable to the 
central nervous system, while the lesions present have 
been those characteristic of a meningoencephalo- 
myelitis, destruction of neurones, perivascular infiltra- 
tion, with slight involvement of the meninges, and 
occasionally extensive necrosis of the brain substance. 
In certain nerve-cells intranuclear inclusions have 
been found, very similar to those produced by the 
neurotropic strain of yellow fever virus. In the 
earlier passages, in addition to these nervous changes, 
certain mice exhibited small areas of focal necrosis 
in the liver, though the widespread damage character- 
istic of the viscerotropic strain was absent ; hæmor- 
rhage in the stomach was not found. In later 
passages, the lesions are confined to'the central 
nervous system. After intraperitoneal inoculation 
of the neurotropic strain, the virus circulates in the 


THE LANCET] 


blood stream for a few days, then tends to localise 
in the spleen. Quite frequently, however, and 
certainly more often than is the case with neurotropic 
yellow fever virus, adult mice inoculated intra- 
peritoneally have developed nervous symptoms. 
Intraperitoneal inoculation accompanied by cerebral 
trauma localises the virus in the brain as in the 
case of yellow fever. Intranasal instillation of the 
neurotropic virus in mice is also followed by the 
development of encephalitis. 

Rats, field voles (Microtus agrestis), and ferrets 
have developed encephalitic symptoms after inocula- 
tion with the neurotropic strain of Rift Valley fever 
virus. 

When rhesus monkeys are inoculated with the 
viscerotropic strain of Rift Valley fever virus, whether 
by the intraperitoneal, intracerebral, or intranasal 
route, they have never developed anything more 
than a short febrile reaction, and histologically have 
merely exhibited focal necrosis of the liver. When, 
however, they are inoculated intracerebrally with the 
neurotropic strain, death has invariably resulted with 
the symptoms and lesions of encephalitis. The same 
result has been obtained after intranasal instillation. 
lf the virus has been inoculated intraperitoneally 
without cerebral trauma, no reaction has occurred, 
though immunity has subsequently developed ; when, 
however, an intracerebral injection of starch has 
accompanied the intraperitoneal inoculation, 
encephalomyelitis, as in the case of mice, has followed. 

The pathogenicity of the virus for monkeys is 
thus decreased when the intraperitoneal route of 
inoculation is alone employed, but increased when 
the virus is given the opportunity of obtaining 
access to nervous tissue. 

The reaction of sheep and lambs to the neuro- 
tropic strain of Rift Valley fever virus is at present 
under investigation, 


SUMMARY AND CONCLUSIONS 


A neurotropic strain of Rift Valley fever virus has 
been produced in the mouse. After more than 30 
passages, it has become “‘fixed”’ for nervous tissue 
and when inoculated intracerebrally it always 
produces encephalomyelitis in mice with an absence 
of liver necrosis. 

Rhesus monkeys also succumb to encephalo- 
myelitis when inoculated intracerebrally or intra- 
nasally with the neurotropic strain of Rift Valley 
fever virus. When inoculated intraperitoneally they 
exhibit only a very slight febrile reaction unless the 
central nervous system is at the same time 
traumatised ; they then develop encephalitis. 

The production of a neurotropic form of Rift 
Valley fever virus in a highly susceptible animal, 
by means of the restraining action of immune serum, 
opens up the possibility of producing similar variants 
in the case of a number of other viruses. It also 
offers a possible explanation of the occurrence of 
nervous sequele in certain virus infections which 
do not ordinarily involve the central nervous system. 


REFERENCES 
Alexander, R. A.: Jour. South African Vet. Med. Assoc., 1933, 
iv., 1. 


Daubner, R., Hudson, J. R., and Garnham, P. C.: 
Patb. and Bact., 1931, V., 545. 

Findlay, G. M. : Trans. Roy. Soc. Trop. Med. and Hyg., 1931-32, 
xxv., 229; 1932-33, xxvi., 161. 

Findlay, G. M., and Daubney, R.: THE LANCET, 1931, ii., 1350. 

Findlay, G. M., and Stern, R. O.: Jour. Path. and Bact., 1935, 

Niescbulz. O.: Tijdschr. v. Diergencesk., 1932, lix., 1433. 

Theiler, M. : Ann. Trop. Med. and Parasitol., 1930, xxiv., 249. 


Jour. 


MR. DENIS BROWNE: AN OPERATION FOR HYPOSPADIAS 


[san. 18, 1936 141 


AN OPERATION FOR HYPOSPADIAS 


By DENIS Browne, F.R.C.S. Eng. 


SURGEON TO THE HOSPITAL FOR SICK CHILDREN, GREAT 
ORMOND-STREET, LONDON 


IN common with many others, I got my first 
understanding of hypospadias and my first successes 
in its treatment by following the teaching of Edmunds.? 
For the first time he described the separate elements 
of the deformity, gave rational ways of overcoming 
them, and convincing proof that these ways could 
be successful. I think, however, that I am not 
alone in finding two objections to the technique he 
describes. The first is that it is difficult both to 
understand and to perform; even when one has 
obtained a mental image of exactly what one intends 
to do, the right arrangement of the “ dog-ear’”’ flaps . 
so that they shall lie under even tension all over 
needs experience as well as a good dressmaker’s eye. 

The second objection is more important: it is 
that there is one weak spot in the new urethra, the 
point where the deep and superficial lines of sutures 
cross. Here there is a short direct outlet for urine 
passing along the channel, only controlled by what- 


Q----# 


FIG. 1.— Outlining of incision for transplantation of prepuce. 
(a) Split down dorsum of penis. (b) Incision along outer 
edge of hood of prepuce. (c) Outline of glans seen through 
prepuce. 


ever immediate adhesion there may be in the sewn 
skin edges; and it 1s here that a sinus not infre- 
quently forms, needing a secondary operation for its 
closure. 

I believe the following procedure, admittedly 
based on Edmunds’s technique, is easier to under- 
stand and perform, and less liable to fistula forma- 
tion. I derived it from considering that if one had 
to make a tube like the urethra on any plane surface 
of the body, and had unlimited skin to do it with, 
there would be one obvious method of choice. This 
would be to cut out a flap of skin alongside the floor 
of the new passage, to turn this skin back and suture 
it to form a tunnel, and then to cover in the raw 
area left by pulling across it another and larger flap 
from the other side. From a tube formed in this 
way there could be no direct exit for fluid at any 
point, as the two lines of sutures lie far apart, and 
in consequence the probability or primary complete 
healing would be very high. | . 

In the penis of hypospadias there is of course not 
nearly enough skin to allow of this being done with- 
out dangerous tension ; but there is close by a suffi- 
cient available reserve in the prepuce. Where my 
method differs from that of Edmunds is that instead 
of dividing this skin into two and swinging each 
half round underneath, I transplant it back up the 
dorsum of the penis, and so free the original skin 


1THE LANCET, 1926, i., 323. 


a 


142 THE LANCET] MR. DENIS BROWNE: AN OPERATION FOR HYPOSPADIAS (san. 18, 1936 


FIG. 2.—Prepuce dissected up and split into a ribbon ready for 
transplanting into the bare area left by the retraction of the 
edges of the dorsal incision on the penis. (a) Bare arca on 
penis. (b) Original tip of prepuce. 


of the sides and back for the simple tunnel formation 
I have described. I have sometimes tried to explain 
the idea by comparing it to the changing of a single- 
breasted coat into a double- breasted one ; the 
necessary fullness for the overlap being given by the 
insertion of a new piece of material down the middle 
of the back. 


TECHNIQUE 


1. Transplantation of the prepuce.—An incision is 
made straight down the dorsum of the penis from 
its root to the 
base of the 
prepuce. Here 
it diverges to 
either side 
along the sides 
of the “hood,” 
running about 
two-thirds of 
the way along 
thesidesof this. 
The two layers 


BIG: 3 Dorsal view. of penis a of skin in the 

ransplantation o e prepuce. a ; 

Original tip of prepuce. (b) Apex of hood are then 
dorsal incision. separated, so 


that a single 
broad ribbon is produced ; this is done very gently, 
as much as possible by blunt dissection with- 
out injuring the large veins. There is no objection 
to leaving a loose sack of skin where the tip of the 
prepuce originally lay. 

The dorsal incision retracts into a wide gap as 
soon as it is made, and into this the ribbon is now 
fastened by vertical mattress sutures, with its pointed 
tip fitting comfortably into the beginning of the cut 
at the root of the penis. 


2. Straightening the penis.—This most important 


I TET >, 


Wy, Say Wy 
E Llib tea dt oy, 


FIG. 4.— Outlining of flaps for making new urethra. (a) Opening 

of urethra. (b) Incision freeing lining of new urethra. 
io) Incision freeing flap that will cover the raw area left by 
forming new urethra. 


Dele 
` er ae 
. ae 
e ET a E bd a oe 
. a we >.” ae eet 
OQ an he Cae EA b 
-RES A x H e TERR Art aH . r Ta 
atte ee be res = ae C 
; h zE eds MF hoe had x 
: = ae oor 
*. 


A me arhi Ha T AAE > 


ete cane ye canta /4 


FIG. 5.—Appearance when the new urcthra has been formed, 
but not yet covered in. (a) Outer flap raised, ready to be 
pulled across the raw area. (b) Line of continuous Connell 
type stitches forming new urethra. (c) Gutter showing line 
of reflexion of inner ilap. (d) Catheter in urethra. 


step in the operation is done exactly as described 
by Edmunds, either at the same time as the implan- 
tation of the prepuce, or later. The whole of the 
fibrous band which ties the penis into a permanent 
chordee shape in any marked degree of hypospadias 
is freed from the body and allowed to retract towards 
the base, carrying with it the urethral opening, 
which thus comes to lie much further away from 
the glans than it did originally. The raw gap so 
left is easily covered in from the sides owing to the 
relaxation given by the dorsal insertion. This 


RY / 
ARY UTHAI / 


FIG. 6.—Appearance at end of operation. (a) Deep lihe of 
sutures, shown as if visible through skin. (b) Superticial 
vertical mattress sutures. 


straightening of the penis should be done early in 
order to allow of its proper development ; some time 
during the second year is a suitable time, as before ` 
that the small size of the parts makes operating very 
difficult. 

3. Construction of urethra.—About the age of four 
is a suitable time for this. It should never be done 
till at least six months after the first operation, in 
order to let the penile skin regain its normal elasticity 
and looseness. 

Two longitudinal incisions enn the skin which 


FIG.°7.—Approximate lines of sutures in Edmunds’s operation. -` 
(a) Deep line of sutures. (b) Superficial line of sutures, ~ 
(c) Weak point in tloor of new urethra where the two Hoed ër 
of sutures cross. l 


~ 


THE LANCET] 


will form the new urethra, that on the side from 
which the inner flap is to be raised being naturally 
further from the mid-line than the other. Each 
flap is freed by lateral cuts to appropriate distances 
at the top and bottom of each incision, and they 
are gently dissected up. A small rubber catheter is 
now passed, lubricated with 1/1000 flavine in paraffin, 
and over it the inner flap is turned back and sutured 
in position by a continuous catgut suture. This 
suture should be of the Connell type, only picking 
up the deep surface of the skin, and not penetrating 
to the lumen of the new urethra, so that no suture 
can convey urine into the tissues by capillary attrac- 
tion. It seems to me that this lateral line of non- 
penetrating 
continuous 
suture must 
be consider- 
ably more 
waterproof 
than the 
median in- 
terrupted 
stitches tied 
in the lumen 
of the ure- 


thra which 
are used by 
FIG. 8.—Diagram of connexion of pinhole Edmunds. 
meatus and blind sinus in first degree The outer 
hypospadias. (a) Opening of blind sinus. flan is th 
(0) End of sinus. (c) Pinhole opening to p 18 then 
urethra. (d) Tissue divided to connect gewn into 
openings. (e) Urethra. 


position by 
vertical 
mattress stitches, and it will be seen that the two 
suture lines lie far apart. At the only point at 
which it may look that they would coincide, just 
below the original. opening, the retraction of the 
scrotal skin ensures: a wide difference of line. For 
all the stitching I use a suture which I originally 
got Messrs. Armour and Co. to make for intestinal 
anastomoses in infants, a very fine straight round- 
bodied eyeless needle carrying 6/0 chromic catgut. 

The catheter is left in for twenty-four hours. 
This is not long enough to start a urethritis, but 
allows time for the coagulation of the tissue juices 
to seal the wound and waterproof it against the flow 
of urine. 


RESULTS 


I have tried this method on eight cases, all of 
which have healed by first intention without a fistula. 
I have also used it successfully in a reversed form 
for a case of epispadias, transplanting the apron- 
like prepuce found in this condition into the ventral 
surface of the penis, and then covering in the deep 
urethral gutter with a double flap of the kind described. 
(The split glans can be easily closed by simple rawing 
and suture of its dorsal edges.) 


A NOTE ON FIRST-DEGREE HYPOSPADIAS 


A quite common deformity is that in which the 
urethra ends in a pinhole meatus within the V-shaped 
area of skin under the glans. A formal plastic opera- 
tion of the kind described would be quite useless, 
even if possible. The only disability is that the flow 
of urine, although delivered to almost the right place 
at the tip of the penis, dribbles downwards instead 
of spurting forwards owing to the opening being a 
pinhole on the floor of the urethra. Now it is a 
curious thing that in many of these cases there is 
a blind sinus lined by mucous membrane opening 
closer to the end of the glans, and running backwards 


DRS. HARRIS AND YENIKOMSHIAN: PNEUMOCOCCUS MENINGITIS ([san. 18,1936 143 


half an inch or so, deep to the urethra proper. I 
have in three cases of this sort connected the two 
Openings by passing one blade of a small blunt- 
pointed scissors into each and cutting the tissues 
between. The rather free bleeding resulting can be 
controlled by stitches passed with the fine needle 
described. The results have been excellent. The 


advantage of enlarging such an opening towards its 


normal situation instead of away from it is obvious, 
and there is no tendency to stenosis. — 


PNEUMOCOCCUS MENINGITIS 
FOLLOWING TONSILLECTOMY 
AND TERMINATING IN RECOVERY 


By STANLEY E. Harris, M.D. 
OF PHILADELPHIA, PA. ; AND 
H. A. YENIKOMSHIAN, M.D. Beirut, M.R.C.P. Lond., 
: D.T.M. & H. 


ASSOCIATE PROFESSOR OF INTERNAL MEDICINE, AMERICAN 
UNIVERSITY OF BEIRUT, SYRIA 


PNEUMOCOCCUS meningitis may either be a primary 
infection, or, more commonly, an extension from a 
focus elsewhere in the body. In most of the recorded 
cases it has followed infection of the ear or pneumonia, 
Since we have been unable to find other mention 
of this condition as a complication or sequela of 
tonsillectomy, and because recovery from proven 
pheumococcus meningitis is rare, we are reporting 
the following case. 


CASE RECORD 


A pupil nurse, aged 25, was admitted to the Hospital 
of the American University of Beirut on Feb. 25th, 1926, 
for tonsillectomy. She had suffered from rheumatic 
heart disease since an attack of polyarticular rheumatism 
in 1913. In 1916 her tonsils were clipped (guillotine 
operation), but the stumps were grossly diseased, and she 
had continued to suffer from occasional sore-throats and 
exacerbations of joint pain. The tonsillar stumps were 
removed under local anesthesia, and after six days of 
uneventful convalescence she was discharged with a 
normally healing throat. 

On the same afternoon, March 3rd, she began to have 
headache which was not relieved by aspirin and phenacetin, 
and her temperature rose to 38°C. (100-4°F.). These 
symptoms persisted till March 6th when the temperature 
rose to 40° C. (104° F.) and she was admitted to the medical 
service complaining of extremely severe, bursting head- 
ache, diplopia, and projectile vomiting. On examination 
she was found to be drowsy, but could answer questions 
intelligently when aroused. There was slight ptosis of the 
right upper lid and the right external rectus muscle was 
weak, causing strabismus. The pupils were equal and 
reacted to light and in accommodation. Slight muscular 
twitchings were noted over the face. Except for a few 
whitish spots over the fauces the pharynx and the mouth 
were negative. There was no glandular enlargement. 
The area of cardiac dullness was increased and a loud, 
rough systolic murmur was present at the apex and 
transmitted to the axilla. The pulmonary second sound - 
was accentuated. The lungs were negative. Tliere was 
no abdominal tenderness or rigidity, and no organs were 
palpable. The abdominal reflexes were very brisk. The 
left knee-jerk was more active than the right. Kernig’s 
sign was present and there was moderate stiffness of the 
neck. There was no Babinski reflex. 

Lumbar puncture was done at once, turbid spinal fluid 
being obtained under considerable pressure. Polyvalent 
antimeningococcus serum was injected, 60 c.cm. intra- 
thecally and 40c.cm. intramuscularly. When examined 
the fluid showed a cell count of 540 leucocytes per c.mm., 


144 THE LANCET] 


85 per cent. being polymorphonuclears and 15 per cent. 
lymphocytes. The globulin content was increased ; 
the sugar reduced to 37:7 mg. per 100 c.cm. Smears 
revealed numerous encapsulated Gram-positive lanceolate 
diplococci, and on planting the fluid in various media 
organisms having all the cultural characteristics of the 
phneumococcus were grown. Unfortunately no serum 
was available for typing, but the bacteriological charac- 
teristics were not those of Type III. 

For three days there was no change in the symptoms, 
the patient crying out almost constantly, owing to the 
unbearable headache. On March 8th another lumbar 
puncture was done, purulent fluid was drained off, and 
20 c.cm. of polyvalent antipneumococcus serum was 
given intrathecally. The spinal fluid again contained 
pneumococci on smear and culture. Antipneumococcus 
serum, 20 c.cm., was given intramuscularly and on the 
following day 20 c.cm. of 1 per cent. Mercurochrome 
intravenously. A very severe reaction followed this last 
injection, the temperature rising to 41°C. (105-8°F.); 
the patient went into collapse. Next morning, the 10th, 
her symptoms were much improved. Lumbar puncture 
yielded 30 c.cm. of fairly clear fluid which was replaced 
by 20 c.cm. of antipneumococcus serum, another 20 c¢.cm. 
being given intramuscularly at the same time. Improve- 
ment continued, no further specific treatment was given, 
and except for urticaria which appeared on the llth 
her progress to recovery was uneventful. She was dis- 
charged cured on March 25th, soon took up her duties in 
the training school and completed her course without 
further illness. 


DISCUSSION 


It has long been the consensus of medical opinion that 
the prognosis of meningitis due to the pneumococcus 
is extremely unfavourable if not hopeless. Schott- 
müller ! reported 100 per cent. mortality in 100 cases, 
and more recently Davidson and Wollstein ? have 
reported a series of 122 cases in children without a 
single recovery. Although admitting that some 
patients have recovered, Waterfield * in a review of 
24 fatal cases at Guy’s Hospital is frankly sceptical 
concerning the diagnosis in the more than 150 “ proven 
cases with recovery ” collected from the literature 
by Goldstein and Goldstein 4 in 1927. In many of 
these cases, and in a few presented since that time, 
insufficient data are given concerning the methods 
used in identification of the causative organism or, 
as in the case reported by Goldstein and in those of 
Croft,> and of McAuley and Hilliard,® no growth was 
obtained on culturing the spinal fluid, the diagnosis 
being based on the finding of organisms resembling 
the pneumococcus in stained smears. Nevertheless, 
in a not insignificant number of the older cases and 
in at least 17 of the more recent reports, the diagnosis 
was sufficiently established by bacteriological studies 
for the prognosis in future to be less gloomy. 

In these 17 cases pneumococcus Type I. was found 
in three instances 7; in two the organism was of 
Type III.§; in three of Group IV.°®; and in the 
remainder }° the type was not noted. It would 
appear that when recovery has occurred the causative 
organism in most instances has belonged to a relatively 
avirulent strain of the pneumococcus. A review 
of the therapeutic measures employed suggests that 
the second important factor leading to recovery is the 
vis medicatrix nature. 

Since antipneumococcus serum became available 
it has been employed in the treatment of many cases, 
occasionally with favourable outcome. Reveno and 
McLaughlin? gave large doses of specific serum 
intrathecally and intravenously with favourable 
results in their case of Type I. pneumococcus menin- 
itis. In the 9 other cases collected from the recent 
literature! and in our own case, where anti- 
pheumococcus scrum was used, its role in bringing 


DRS. HARRIS AND YENIKOMSHIAN : PNEUMOCOCCUS MENINGITIS 


[yan. 18, 1936 


about recovery is open to question. In none of 
them was the serum known to be type-specific. 
In several cases very small doses were employed and 
the relationship between serum administration and 
clinical improvement is not clearly shown. Repeated 
lumbar puncture is another procedure which has 
been often carried out. In 9 of the 17 cases !? referred 
to, it was the chief method of treatment. Combined 
cisternal and lumbar puncture and cisterno-lumbar 
irrigation with normal saline solution was done in 
two of them. 


Other therapeutic measures which have been 
advocated have either failed in other hands to give 
the results suggested by their proponents or have 
not been accorded sufficient clinical trial for judgment 
to be passed upon their efficacy. Among these may 
be mentioned ethyl-hydrocupreine (Optochin Base) 
and its soluble hydrochloride which gave much promise 
experimentally and which have been widely used }$ ; 
hexamine (urotropine), which Murphy 1° gave to his 
patient in large doses and to which he thought the 
rapid relief of symptoms might be attributed ; 
potassium permanganate solution, which was 
administered by Weinberg 8 according to the Nott 
technique as almost the sole treatment. | 


Mercurochrome has not proved effective either 
experimentally or clinically against the pneumococcus, 
In a case reported by Stoessiger,!4 in which Gram- 
positive diplococci resembling pneumococci were 
found in the spinal fluid, mercurochrome was given 
intraspinally, and the patient “ was on the road to 
recovery ”? after the third injection. In his case as 
in ours a severe reaction with considerable rise in 
temperature resulted from the mercurochrome injec- 
tion. It is interesting to speculate whether in both 
cases the shock and temperature elevation did not 
play a part in inducing the favourable outcome. 


REFERENCES 


1. Schottmiiller (quoted by Steinbrink) : Therap. d. Gegenwart, 
1925, xxvii., 186. 
2. Davidson, L. T., and Wollstein, M.: Acta Pediat., 1930, 


xi., 367. 

3. Watertield, R. L.: Guy’s Hosp. Rep., 19338, Ixxxiii., 452. 

4. Goldstein, H. I., and Goldstein, H. Z.: Internat. Clinics, 
1927, iii., 155 (With bibliography). 

5. Croft, C. R.: THE LANCET, 1928, ii., 700. 

6. McAuley, J., and Hilliard, F. M.: Brit. Med. Jour., 1933, 
i., 139. 

7. Harkavy, J.: Jour. Amer. Med. Assoc., 1928, xe., 597; 
Amesse, J. W.: Colorado Medicine, 1931, xxviii., 361 ; 
Reveno, W. S., and MeLaughlin, N.: Ann. Internal 
e vii., 1026 (also agglutinated by Type Hl. 
serum). 

8. Cavenaugh, J. B.: Jour. Laryng. and Otol., 1933, xlviii., 
337; Weinberg, M. H.: Jour. Nerv. and Ment. Dis., 
1931, Ixxiv., 38. 

9. Bedell, C. C.: Jour. Amer. Med. Assoc., 1934, cii., 820 ; 
Rohrbach, H. O0.: Pennsylvania Med. Jour., 1929, xxxii., 
646; Globus, J. H., and Kasanin, J. I.: Jour. Amer. Med. 
Assoc., 1928, xe., 599. 

Creagh, E. P. N.: Jour. Roy. Army Med. Corps, 1932, 
lix., 212; Murphy, R.: ibid., 1929, lii., 293; Clark, 
J.G.: THe LANCET, 1932, ii., 1330 ; Shuller, E. H. Jour. : 
Oklahoma Med. A., 1932, xxv., 137; Segers, A., and 
Sehere, S.: Semana méd., 1932, ii., 587 ; Simpson, A. S.: 
THE LANCET, 1927, i., 390; Uhr, J. S.: Arch. of Pediat., 
1929, xlvi., 121; Apfel, H.: Ibid., p. 516; Lynch, L. J.: 
New Eng. Jour. Med., 1930, eciii., 256. 

Rohrbach, Schuller, Clark, Creagh, Segers and Schere, 
Simpson, Apfel, Lynch, Ratnotf and Litvak. 

Clark, Rohrbach, Bedell, Shuller, Amesse, Creagh, Segers 
and Schere, Uhr, Globus, and Kasanin. 

Steinbrink: Therap d. Gegenwart, 1925, xxvii., 186; 
Ratnoit, H. L., and Litvak, A. M.: Arch. of Pediat., 
1929, xliii., 466. 


14. Stoessiger, LL. N.: Brit. Jour. Child. Dis., 1930, xxvii., 35. 


10. 


l1. 
12. 


13. 


EAST LANCASHIRE WORKPEOPLE’S HOSPITAL FUND. 


This fund is making excellent progress, for the cost of 


working is very small and the bank interest almost covers 
the expenses. Over £150 more is available for distri- 
bution than last year and the fund has been ablo to help 
several medical charities in Blackburn, 


THE LANCET] 


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Temperature chart showing response to Hriecolons of antiserum (8) and whole blood (B). 


DRS, HENDRY & GRIFFITHS : WHOLE-BLOOD INJECTIONS IN SEPTICEZMIA [JAN. 18,1936 145 


iL 


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SRNUIWEREDCRAWSONERUUGUGH EESUUOSERNAGOS 


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The figures before B and 8 indicate 


the number of cubic centimetres injected. 


STREPTOCOCCAL SEPTICZAMIA TREATED 
WITH WHOLE-BLOOD INJECTIONS 


By J. A. HENDRY, B.Sc., M.B. Aberd. 
PHYSICIAN TO THE DEVONSHIRE ROYAL HOSPITAL, BUXTON ; 


G. J. GRIFFITHS, B.Sc., M.B. Lond. 


PATHOLOGIST TO THE HOSPITAL 


AND 


Mucu has been written on the use of streptococcal 
antiserum in the treatment of septicemia. On the 
whole the results have not been satisfactory, although 
in the treatment of puerperal sepsis Burt-White } 
reported successes and in two cases recorded by 
Pinnock and Sanguinetti? good results followed 
the use of streptococcal antitoxm. 

Human blood-serum was used by Lazarus-Barlow 
and Blayney Chamberlain? in the treatment of 
septicemia and they report success in 9 out of 12 
cases. They suggest the use of whole blood in place 
of serum, and we adopted this method in the present 
case because the patient was seriously ill and it 
seemed inadvisable to remove her to hospital. The 
procedure used was the injection of 15c.cm. of 
whole blood taken from the patient’s husband and its 
immediate injection into the thigh. No apparatus 
was required other than sterile needles and syringe ; 
nor was blood-grouping necessary. 


CASE RECORD (SEE CHART) 


While nursing her only child, who had a sore-throat, 
Mrs. A., aged 30, developed tonsillitis which lasted two 
days. This was on Oct. 24th, 1934. A week later 
sore-throat again developed, and on Nov. 7th it became 
serious ; when the patient was seen by one of us (J. A.H.) 
her temperature was 101°F. and her pulse-rate 120, 
the tonsils and pharynx looking shiny and red. On 
Nov. 10th she became delirious, with terrifying dreams 
at night. Red raised patches appeared on the left side 
of the forehead, the right supraclavicular region, the right 
upper arm, the right wrist, and the right thigh above the 
knee. There was general stiffness but no meningismus. 
The temperature was now 104° F. and the pulse-rate 140. 
A blood culture was taken and the urine examined, the 
latter being found to contain red blood-cells, slight excess 
of leucocytes, and an occasional cellular cast. Strepto- 
coccal antitoxin (10c.cm.) was given, with a further 
10 c.cm. next day when the blood culture showed a short- 


chain streptococcus. The antihemolysin titre of the 
serum was 75 units (maximum normal 50 units). 


.On Nov. 12th the condition remained serious. There 
were severe headaches, the red patches noted on the 10th 
were more pronounced; also there was apparent rigidity 
of the upper and lower limbs. Antitoxin (20 c.cm.) 
was again given, and a further 30c.cm. on Nov. 13th. 
From the 14th-23rd there was no improvement. The 
patient became emaciated and depressed and lost appetite. 
Her heart was enlarged and there was a systolic mitral 
murmur. An abscess appeared over the right wrist and 
it was incised on Nov. 23rd, a culture being taken at the 
same time. This was found to contain hemolytic strepto- 
cocci, and they were sent to Dr. F. Griffith, of the Ministry 
of Health, who reported that the organism was of the 
Carter type. He mentioned that this type had been 
isolated in a family outbreak in which a child died of 
acute peritonitis following a labial infection, the mother 
finally recovering after severe cellulitis in the region of the 
breast. A vaccine was prepared from the streptococcus, 
the strength being 100 million per c.cm., and this was 
given to the patient’s husband on alternate days until the 
dose was 100 million, the object pene to give the patient 
an immuno- transfusion. 


On Nov. 27th an abscess over the right shoulder was 
opened; pus poured freely from it. For a time the 
patient’s condition improved, but it deteriorated on the 
30th; the headaches returned and she became depressed 
and exhausted. On Dec. 2nd another abscess, on the 
left arm, was incised and the patient received the first 
injection of husband’s blood (15c.cm.). Thesame quantity 
was given next day, and at 2 p.m. the temperature was 
normal], the maximum evening temperature being 100° F. 
A further 15c.cm. was given on the 4th; there was 
general improvement, and the patient was free from head- 
aches and able to take more food. Progress was 
interrupted, however, on the 10th when the temperature 
rose to 104° F., and on the llth the state of affairs was 
not satisfactory, the patient being restless and depressed. 
An injection of 15c.cm. of whole blood was given and 
another next day, when the maximum temperature was 
102° F. and redness and swelling were apparent above the 
right knee, with stiffness of the joint. Fluctuation was 
obtained above the right knee on the 13th and an incision 
was made, but no pus was found. Injections of blood 
(15 c.cm.) were again given on Dec. 13th, 15th, 18th, and 
24th, and a further incision was made about the middle of 
the thigh on its inner side. On the 25th, when the patient 
received a further dose of blood, pus was discharging 
freely from right thigh and she felt much better. The 
last blood injection was given on the 27th, when improve- 
ment was fully maintained, and on the 28th all incisions 


146 


THE LANCET] 


MR. A. P. BERTWISTLE : GROOVED ALUMINIUM VERSUS WOODEN SPLINTS 


fyan. 18, 1936 


showed signs of healthy healing. 
temperature was 99° F. 

From Dec, 28th onwards the patient made good progress 
and on Jan, 2lst she was convalescent. When seen on 
April 27th after a stay in Ireland she had put on over 
a stone in weight and there were no signs of residual 
infection. The antihzemolysin titre had risen from 75 units 
at the onset of the infection to 250 units on April 27th. 


Although in this case there was a slight fall in 
temperature after each injection of streptococcal 
antitoxin, there was little improvement clinically. 
This may have been due to the absence from the 
antiserum of the specific antibody corresponding to 
the bacterium infecting the patient. Each injection 
of whole blood from the donor immunised with an 
autogenous vaccine caused profound improvement, 
and they seemed to precipitate the formation of 
localising abscesses in the red patches which appeared 
at the onset of the illness. As the antihemolysin 
titre of the serum increased only from 75 to 250 units 
it is doubtful whether any improvement can be 
attributed to the antihemolysin. (It may be recalled 
that Todd 4 in his work on the infection of mice by 
hemolytic streptococcus found that no protection 
against infection was obtained by the use of anti- 
toxin nor by the use of high-titred antihzmolysin ; 
in all probability the improvement in some of the 
mice was due to a protective antibody at present 
unknown.) The possibility of complement cannot 
be neglected, for it has been found by Cadham 5 
that in acute infection the complement titre may be 
low during the acute phase of the disease. The 
introduction of complement by the way of whole 
blood from a healthy person may in this case have 
done much to combat the infecting organism 


The maximum 


REFERENCES 


. Burt-White, H.: THE LANCET, 1930, i., 16. 

. Pinnock, D. D., and Sanguinetti, H. H.: Ibid., 1934, x., 507. 

. Lazarus-Barlow, P., and Chamberlain, L. P. B.: Ibid., 
1934, x., 503. 

. Todd, E. W.: Jour. Path. and Bact., 1935. xl., 243. 

. Cadham, F. T.: Brit. Med. Jour., 1930, ii., 460. 


Qa Gm 


GROOVED ALUMINIUM VERSUS WOODEN 
SPLINTS 


By A. P. BERTWISTLE, F.R.C.S. Edin. 


THE materials used for splints by doctors in their 
own surgeries are amazing ; I have seen folded news- 
paper, cardboard, and rough pieces of boxwood 
employed. Many hospitals use wooden splints, some 
fashioned, others not. The St. John Ambulance 


FIG. 1.—Jones’s cock-up splint. 


Brigade use straight wooden splints. I believe that 
if the advantages of grooved aluminium were more 
generally realised this would be the material of choice. 
Aluminium splints may be divided into two classes :— 


1. Emergency, home-made.—Sheet aluminium, gauge 22. 
will be found to be the best, for it is sufficiently strong 
and yet is easily cut with tinsmith’s shears, which are 
like massive scissors and readily procured. The requisite 
length is cut, sharp corners are removed, and the splint 
is guttered by hammering over a rounded object or even 
by hand. This guttering is imperative, since without it 
aluminium will bend under a slight strain. Half-inch 
adhesive plaster is fastened round th’ edges ; this serves 


to do away with rough edges and helps to steady the 
subsequent padding. Such splints are invaluable for 
special fractures—e.g., in small children. A stock should 
always be available. | 


2. Rolled.—These are greatly to be preferred, since the 
even rolling makes for increased strength. The tinsmith 
rolls them in his rollers so that the gutter forms an arc 
of a circle with a radius of 2 in., more or less; more in 
the case of splints of more than 2} in. across and much 


less in the case of finger splints. The edges are covered 
with adhesive as before. 


The following are the advantages claimed. (1) 
Strength. Experimentally a rolled tinsmith’s splint 
9 in. long by 2} in. wide, of 22 gauge, suitable for 


FIG. 2.—Forearm splint. 


a forearm, supported at each end, withstood a weight 
of 112 lb. placed on its middle. Such strength is 
quite sufficient to cope with most of the stresses and 
strains to which the splint would be liable. An 
emergency splint broke down under half the weight. 
(2) Economy. The fashioned wooden splint—and no 
other wooden splint should be permitted—costs 
considerably more than the aluminium one. The 
Robert Jones cock-up splint, which is readily 
made by cutting out a section to accommodate the 
thenar eminence and turning the end backwards, 
costs much less than Carr’s splint for Colles’s fracture. 
(Incidentally, surely the dorsiflexed position is the 
proper one for Colles’s fracture? The- fragments 
showing little tendency to 

movement, the wrist ismuch 
stronger in that position 
than palmar-flexed, and the 
fingers can be freely moved.) 
(3) Lightness and small bulk. 
The aluminium splint has 
the double advantage of being more comfortable to the 
patient and of being easily stored. The two splints 
used for Colles’s fracture weigh 6 oz., whereas two 
aluminium ones weigh 2 oz. and are stored in a frac- 
tion of the space, unpadded. (A few placed tinder 
the seat of a motor-car may on occasion be invaluable.) 
(4) Asepsis. Open fractures and those associated 
with wounds are liable to soil the splint, which should 
be discarded. Aluminium ones may be boiled. 
(5) Radiolucency. A fracture may be radiographed 
with the splint in situ. 

Aluminium splints are ideal for fracture of the 
radius and ulna, the commonest bones to suffer. 
They are excellent for fractures of the digits, 
often allowing the patient to continue his work, as 
a clerk for example. In the case of the toes, especi- 
ally the great one, the splint has to have a sole, and 
in practice needs changing weekly because it is liable 
to break if weight is borne. Aluminium splints may 
be used for fracture of the fibula, and are invaluable 
in the first-aid treatment of fractures of the tibia 
and fibula in children and adults and of the femur 
in children. In these days of motor accidents and 
X ray plants too little attention 1s paid to the all- 
important first-aid treatment of fractures, 


FIG. 3.—Splint for great toe. 


RovaL Society oF Arts.—On Feb. 10th, 17th, 
and 24th Major-General Sir Robert McCarrison, late 
director of nutrition research, Indian Medical Research 
Fund Association, will give three Cantor lectures to the- 
society (John-street, London, W.C.) at 8 P.M. He will 
speak on Nutrition and National Health. 


THE LANCET] 


{[san. 18, 1936 147 


MEDICAL SOCIETIES 


A 


2 
ROYAL SOCIETY OF MEDICINE 


SECTION OF ORTHOPÆDICS 


AT a meeting of this section. on Jan. 7th, with 
Mr. ALAN Topp in the chair, methods of treating 


Club Feet and Pes Cavus 


were illustrated by cinematograph films and by 
patients showing successful results. The first film, 
exhibited by Mr. DENIS BrowngE, detailed his method 
of treating congenital talipes in infants. He felt 
convinced that one class of deformity was due to 
mechanical intra-uterine forces. The most important 
from the point of view of the child’s future was 
talipes equino-varus, which, he believed, was a mould- 
ing deformity due to pressure of the uterus on the 
outer side of the foot; the responsible single factor 
was the position of the foot in the uterus; a normal 
right foot took the pressure of the uterine wall on 
its sole. The essential part of the deformity was a 
twisting inwards of the fore part of the foot, which 
was forced round into the reverse position. In these 
cases there was also a thinning of the skin over the 
convexity of the foot. It was very important to treat 
this deformity in infancy, while the bones were soft 
and the tissues supple. After forcible manipulation to 
bring the foot beyond the normal position, the ankle 
was dorsiflexed and kept in position with strapping, 
and both feet were bandaged to one rigid foot-piece. 
This treatment restored muscle balance, and the 
vigorous kicking indulged in by the child showed 
the muscles to be in gocd working order; indeed 
this kicking was a very important factor in the treat- 
ment. A later stage was depicted with the splint 
removed and the foot in a normal position, with no 
tendency to revert to the abnormal. As soon as 
the child was able to walk it was made to stand up 
in the splints, and twice daily the foot was strongly 
dorsiflexed. 

Mr. B. WurtcHurRcH HOWELL congratulated Mr. 
Browne on his results, which represented a great 
advance in the treatment of club-foot. There was 
likely to be a difficulty if the method’ was carried 
out as a routine in outlying country districts, where 
after-care might be inadequate. 

Mr. Navucuton Dunn (Birmingham) remarked 
that the series of results shown by Mr. Browne were 
extraordinarily good. This method of maintaining 
external rotation was the best he had seen, and, as 
it was simple, he considered it was more applicable 
to treatment in country places than other current 
methods. He stressed the importance of counter- 
balancing the corrective forces by equal pressure 
on the outer side of the neck of the bone, because, 
unless the operator exercised care in this respect, 
a rotation of the astragalus on the ankle-joint would 
obliterate the hollow in front of the external malleolus. 
The presence of this indicated true correction but 
in its absence a relapse was almost sure to follow. 
Another important point was that over-correction 
of the club-foot deformity might result in severe 


valgus deformity. It was essential first to secure- 


over-correction and then a restoration of the muscle 
balance. It was a great advantage if, as Mr. Browne 
had said, it was unnecessary to elongate the tendo 
Achillis, but in some patients he himself had not 
found that the case. If the tendon was not fully 
stretched, the patient would be liable to have a 
permanent flat-foot. The surgeon must not maintain 


over-correction too long, and he must be sure that 
the tendo Achillis was long enough to allow dorsi- 
flexion in the position of inversion. 

Mr. DENIS BROWNE replied that cutting the tendo 
Achillis was, in his opinion, a crippling and deforming 
procedure. 

The CHAIRMAN demonstrated by means of a film 
his operation for the treatment of pes cavus, the 
results of which were shown to be excellent. He > 
explained that, although he worked at and evolved 
the procedure independently, he did not claim for it 
any originality. 

Clinical Cases 


Mr. C. LAMBRINUDI showed two lantern slides of 
a case of osteochondritis of the outer condyle of the 
femur. The patient, a woman aged 70 years, had 
fallen down and hurt the inside of her knee. Shortly 
afterwards a swelling appeared there which remained 
localised, and she had since suffered a good deal of 
pain. She had sought advice at several places, but 
not until the exhibitor saw her was a skiagram taken. 
Both flexion and extension were preserved, and no 
extra heat could be detected in the part. She was 
definitely better after a short time in bed. 


After describing the good result from fascial 
repair of a torn ligamentum patellw in a boy aged 17, 
Mr. Rocyn JONES showed a case for diagnosis. 
The patient, a man aged 57, and seen that day for 
the first time, occupied himself in slaughtering 
diseased animals. Some weeks before, following a 
scratch, his finger had become swollen and the 
swelling had persisted and increased. It was not 
tender, but the tendon sheath felt boggy; move- 
ment of the metacarpo-phalangeal joint was limited. 
The bone did not show any suggestion of a patho- 
logical condition. 

Mr.. V. H. ELLIs suggested that the condition was 
a tuberculous infection, which was common among 
those engaged in animal slaughter. It was probably 
a tuberculous teno-synovitis and should be immobi- 
lised in plaster for a time to see what happened. 

The CHAIRMAN did not regard the condition as 
tuberculous, but probably an anaerobic infection 
of low virulence. He suggested puncture, and 
an attempt to cultivate the material obtained on 
both anaerobic and aerobic media. 

Mr. C. IIOPE CARLTON also thought it was not 
tuberculous but he would hesitate to puncture it. 
That kind of low-grade infection in the fingers was 
not uncommonly seen in industrial areas, and the 
outlook, he thought, was bad. Some form of high 
temperature treatment and radiant heat could be 
tried, but even then the prospect of retaining the 
finger was poor. | 

Mr. DUNN said he was not sure whether this was 
a tuberculous condition or a low-grade infection, 
but he had treated a similar condition in a butcher. 
The sheath was exposed and there was a general 
synovial thickening, which was removed surgically, 
and the result was good. It would be a waste of 
time to immobilise a finger in a man who wds eager 
to resume work; amputation would be best in the 
case of recurrence. 


Mr. E. P. Brockman also showed as a case for 
diagnosis a man, aged 60, who in 1929 had com- 
plained of pain in the hip-joint, and, a year later, 
arthritis was present in the joint. He did a Rick- 
man’s reconstruction and found only osteo-arthritis 
with some pedunculated folds in the synovial 


148 THE LANCET] 


membrane. The man said that in 1915 he had had a 
cyst removed from the hip-joint. No tubercle had 
been found. Last year the man could not walk so 
well, his pain had become greater and at length 
persistent, and a lump was noticed. Bearing in 
mind the man’s age and the absence of remissions 
in the pain, he thought it was likely to be a case of 
sarcoma. 

Mr. Dunn diagnosed an ossifying chondroma, the 
pain being probably due to a stretching of the sciatic 
nerve over the bone. The best treatment was to 
expose the area and remove the tumour for patho- 
logical investigation. 


ROYAL ACADEMY OF MEDICINE IN 
IRELAND 


AT a recent meeting of the section of surgery, with 
the president, Mr. SETON PRINGLE, in the chair, 
Mr. A. B. CLERY read a paper on the 


Enucleation of Pleural Adhesions by Open 
Operation 


This operation, he said, was particularly indicated in 
patients with one or two apical adhesions extending 
into the region of the subclavian vessels. The skin 
incision was as for an upper thoracoplasty, the 
deeper muscles being divided in the line of the third 
rib. Having retracted the scapula, 2} to 3 inches 
of the rib were resected, and the pleura opened by 
diathermy. Light-bearing retractors were introduced 
into the pleural cavity and the adhesions enucleated 
from their attachment to the parietal pleura by the 
diathermy needle under direct vision. _ 

Dr. G. T. O'BRIEN described the clinical course 
of three patients upon whom this operation had been 
carried out. In two of them the sputum, previously 


REVIEWS AND NOTICES OF BOOKS 


[JaN. 18, 1936 


T.B. positive, was negative within a fortnight of the 
operation, and cavities had closed in six weeks. In 
the third case lateri'ly directed adhesions were 
enucleated, but infiltration of tissue by tubercles 
about the subclavian vessels prevented the Jung 
apex from being freed. The cavity in this case had 
diminished in size. Treatment by artificial pneumo- 
thorax had been continued in all three cases. 

Mr. F. J. HENR® thought there was scope for 
preliminary thoracoscopy in these cases, as some of 
the adhesions might be suitable for closed division. 
He drew attention to the necessity for air-tight 
closure of the wound, or the pneumothorax might 
become incompetent by leakage, the lung re-expand, 
and the adhesion become reattached. To prevent 
this, it might be well to suture the cuff of enucleated 
pleura over the raw stump of the adhesion. 

Mr. T. A. BOUCINER-HAYES referred to two cases 
he had treated in a similar manner, one of which, 
in whom the third and fourth ribs were resected, 
developed surgical emphysema: 

Dr. J. B. MAGENNIS, while agreeing that the method 
afforded a new way of dealing with adhesions which 
could not be dealt with by “thoracoscopy, thought 
it would be wise to do a preliminary thoracoscopy. 
There was, he felt, a definite danger of surgical 
emphysema. 


Mr. CLERy, in reply, said he did not decry the 
value of thoracoscopy ; he wanted to show that the 
open operation could be done if necessary. Surgical 
emphysema, he thought, would not be a serious 
complication. 


Dr. R. STUMPF read a communication on a new 
method of low-voltage X ray therapy for easily 
accessible cancers, known as Chaoul’s contact treat- 
ment. Of 35 cases in which the treatment was 
completed, 25 cases were clinically healed. 


REVIEWS AND NOTICES OF BOOKS 


Body Water—the Exchange of Fluids in Man 
By Joun P. PETERS, M.D., Professor of Internal 


Medicine, Yale University School of Medicine. 
London:  Bailliére, Tindall and Cox. 1935. 
Pp. 405. 18s. 


WATER is so close to the roots of life that there is 
no branch of medical or physiological research where 
the investigator does not sooner or later encounter 
problems involving some insight into fluid meta- 
bolism. While it seems that certain aspects of the 
subject, such as the impermeability of the cell mem- 
brane to the potassium ion, are likely to remain 
inscrutable as long as life remains undefined, a great 
deal of useful information has accumulated about 
less obscure questions. Anyone who attempted to 
survey comprehensively the spate of papers on 
water metabolism which flows in ever-swelling volume 
through the channels of the biological press could 
only produce the type of review which exacts the 
epithet “monumental,” and, being essentially life- 
less, earns it. Interminable catalogues of conflicting 
conclusions and opinions, punctuated by strings of 
surnames in unlovely juxtaposition, and unleavened 
by critical comment, dismay rather than help the 
reader. Prof. Peters has avoided this danger and 
has somehow succeeded in weaving the 900 odd 
items of his bibliography into an intelligible argument. 

He has concerned himself in the earlier chapters 
with the transfers of fluid which are continually 


occurring between the various compartments of the 
body: from blood-vessel to interstitial space, to 
serous or jomt cavity, to subarachnoid space; from 
interstitial space to lymphatic, from plasma to 
corpuscles, and so on. He attempts to explain these 
movements in terms of certain physical and physio- 
logical postulates, hke the Donnan theory of mem- 
brane equilibrium and the Starling theory of the 
formation of interstitial fluid. It is a difficult task, 
for hydrostatic principles and collodion membranes. 
are simple compared with hydrodynamics and 
membranes of varying permeability, but Prof. 
Peters handles his bulky data well. One or two 
minor points call for criticism. There is a school 
which clings to the odd belief that the intercellular 
spaces are filled with a protein gel, a sort of sponge 
which soaks up or exudes fluid in response to changes. 
in hydrogen-ion concentration. In recoiling from 
this untenable hypothesis the author goes too far 
and implies that the immediate environment of the 
cell is wholly saline and circulating. But something 
tangible must also be present to maintain the archi- 
tectural integrity of tissue, and whether that some- 
thing is the mucinous ground substance of the older 
histolog ists, or the reticulum of more modern writers, 
there is certainly a fixed, as well as a circulating 
component in the environment of the cell, and the 
physiologist will sooner or later have to take it into 
consideration, Again, in discussing synovial fluid 
Prof. Peters finds great difliculty in accounting for 
the presence of mucoprotein. He is evidently not. 


Rc 


THE LANCET] 


alone in this difficulty, for he quotes attempts which 
have been made (of course ursuccessfully) to dis- 
cover mucous secreting glands in synovial tissue. 
Surely it is well enough established that mucoprotein 
is a normal constituent of most tissues. 

In a later chapter Prof. Peters considers the various 
ways by which the body gains or loses water, an 
important subject if only in view of recent attempts 
to make the measurement of water exchange a 
practical clinical proposition. The technical diffi- 
culties and possible sources of error in what to the 
uninitiated may appear a simple procedure are 
discussed at some length, and the reader is left with 
the feeling that for ordinary purposes measurement 
of fluid intake, urine output, and body-weight, how- 
ever unscientific, remains at present the only prac- 
ticable way of deciding whether a patient is gaining 
or losing water. The latter, and perhaps the more 
valuable half of the book, is devoted to a considera- 
tion of the physiology of the secretion of urine, and 
forms an up-to-date and readable review of this 
most difficult subject. 

Prof. Peters’s book is not likely to appeal to the 
general reader, but the physiologist or clinician 
whose researches have brought him unexpectedly to 
the shore of fluid metabolism would be well advised 
to consult it. It should at any rate save him from 
drowning in a sea of irrelevant references. 


Aids to Medicine 


Fifth edition. By James L. LivinGsToneE, Physi- 
cian to King’s College Hospital; Assistant Physi- 
cian to the Hospital for Consumption and Diseases 
of the Chest, Brompton. London: Bailliére, 
Tindall and Cox. 1935. Pp. 422. 5s. 


AN eastern potentate commanded his wise men to 
write the history of his people, but rejected their 
work because it was too long; they abridged it 
again and again, and finally satisfied him on his death- 
bed with the version, “ They lived; they suffered ; 
they died.” Medicine has not yet been compressed 
quite so far, but in Dr. Livingstone’s ‘‘ Aids ” it is 
reduced to remarkably small compass. The fifth 
edition has been brought up to date, and is based, 
as may be inferred from the preface, on Price’s text- 
book and Tidy’s Synopsis. The summarising is well 
done, and the text is clear, easily read, and quickly 
grasped ; if the student needs to swallow his medicine 
in pill form just before his examination this 1s no 
doubt an excellent pill—perhaps the best, with one 
notable exception, and that is a summary made by 
the student himself. To condemn the “aids” 
altogether is admittedly a counsel of perfection, but 
it is to be hoped that many of our students are 
intelligent enough, well enough taught, and wisely 
enough examined to be able to dispense with them. 


Early Diagnosis of the Acute Abdomen 


Seventh edition. By Zacuary Cope, B.A., M.D., 
M.S. Lond., F.R.C.S. Eng., Surgeon to St. Mary’s 
Hospital, Paddington; Senior Surgeon to the 
Bolingbroke Hospital. London: Humphrey Milford, 
Oxford University Press. 1935. Pp. 254. 10s. 6d. 


Tms book is already well known. Changing 
conditions have called for alterations in the text, 
and it is likely that in time further modifications will 
be required, especially in the chapters dealing with 
intestinal obstruction. It is questionable, for instance, 
whether thé statistics from St. Mary's Hospital, 
showing that out of 300 cases of acute obstruction 


177 were cases of strangulated hernia, give a true ' 


REVIEWS AND NOTICES OF BOOKS 


[san. 18, 1936 149 


picture of the present incidence of ‘strangulation 
now that radical operations for hernia are more 
frequently performed béfore the onset of complica- 
tions. It is also to be noted that in this book, which 
is distinguished by the clearness and soundness of 
most of its teaching, the account of intussusception. 
should be rather unconvincing and out of harmony 
with present day views on this condition. Mr. 
Cope’s work records the fruits of careful clinical. 
study, and herein lies its excellence. The introduction 
of more elaborate methods of examination seems. 
rather to detract from its value. For example, it is 
doubtful whether it is sound to regard the use of 
radiography as an advance in the early diagnosis of 
intestinal obstruction, and it is surely a mistake to 
suggest that cystoscopy should be undertaken to 
diagnose rupture of the bladder. Insufficient stress 
is laid upon the value of auscultation in the investi- 
gation of cases of acute intestinal obstruction, and 
more detailed consideration might well have been 
given to rupture of the spleen. These criticisms on 
matters of detail are made in the confident belief that 
many further editions of this valuable monograph 
will be called for. 


Healing : Pagan and Christian 


By GEorGE Gorpon Dawson, M.A., B.D. Camb. 
London: Society for Promoting Christian Know- 
ledge. 1935. Pp. 322. 9s. 


In this book the author attempts to consider in a 
comprehensive manner the principles of therapeutics ; 
he finds the restoration of health to occur through 
the three avenues of the body,‘ mind, and spirit, and 
labels the usual treatment of the sick as departmental. 
It follows that arguments are set out for religious 
healing as distinct from therapeutic treatment, and 
for coöperation between the pastor and the physician 
in effecting cures. The first part of the book 
surveys the very earliest conceptions of disease and 
death, reviewing the art of healing as displayed by 
the ancient civilisations and by primitive doctors. 
This brings us along a well-worn track through the 
medicine of the Greeks and Romans to theChristian era, 
so leading to the chapters dealing with the methods. 
of healing associated with the Christian Church. 
Here proper stress is laid upon the value of monkish 
learning, and although there is not much to be said. 
in this connexion which is not familiar to those who 
are at all well read, the material is set out in an easily 
assimilable form for the uninformed. But presumably 
the book was written largely to promote the views, as. 
expressed in the closing sections, on mental and 
spiritual healing, and because these views are clearly 
set out we recommend them to attention. The 
medical profession ig more ready to listen sympa- 
thetically to evidence pointing to the value of 
religious healing than the church appears to know. 


Félix Lejars : Traité de Chirurgie D’urgence. 
Ninth edition. By PIERRE Broca, Professeur 
agrégé à la Faculté de Médecine de Paris ; Chirurgien 
des Hôpitaux. Assisted by ROBERT CHABRUT, 
Ancien Chef de Clinique à la Faculté de Médecine 
de Paris. In two volumes. Paris: Masson et Cie. 
1936. Pp. 1299. Fr.200. 


Tne last edition of this book appeared in 1921. 
It was popular because of the simple and clear way 
in which every problem was tackled and explained, 
and because the recommendations were so obviously 
the fruit of the experience of a master surgeon. The- 


150 THE LANCET] 


scope is a little different from that of any treatise 
on emergency surgery we have available in this 
` country. It is more comprehensive, including many 
affections which are not immediately urgent in the 
strict sense of the word, and is the more valuable 
for its wider appeal. The book is addressed to the 
practitioner as well as to the young hospital surgeon. 
Emergency operations in every branch of surgery 
including the female genital organs, the ear, the eye, 
and the nose are described. The use of the csophago- 
scope is recommended though its technique is 
not given; neither for that matter is that of the 
cystoscope and the urethroscope. These methods 
are evidently considered too specialised for those 
to whom the book is primarily addressed. But it is 
not only practitioners and junior surgeons who will 
find it useful. It should be on the shelves of every 
operating surgeon, and easily accessible, for precise 
instructions are given for the treatment of emer- 
gencies seldom encountered apart from war, such 
as stab wounds involving the large vessels at the 
root of the neck, and rare emergencies, such as stran- 
gulated obturator and sciatic herniæ. The new 
authors have carried out an extensive revision of 
the work, have added much new matter, and have 
succeeded admirably in preserving its attractive 
character. 


The Nelson Loose-Leaf Living Surgery 
Renewal pages. Vol. III. Orthopedic Surgery. New 
York : Thomas Nelson and Sons. 1935. Pp. 179. 


THE most recent renewal pages to reach us of this 
composite surgery are really the first instalment of 
a revised and enlarged section on orthopedic surgery. 
The death of the former author, Nathaniel Allison, 
has necessitated the appointment of a new editor, 
R. K. Ghormley, who has called to his aid a number 
of experts in the different branches of orthopzdic 
surgery. This gives a very individual character to 
the subsections, and the teaching in some places 
differs materially from that of British surgeons. 
Thus the only treatment of spinal caries seriously 
considered is a bone-fusing operation ; in the treat- 
ment of congenital torticollis division of the upper 
end of the sternomastoid is recommended, whilst 
the contraction of the cervical fascia and scalenus 
anticus as component factors is ignored. Such 
deviations from current practice in this country, 
however, make the volume the more valuable to 
British surgeons. There is an attractive chapter on 
malacic disease of bone and another on degenerative 
diseases of the spine, where the pathology of the 
intervertebral discs receives due notice. The growing 
fecling against violent measures in the correction of 
congenital talipes equino-varus is well expressed in 
an informative article. These examples are men- 
tioned to show that the work is being kept well 
abreast of current thought, and the publishers and 
editors must once more be congratulated on main- 
taining the high ideal of service envisaged at the 
inception of this novel system of text-book con- 
struction. 


British Journal of Children’s Diseases 

In the October-December issue (vol. xxxii.) 
Dr. E. Ashworth Underwood concludes his article 
on the Neurological Complications of Varicella with 
a general discussion on pathogenesis. A bibliography 
of 186 references is appended together with a list 
of 120 cases collected from the literature from 1873 
to 1935, including an original case of cerebellar 
ataxia in a girl of 8.—In the concluding part of his 
Analysis of over Four Thousand Cases of Educational 


NEW INVENTIONS . 


[san. 18, 1936 


Deafness Studied during the Past Twenty-five Years, 
Mr. Macleod Yearsley maintains that the education 
of the deaf must be based not on the considerations 
of different systems but on the study of the deaf 
child as an individual. According to his scheme of 
classification, which is based on school medical 
inspection, deaf children fall into four groups: the 
slightly deaf, the semi-deaf, the very deaf, and the 
defective deaf, without there being an absolute 
line of demarcation between the groups. He is 
opposed to residential deaf schools, except where 
they are necessary to serve large areas without day 
deaf schools, and is pessimistic as regards the general 
condition of deaf education in this country and its 
future prospects. Lie recommends that fresh legis- 
lation of a wide nature should be started without 
delay by an Act which would embody the necessity 
for early detection of deafness, education of the deaf 
from pre-school to post-school age, and training and 
employment.—Dr. J. W. Healy contributes a paper 
on Diabetes Insipidus as a Manifestation of General 
Miliary Tuberculosis. The patient was a male 
child aged 24 years in whom the cause of death was 
acute external hvdrocephalus and acute tuberculous 
meningo-encephalitis, the terminal phenomenon of 
a tuberculous infection of much longer duration. 
An intercurrent attack of diphtheria was a sub- 
sidiary contributing factor. The fact that diabetes 
insipidus appeared before other symptoms and that 
pituitary diseases had progressed to a greater extent 
than the tuberculous lesions elsewhere suggested 
that the onset of the syndrome correstcnded with 
the commencement of tuberculous infiltiation of the 
pituitary.—The abstracts from current literature 
are devoted to nervous and tnental diseases. 


~NEW INVENTIONS 


A TUBE FOR CONTINUOUS GASTRIC 
ASPIRATION 


CONTINUOUS aspiration of 
the stomach is a valuable 
form of therapeusis in such 
conditions as intestinal ob- 
struction, acute dilatation of 
the stomach,. vomiting after 
gastric operations, and per- 
sistent vomiting of pregnancy. 
When the tube is introduced 
by way of the nasal route it 
can be left in situ for many 
hours. The patient can drink 
as he pleases and this, as 
well as satisfying his thirst, 
helps to wash out his stomach. 
If one nostril and the back of 
the throat are cocainised the 
tube can be introduced almost 
without discomfort. The tube 
illustrated is designed for this purpose. The spring 
within its terminal portion so stiffens it that the 
nose can be i 

lf eve 


GENITO NFC CO LTO, 


catheterised 
easily. The 
end of the 
tube is seen 
at the back 
of the pha- 
rynx, where 
it is grasped l 
by a long hæmostat, which is used to milk the tube 
down the œsophagus. 

The tube is made by the Genito-Urinary Manu- 
facturing Co., Ltd., and is supplied in two sizes. 


HAMILTON BarLey, F.R.C.S. Eng.. 


THE LANCET] 


THE LANCET 


LONDON: SATURDAY, JANUARY 18, 1936 


A FORWARD MOVE IN EDUCATION 


THE history of the school medical service is 
one of gradual expansion from the routine inspec- 
tion of children at certain set periods of their 
school life to a fairly comprehensive system of 
care and treatment in clinics, hospitals, and 
special schools. Its development was noticeably 
rapid in the early years after the war, but the 
depression of recent years has caused some retarda- 
tion in the rate of advance. In spite of the vigorous 
support which nursery schools have received, 
especially from women’s organisations, remarkably 
little provision of this kind has been made, and 
some of the other special services are only a little 
less inadequate in many areas. The Board of 
Education now lays stress upon the need for a 
forward policy on the part of local authorities,' 
and as these are still grant-earning services, 
unaffected by the introduction of a block grant 
by the Local Government Act, 1929, it is likely 
that those authorities whose finances are not 
crippled by the burden of public assistance will 
respond. Attention is drawn to the fact that the 
dental service is seriously incomplete in most 
parts of the country. In order to afford sufficient 
dental care it is estimated that one dentist is 
required for every 5000 urban, or 4000 rural, 
children. School dentists fall notoriously short 
of this number, and many children cannot receive 
attention without prolonged and harmful delay. 
At the same time it must be remembered that this 
service has hardly touched the fundamental 
problem of the prevention of dental caries. There 
is urgent need for confirmation and extension of 
the work of Mrs. MELLANBY and others on the 
relation between dietary and caries. Part of the 
expansion of school dentistry might be avoided 
if we were sure of our facts and were therefore 
able to devote more energy to the education of 
mothers and children in the prophylaxis of dental 
decay. Unfortunately we are not yet in a position 
to put simple and incontrovertible information 
on the subject before the public, and until agree- 
ment has been reached among research workers 
we must depend upon conservative dentistry to 
ensure that the children leave school with healthy 
mouths, at least, if not with perfect teeth. 

It is disconcerting to learn that the children 
under 70 authorities are still without provision 
for the prevention and correction of crippling 
defects. This is a straightforward problem, and, 
although the cost of such schemes per case may 
be high, the actual number of cases in any area is 


> ì Board of Education : 


Circular 1444, Jan. 6th, 
H.M. Stationery Otce. i 


1936. 


A FORWARD MOVE IN EDUCATION 


[yaN. 18, 1936 151 


comparatively small. Institutions and skilled 
personnel are available so that local difficulties 
should be easily surmounted. As to acute rheu- 
matism, the grave cardiac sequelæ of which are 
emphasised in the Board’s circular, there may be 
some difference of opinion about the most suitable 
type of provision. The modern treatment of 
early carditis requires practically the same sort 
of immobilisation as is practised in diphtheria, 
and this can rarely be obtained except in hospital. 
Fortunately the number of patients at any one 
time is not great, but they are better isolated 
from children suffering from other diseases, sub- 
jected to a reasonable open-air régime and mentally 
employed as in open-air schools. Wards set apart 
in general or fever hospitals may serve the pur- 
pose, but there is much to be said for quite separate — 
institutions with attractive grounds. These insti- 
tutions are still small, and experience shows that 
they need not be costly to run. Day and resi- 
dential schools, both for the physically defective 
and the mentally subnormal, have not been 
developed to the extent which their established 
value might have led us to expect. A forward 
policy is now recommended by the Board. It is 
perhaps significant that no mention is made of 
special classes in ordinary schools for mentally 
subnormal children. This type of provision has 
been advocated, for rural areas at least, but it 
would appear that the Board’s advisers prefer 
residential schools, if necessary under joint manage- 
ment. We should like to be sure that special - 
classes have proved a failure before the more 
expensive alternative is adopted for every type 
of mentally subnormal child. In contrast, it 
appears to be left largely to local discretion whether 
children under 5 years of age, for whom authorities 
are now urged to make accommodation, should 
be received into specially constructed nursery 
schools or into modified parts of existing schools. 
When it is remembered that health, cleanliness, 
nourishment, and character training are the first 
requisites for these young children, and that few 
existing schools are capable of being suitably 
modified for the purpose, the case for ad-hoc 
schools seems overwhelming. Other recommenda- 
tions of the Board, for instance, that special 
classes in ordinary schools should be provided for 
the partially sighted and the hard of hearing, and 
that the curriculum should be reorganised on the 
lines of the Hadow report, and, above all, the 
prospective raising of the school age, will place 
sufficient strain on the existing schools and their 
capacity for structural modification. A circular 
which is promised on the subject of physical 
education may make still further demands on 
both the internal and playground space of schools, 
so that it may be found more practicable to provide 
such facilities as those required for the younger 
group of children in totally separate buildings: 
Education authorities are faced with a very 
complicated problem. School buildings are costly. 
Rightly or wrongly, they are solidly built to last 
for many years. Changing ideas in education tend 
to make their planning obsolete while their structure 
is still sound. The child population is declining, 


152 THE LANCET] 


and will soon fall rapidly, so that an inclina- 
tion to avoid new construction for new types of 
provision is natural. 
unhygienic and cannot be modernised. While the 
prospective fall in the demand for accommodation 
must be kept in mind, it should not be allowed to 
influence too much the policy of local authorities 
in regard to the new or better types of service 
they are now being encouraged to give. 


DILATATION OF THE URETERS IN 
PREGNANCY 


It has long been known that the ureters and 
renal pelves tend to dilate during pregnancy, and 
this tendency is clearly of fundamental importance 
in the etiology of pregnancy pyelitis. An obvious 
anatomical cause of the dilatation is the pressure 
of the gravid uterus on the ureters as they cross 
the pelvic brim, and for many years such pressure 
was held to explain the changes found. But 
the newer knowledge gained by modern urological 
methods has led to the suggestion that it is due to 
an atony of the ureters caused by some chemical 
substance circulating in the blood stream. 


Dr. Duaautp Barm», of Glasgow, has made an 
extensive study of the changes in the upper 
urinary tract during pregnancy and the puerperium, 
and the results of six years’ careful clinical research 
are at present being published.' He has approached 
the problem from both the anatomical and the 
functional side, for he has examined much post- 
mortem material and made many investigations 
on the living subject not only by intravenous 
pyelography and chromocystoscopy but also with 
an ingenious apparatus for measuring the tone of 
the ureteric musculature. His results, and also 
those obtained at the Johns Hopkins University,? 
demonstrate two factors in the dilatation of the 
ureters. That pressure by itself can bring about 
dilatation is shown by pyelograms taken in cases 
of pelvic cellulitis, ovarian cysts, and fibroids 
(though here it is never so advanced as during 
pregnancy); moreover, it is only anatomical 
differences that can account for the more frequent 
dilatation of the right ureter. Studies of the 
ureteric tone, however, show equally conclusively 
that during pregnancy the ureters become atonic : 
uterine pressure, when present, causes no com- 
pensatory hypertrophy or hypertonus ; the ureter 
just stretches. Atony develops very early in 
gestation and is probably the cause of the early 
dilatation sometimes seen, though as a rule the 
pressure of the uterus on the atonic ureter is the 
deciding factor. One other possible cause also 
calls for consideration. At the lower end of 
the ureter there is a well-developed sheath of 
fibrous tissue and longitudinal muscle bundles, and 
it has been noticed that during pregnancy this 
sheath hypertrophies—so much so that the 
dilatation of the ureters has been ascribed to 


? Baird, D.: Jour. Obst. and Gyn. Brit. Emp., 1935, xlii., 
577 and 733. 

* Hundley, J. M., Jun., Walton, H. J., Hibbitts, J. T., Siegel, 

. A., and Brack, C. B.: er. Jour. Obst. and Gyn., 

November, 1935, p. 625. 


DILATATION OF THE URETERS IN PREGNANCY 


Many schools, however, are. 


a 


fyan. 18, 1936 


hypertrophy of the muscle in the ureteric sheath, 
though the changes in the rest of the ureter are 


-not those usually associated with obstruction 


at the outlet. The workers at Johns Hopkins 
University lay some stress on this hypertrophy, 
which they regard as hormonic in origin. They 
have found similar, though less conspicuous, 
changes throughout the urinary tract and suggest 
that cestrin, which is known to produce hyper- 
trophy, cedema, and increased vascularity of the 
generative tract, might bring about similar changes 
in the urinary tract, since the two are derived 
from the same embryonic structures. The exact 
distribution of the epithelium which is speci- 
fically sensitive to cestrin is discussed by Dr. 
ZUCKERMAN in our present issue, with special 
reference to enlargement of the prostate. 


The results reported by Mr. Harotp Burrows 
at the November meeting of the section of com- 
parative medicine of the Royal Society of Medicine 
are all the more interesting in the light of this 
recent work. He has been studying the effects of 
the prolonged administration of cestrogenic sub- 
stances to mice, and in addition to other remarkable 
phenomena already reported 3 he has noticed that 
after several months the urinary tracts of the mice 
become grossly dilated and that purulent cystitis 
and pyelitis sometimes follow. LacassaGne 4 and 
Burrows originally ascribed these changes to 
urethral obstruction caused in the female by the 
keratin debris in the vagina, and in the male by 
the enlargement of the accessory genital glands. 
After further experiment on male mice, however, 
Burrows now thinks they may be due to failure 
of the nervous or chemical control of the neuro- 
muscular apparatus of urination; for he could 
find no definite urethral obstruction, despite the 
enlarged accessory glands and the keratinisation 
of the urethral mucous membrane. ‘Those who 
were fortunate enough to see the specimens he 
demonstrated could not but be impressed by the 
large dilated ureters and the hydronephroses, and 
it is hard to resist the conclusion that there is 
Some connexion between these findings and the 
ureteric dilatation seen in pregnancy, especially 
since it is known that large amounts of cestrogenic 
substances are excreted in the urine of pregnant 
women. On the other hand, the dilatation in mice 
was obtained only after administration of the 
oestrogens over periods far longer than the normal 
period of gestation in the mouse, and MENGERT ê 
has shown that the ureters of the cow, pig, 
macacus monkey, dog, cat, rabbit, guinea-pig, and 
rat do not dilate in pregnancy. Burrows has 
demonstrated very clearly yet another property 
of the cestrogenic compounds, but in our present 
state of knowledge it would not be safe to draw 
general conclusions from effects observed in one 
animal, 

Other experimental work, moreover, lends little 
support to the idea that cestrin is responsible for 


* Burrows, H.: Brit, Jour. Surg., 1934, xxi., 507; Amer. 
Jour. Cancer, 1935, xxiii., 490 ; Jour. of Physiol., 1935, lxxxv., 
159. 
* Lacassagne, A.: Compt.rend. Soc. de biol., 1933, exitii., 590. 

* Mengert, W. F.: Amer, Jour, Obst. and Gyn., 1934, xxvii., 544. 


THE LANCET] 


THE GERSON 


DIET [san. 18, 1936 153 


ureteric dilatation in pregnant women. According 
to the current theory of the hormonic control of 
pregnancy, cestrin makes the uterus sensitive to 
the oxytocic principle of the posterior pituitary, 
increasing its tone, while the corpus luteum 
hormone (progestin) renders it refractory and thus 
decreases its tone. In the first half of preg- 
nancy the corpus luteum is dominant and the 
uterus is atonic ; then the influence of progestin 
gradually wanes while that of cestrin waxes and 
the uterine tone consequently increases. It is 
noteworthy that Barrp finds a similar sequence 
in the human ureteric musculature, the tone of 
which also increases towards the end of pregnancy. 
In our own columns last year it was shown ® that 
during the greater part of pregnancy the cestrin 
excreted in the urine was mostly present in a 
“combined ” form of low physiological potency, 
and that it becomes active only with the approach 
of full term. It seems reasonable to suppose that 
it is the presence of the active cestrin excreted 
with the approach of full term that makes the 
uterine muscle highly sensitive to pituitrin and so 
leads to the expulsion of the foetus. According 
to these views it is the corpus luteum hormone 
(progestin), and not cestrin, which one would 
expect to cause dilatation of the ureters; and, in 
fact, progestin has generally been regarded as 
responsible for their atony during pregnancy. 


THE GERSON DIET 


' Ir is now more than ten years since Dr. Max 
GERSON, then a general practitioner in Westphalia, 
introduced a special salt-free diet for the treatment 
of tuberculosis and other chronic diseases affecting 
the general nutrition of the body. The origin of 
the treatment is of some interest, for it arose 
out of a personalexperience. Fifteen years earlier, 
when GERSON was working in a hospital in Berlin, 
he made some experiments to see if a change in 
diet would cure the attacks of migraine from 
which he then suffered. Finding success from the 
elimination of salt, he tried the same thing on 
other people and was profoundly impressed by 
the results. It was the incidental recovery from 
lupus of a patient treated for migraine on this 
dietary that led to its trial in tuberculosis. The 
diet as modified by Dr. A. HERRMANNSDORFER, 
assistant to Prof. E. SAUERBRUCH, was extensively 
used in the treatment of patients with bone and 
joint tuberculosis at the Charité in Berlin. The 
essential feature of this modified diet was the 
large proportion of albumin and fat, with little 
carbohydrate and no common salt, the principal 
ingredients being unsalted butter, raw and cooked 
fruit, salad, steamed vegetables, meal and flour, 
eggs, pudding, unshelled rice, sugar, nectar, olive 
oil, and dripping. The Berlin Medical Society 
discussed the treatment in August, 1929,7 when 
the Giessen clinic reported success with lupus and 
it has since been tried at a number of sanatoria 
and special centres. But GeErson himself soon 


* Cohen, S. L., Marrian, G. F., and Watson, M. 
1935, i., 674. 


7 See THE LANCET, 1929, ii., 404. 


: THE LANCET, 


came to feel that his followers were too willing to 
compromise with patients loth to renounce all the 
pleasures of the table at one swoop. The Gerson- 
Sauerbruch-Herrmannsdorfer diet may have been, 
and probably was, a model of culinary diplomacy, 
but Gerson himself scented heresy and would 
have none of it. What may have widened the 
breach between the two was GERSON’S growing 
conviction that his diet, modified to meet individual 
needs, was capable of curing an increasingly wide 
range of -diseases from rheumatoid arthritis to 
gastric ulcer. 


The true gospel of the Gerson diet is set out 
by its originator in a monograph of more than 
600 pages, most of which, despite the title,’ deal 
with the diet and its modifications. The author 
believes that his diet will induce healing of pul- 
monary tuberculosis even in advanced cases 
provided that sufficient functioning lung tissue 
remains, that the patient’s general condition is 
not too bad for him to take the diet, and that 
complications such as lardaceous disease are not 
present. But he insists that success depends on 
scrupulous observance of details which require 
nearly a hundred pages of close type to set out, 
although the scheme of the whole course is given 
on a single page (305) of the book. In Germany 
or Austria the cost of the diet is not much above 


that of an ordinary sanatorium menu ; Dr. GERSON 


does not give the actual figures ; presumably the 
cost must vary with the prices of the constituents 
in different areas. More than half the book is 
devoted to protocols of 25 cases, treated at the 
diet station of the Urban Hospital in Berlin under 
the direction of Prof. HERMANN ZONDEK, and of 
26 cases treated later by the author in Austria. 
These protocols include radiograms, blood counts, 
and other details of progress, which can be 
assessed for what they are worth by those who 
have experience of such cases elsewhere. GERSON 
himself briefly summarises the story of the earlier 
series which with one exception belonged to the 
working classes, some of them being unemployed. 
In about half there was some family disposition 
to tubercle and of these all except one had some 
complication which made a favourable issue less 
probable. Two-thirds of the patients were between 
18 and 35 years of age. They were under GERSON’S 
personal care for a period of only three to eleven 
months and he admits with regret that he was 
prevented from seeing the treatment through to 
the end; but of 19 whose treatment went on for 
another two or three months after he left the 
diet station he had news, although he expresses a 
doubt whether the treatment was carried on after 
his departure as correctly as it was when he was 
there. But he warmly thanks the nurses and 
cooks of the Urban centre for their untiring help 
in carrying out the treatment which had met with 
less difficulty there than elsewhere ; two or three 
of the patients received constant attention both 
by day and by night. In no case did they find the 
diet irksome at the outset, but later three of 


®*Diittherapie der oa ene Leipzig and Vienna : 


Franz Deuticke. Pp 


154 THE LANCET] 


them refused suddenly to go on with it; in one 
or two cases there was wilful transgression and 
one patient succeeded in nullifying the treatment 
by getting relatives to smuggle food in. But 
22 of the 25 .went through the course without 
complaint, and although they were all suffering 
from advanced tuberculosis, of which the prognosis 
under ordinary conditions was bad, none of them 
died within the first year. GERSON submitted 
his X ray records to Dr. FELIX FLEISCHNER, radio- 
logist in Vienna, who formed the independent 
opinion that 24 out of the 25 were on the way 
to complete recovery. 

Unfortunately this remarkable experience did 
not secure GERSON’s tenancy of the diet centre 
and he was obliged to continue his work at an 
Austrian hospital where he collected what seemed 
to the outsider an odd assortment of morbid 
changes. Not the least interesting of the cases 
were patients suffering from advanced rheumatoid 
arthritis who had come to him on the recom- 
mendation of some sufferer to whom the diet had 
brought relief. But here again GERSON was unable 
to continue his régime long enough to carry con- 


SURPLUS AND DEFICIT 


[yan. 18, 1936 


viction to his professional colleagues and his 
success must be taken rather as a tribute to his 
personal qualities than as an indication that the 
treatment can be carried out widely. It seems 
that many physicians who have prescribed the diet. 
have found patients rebel against its austerity, 
not least members of GERSON’S own race; they 
simply will not play the game when put on 
any rigorous diet, but eat all sorts of things sur- 
reptitiously. This must make an almost insuper- 
able obstacle to carrying out GERSON’s precepts in 
any hospital which can be called voluntary. There 
is another possible reason for GERSON’S success 
which cannot be repeated outside Central Europe. 
Many of the people with whom he was dealing may 
reasonably be expected to have been in the habit 
of eating much salt pork, salt fish, and similar 
viands ; any diet which corrected this national 
predilection was bound to achieve a certain amount 
of success. That is one reason why we may watch 
with interest a continuance of the experiment in 
a Paris suburb where GERSON is now with the 
help of friends and grateful patients running a 
special clinic. 


ANNOTATIONS 


SURPLUS AND DEFICIT 


Tus is addressed less to our readers than to their 
wives and families, and we ask that it should be 
referred to the proper quarters. The facts are these. 
Clothing of all sorts—new, nearly new, or frankly 
old—can be used to great advantage by the Ladies 
Guild of the Royal Medical Benevolent Fund. The 
Guild has a clothes room at the B.M.A. House in 
London, and at present sends out parcels twice a 
year to more than 350 families or individuals belong- 
ing to our profession but left in financial straits. 
In compiling these parcels great care is taken to 
make them really useful to the recipients, for often 
they are essential to self-respect and a minimum of 
comfort. Sometimes new garments are needed ; 
for example, when the Guild sees to the requirements 
of a girl at boarding-school it makes sure that she 
shall have the same kind of outfit as her schoolfellows. 
Nevertheless money is only a small part of the need 
felt at the clothes room; and whatever is sent to 
it—from evening dresses to coal-scuttles—the sender 
may rest assured that it will be put to the best use 
by those in charge of the department. Of late years 
many have become increasingly aware of the claims 
of the unemployed, and the competition of such 
admirable organisations as the Personal Service 
League has in fact lessened the never-sufficient flow 
of clothing and gifts to the Guild. But often the 
discarded dresses and suits and undergarments of 
professional people are definitely more suitable for 
the dependants of doctors than for the unemployed 
in general; and if the situation of such recipients 
were better known many of us would probably be 
glad to pass on our clothes at a less advanced stage 
of degeneration. It is not only clothes that are 
wanted ; curtains, bits of carpet, blankets, sheets, 
towels, toys—any of these things may make a big 
difference to old people who have known better 
times or young ones who have not. At this time of 
year, however, the first and foremost need is warmth, 


and anyone who can produce a warm coat or an 
eiderdown or a boy’s jersey could not do better than 
send it at once to the Ladies Guild of the R.M.B.F. 
at B.M.A. House, Tavistock-square, London, W.C.1, 


CHRONIC GASTRITIS AND PERNICIOUS ANAEMIA 


IN pernicious anæmia Castle’s intrinsic factor is 
not produced by the patient’s stomach, and there is 
a complete achlorhydria which usually persists 
indefinitely in spite of treatment. Fifty years ago 
Fenwick showed that the gastric mucosa, at least 
during a relapse, is atrophic, and the atrophy has 
since been regularly demonstrated by pathological 
and gastroscopic observations. Those are established 
facts, and they are commonly taken to mean that the 
gastric mucosa, congenitally defective or progressively 
damaged by gastritis, first loses its acid-secreting 
power and then its power of secreting intrinsic factor, 
at which stage pernicious anemia appears secondary 
to the gastric defect, which is permanent and 
irreparable. This working hypothesis, however, has. 
recently been somewhat shaken. Jones, Benedict, 
and Hampton,! from Harvard, describe 5 interesting 
cases of pernicious anemia in which repeated gastro- 
scopic examinations were made, and in 3 of the 5. 
were checked at operation by direct inspection and 
biopsy. They found atrophic changes in some cases, 
but hypertrophic changes in others, and what is more. 
important, they have good evidence that these 
stomachs reverted strikingly towards normal when 
the pernicious anemia remitted under treatment. 
If that is confirmed, it means that the structural 
changes in the gastric mucosa in pernicious anemia 
are reversible, as the lingual changes in both pernicious. 
anemia and sprue are already known to be. If so, 
they can scarcely be a congenital defect, and are not 
easily explained as “inflammatory” in the classical 
pathological sense. The door is open for the suggestion 
that some sort of nutritive deficiency may determine 
them, and the suggestion is forthcoming, by analogy, 


1 Jones, ©. M., Benedict, E. B., and Hampton, A. O.: Amer. 
Jour. Med. Sci., November, 1935, p. 596. 


THE LANCET] 


from Miller and Rhoads,? who, by feeding swine 
on deficient diets, have caused acid and intrinsic 
factor to disappear from their gastric juice; they 
are not yet certain whether they have induced 
atrophic changes in the gastric mucosa at the same 
time. Whether it proves directly applicable to the 
pernicious ansemia problem or not, this work is of 


great value for directing attention to the influence of 


dietary factors on the structure and function of 
mucous membranes in general, a subject well worth 
further investigation. 


A JOURNAL FOR THE PUBLIC DENTAL OFFICER 


WE have received a copy of the first number of the 
West Riding Dental Journal, the first dental journal 
in this country to be issued expressly for the public 
dental officer. It is published by the dental staff 
of the West Riding County Council of Yorkshire 
with the laudable object of coédrdinating the medical 
and dental services in the riding. This issue opens 
with a series of excerpts from various reports which 
illustrate some of the salient features of school 
dentistry as well as the variation in.methods adopted 
in different areas. A number of abstracts from 
current literature on the subject of school dentistry 
should prove helpful to the dental staff. Propaganda 
plays an essential part in securing the popularity 
of the school dental service and a committee of school 
dental officers in the West Riding has been considering 
this problem and their report is published here. 
We congratulate the West Riding authority on their 
enterprise. 


THE MANIC-DEPRESSIVE AT LARGE 


AT Tuesday’s meeting of the Society for the Study 
of Inebriety an enlightening account of the inter- 
relations between alcoholism, crime, and manic- 
depressive disorder was given by Dr. W. Norwood 
East, a commissioner of prisons. His paper appears 
in full on p. 161 of this issue.. Dr. H. J. Norman, 
who followed him, expressed surprise that no one 
before Kraepelin should have given a really adequate 
description of the disorder. While the acute phase 
lasts there is no difficulty, even for the layman, in 
deciding that the person is insane, but at the beginning 
of a phase the question of diagnosis may not be at 
all easy ; and when the phases are of brief duration, 
the symptoms may no longer be obvious when the 
individual comes under observation. Still greater is 
the difficulty when the morbid cycle is of the mild 
or cyclothymic type, in which eccentricities of conduct, 
even to a criminal extent, may occur, especially if 
self-control is still further impaired by alcoholic 
excess, The taking of alcohol to excess, often merely 
4 symptom, is definitely so in some of these persons. 
As Clouston had pointed out, the morbid craving 
may be coincident with the period of depression, 
but far more commonly with the beginning of the 
periods of exaltation. Dr. Norman agrees with Dr. 
East that crimes of violence are committed much 
more frequently by the depressives; but it is the 
excited and exalted subjects who give the greatest 
amount of trouble by their mischievousness, malice, 
perversion of the truth, intractibility, and destructive- 
ness. For this reason those who have charge of 
manic-depressives often welcome, with a sigh of 
relief, the onset of the depressive phase. Dr. Norman 
admitted that the treatment of manic-depressive 
disorder is unsatisfactory. When its etiology is 
discovered, it may be possible to devise etlicient 


* Miller, D. K., and Rhoads, C. P.: Jour. Clin. Invest., 1935, 
Iiv., 153. 


THE MANIC-DEPRESSIVE AT LARGE 


(yan. 18, 1936 155 


therapeutic measures. Psychological treatment has 
not been successful. Dr. Norman said he was in full 
accord with Dr. East that imprisonment may be the 
only means of protecting the manic-depressive 
alcoholist from himself—if he does not become 
certifiably of unsound mind. But since anyone has 
the right to drink himself paralytic and poverty- 
stricken, the question of treatment becomes a forensic 
one. Some more effective means might, Dr. Norman 
thinks, be found to limit the right of the individual 
to do mischief to himself and .to others—something, 
it may be, on the lines of the ‘family council ” 
whereby a person is placed indeterminately under 
care and until such time as he can make his conduct 
approximate to that of the normal citizen. Clouston 
had insisted that the legislature must provide some 
remedy for this great evil to society and the intolerable 
hardship to relatives. ‘‘ Something,’ Dr. Norman 
concluded, “ might even have been made of Nero if, 
instead of being pandered to and given unlimited 
power, his liberty had been restricted and he had 
been compelled to obey for a longer period the wise 
counsels of Seneca and of Burrus. He might really 
have become a good violinist or a competent 
charioteer and thus fulfilled two of his ambitions 
instead of providing an example for incendiaries and 
multiple murderers.”’ 


PAIN FROM THE BILE-DUCTS 


Tuat biliary pain is sometimes due to dyskinesia 
of the muscle of the ampulla of Vater has been 
known for some time, and Dr. Charles Newman’s 
Goulstonian Jectures of 1933 made it clear that the 
two main types of disorder—the spastic and the 
atonic—are of everyday occurrence and everyday 
importance.! Hitherto the condition has been studied 
mainly by physicians and physiologists, and it is 
surprising that surgeons have not taken more 
interest in what is, after all, one of the common 
causes of symptoms persisting after cholecystectomy. 
The deficiency in surgical investigation has now been 
remedied, however, by Best and Hicken,? who have 
confirmed previous observations, and have demon- 
strated the spasm of the ampulla muscle after 
cholecystectomy by filling the bile-duct system with 
radio-opaque oil. The complete obstruction to the 
flow of bile and its purely spasmodic nature are well 
shown by the photographs they reproduce, and their 
work is a pretty demonstration of the rightness of 
conclusions drawn from the results of indirect investi- 
gation with the duodenal tube and from the beneficial 
effects of paralysing the muscle with atropine. There 
can now be no doubt that a purely functional spasm 
may lead to complete obstruction of the common 
bile-duct, and to considerable pain and digestive 
disturbance. One of the causes of this spasm is 
cholecystectomy, and it is the explanation of many 
instances of continued symptoms after operation. 
Best and Hicken also recognise, of course, that gall- 
stones and cholecystitis may reflexly cause such a 
spasm, but in their more surgical material have 
naturally taken less account of its origin in such 
conditions as duodenal ulcer, or of the commoner 
“ primary ”? cases in which there is a more wide- 
spread state of vagal over-stimulation, attributable 
to “constitutional” causes. For the same reason 
they lay less emphasis than other writers on the 
value of sedative therapy with belladonna; but as a 
matter of fact it is remarkably successful in these 


1THE LANCET, 1933, i., 785, 841, 896, and 915. 
* Best, B. R., and Hicken, N. F.: Surg., Gyn., and Obst., 
December, 1935, p. 721. 


156 


THE LANCET] 


‘“ surgical’? cases. IJInsistence on the importance of 
functional, as well as organic, abnormalities bas led 
to the relief of hitherto intractable symptoms arising 
from the extra-hepatic biliary system, and there 
must be other clinical lope in which it would 
be equally helpful. 


A MENINGEAL FORM OF WEIL’S DISEASE 


UNDER the name of “ spirochétose méningée pure ” 
French writers have been familar since 1918 with a 
remarkable manifestation of human infection with 
Leptospira iclerohemorrhagie which seems to have 
escaped attention in this country and in Germany. 
It takes the form of a mild or moderate meningeal 
syndrome often accompanied by conjunctival suf- 
fusion, herpes labialis, and pyrexia.1 The cerebro- 
spinal fluid shows only a slight increase in protein 
but a very large increase in cells, the majority of 
which are lymphocytes ; counts up to 400 per c.mm., 
are on record. Jaundice may be present in this 
meningeal form of Weil’s disease, but quite a number 
of cases are quoted in which there was no jaundice 
at all and in which conjunctival suffusion and a 
history of immersion in polluted water were the only 
pointers to the true nature of the disease. The 
cerebro-spinal fluid contains agglutinins for L. ictero- 
hemorrhagie but their titre is “much lower than in 
the blood. Guinea-pigs have been infected with 
blood and urine from pure meningeal cases. Where 
there is no jaundice or renal insufficiency the prognosis 
is highly favourable, and there appear to be no 
sequela. In view of the known existencé of Weil’s 
disease in this country among sewer-workers, canal- 
workers, coal-miners, and handlers of fish, the possi- 
bility of this meningeal form of the disease should 
be kept in mind, and it should not be necessary to 
wait for the appearance of jaundice before suspecting 
the possibility of leptospiral infection. 


‘‘CROCODILE TEARS” 


In 1905 H. K. Anderson ? found that after excision 
of the ciliary ganglion the cut preganglionic fibres 
regenerated along the paths of the permanently 
destroyed postganglionic fibres and became functional. 
This was contrary to the accepted teaching of the 
time, which Anderson himself had helped to establish, 
that removal of autonomic ganglia was never followed 
- by the least recovery. The probable explanation of 
the anomaly is now well known, and the laws of 
regeneration have been found to rest upon physio- 
logical rather than anatomical foundations. Trans- 
mission of nerve impulses across ganglia from pre- 
ganglionic to postganglionic fibre is almost certainly 
achieved by the former liberating an acetylcholine- 
like substance which stimulates the Jatter and sets 
up new impulses, The preganghonic fibres are said 
to be “cholinergic.” The postganglionic fibres, 
however, are of two kinds, Some of them stimulate 
the organs in which they end by liberating the same 
substance as do the preganglionic fibres, ‘but others 
liberate an adrenaline-like substance. These last are 
said to be “adrenergic.” The law of regeneration is 
that cut cholinergic fibres will, on regeneration, join 
up to old cholinergic end-points, but not to adrenergic 
end-points. Previous to Anderson’s experiment, all 
ganglia which had been experimentally excised had 
had adrenergic postganglionic fibres, and these could 
not have been r eplaced by the choliner gic preganglionic 


Bull. et mém. Soe. méd. 
lbid., 


1 Marie, J., and Gabriel, P., et al. : 
Hôp. de Paris, Nov. 18th, 1935, p. 1454; Mollaret, P.,etal.: 


Dec. 9th. 
* Jour. Physiol., 1905, xxxiii., 156, 414. 


‘ CROCODILE TEARS.’’—ETHER CONVULSIONS 


[san. 18, 1936 


outgrowths. The ciliary ganglion, however, is now 
known to have cholinergic postganglionic efferents, 
and the manner of their replacement occasions no 
surprise (II. H. Dale °’). 

This theoretical background is implied in Mr. I. A. 
Tumarkin’s interesting note (on p. 26 of our issue of 
Jan. 4th) on the syndrome of crocodile tears, when 
this occurs as a late sequel of Bell's palsy. He 
explains it on the ground of abnormal regeneration— 
“the nerve having undergone degeneration, new 
axons are pushing their way out seeking their various 
destinations. Unfortunately some are diverted, and 
find their way to the wrong muscle or gland.” The 
same theory had been advanced * by V. Uprus, 


J. B. Gaylor, and E. A. Carmichael to explain the 


recurrence of localised flushing and sweating after 
eating ; they, as well as Mr. Tumarkin, drew attention 
to the fact that the best authenticated cases of 
crocodile tears followed a primary lesion in the region 
of the geniculate ganglion. The theory lacks actual 
proof, but the investigation carried out by the three 
authors named on a similar syndrome is extremely 
suggestive. The diagnostic importance of the theory 
is pointed out by Mr. Tumarkin, who gives details 
of the ‘‘fantastic course” pursued by the fibres 
causing lacrymal secretion. It is interesting to recall 
that this course was not always accepted, and that 
the general opinion was that the secretory nerves 
originated with the fibres of the fifth nerve. In 1902 
Sir John Parsons published a review 5 of the available 
anatomical, embryological, physiological, and patho- 
logical evidence on the point, and himself inclined to 
the view, now accepted, that they belonged to the 
seventh nerve. From the theoretical point of view, 
their important feature is that they are cholinergic. 
That other cholinergic fibres run in the seventh nerve 
is undoubted, for instance, vasodilator and secretory 
fibres to the submaxillary gland and various parts 
of the mouth, nose, and pharynx. If any of these, 
after section, grew down into the lacrymal gland, 
then an afferent stimulus giving rise (say) to salivary 
secretion would also cause lacrymation. There can 
be little doubt that this is what actually occurs. 


ETHER CONVULSIONS 


ONCE more that puzzling and dangerous com- 
plication, ether convulsions, has been the cause of a 
coroner’s inquiry. On Dec. 3lst at Camberwell, Dr. 
Douglas Cowburn inquired into the death of a woman, 
aged 53, who had been operated on for an abdominal 
growth. The convulsions began about an hour after 
the commencement of the operation, starting in the 
usual way with twitchings of the facial muscles. 
The ether used was proved to be pure, and in this 
and in other details the case does not differ from 
those previously described, though the age of the 
patient is rather above what is usual, and it is not 
reported that the patient had a septic focus or a 
high temperature—two features often observed. 
The convulsions are of course not always fatal, and 
many recoveries are on record. The last fatal case 
of which we have information occurred in London 
last summer, and it has been noted by Dr. Charles 
Hadfield that these fatalities are commoner in the 
warm months, This fits in with the latest theory of 
causation, put forward by Mr. Dickson Wright 6— 
namely, that they are due to heat-stroke. He points 
out that in operating theatres to-day not only is 
the atmosphere kept warm but the patient, often 


3 Proc. Roy. Soe. Med., 1935, xxviii., 15. 
* Brain, 1934, ivii., 443. 
® Roy. Lond, Ophth, Hosp. Rep., 1902, xv., pt. ii. 
e Brit. Med. Jour., 1935, i., 949. 


THE LANCET] 


already pyrexial, lies on a table heated by electricity 
or otherwise, and has probably had an injection of 
atropine which reduces heat-loss by abolishing 
secretion of sweat. Moreover, the ether vapour 
administered is often warmed. To those who share 
our disquiet about overheating and dehydration ? 
this theory is attractive; but it cannot be said to 
fit the facts of all recorded cases. Still less were 
these explained by the older suggestion that ether 
convulsions are due to impurities in the ether. 
This explanation indeed has been found untenable 
in almost every instance in which the ether has 
been carefully tested, although when it was first 
put forward by the late S. R. Wilson of Manchester 
there was much to support it. Some time ago the 
Anæsthetics Committee circulated a questionnaire to 
anesthetists in many parts of the world in the hope 
of getting some light thrown on the causation of the 
convulsions; but the result was a complete dis- 
appointment. Continental anesthetists seemed never 
to have witnessed convulsions under ether, and 
neither Canada nor the United States of America 
was able to provide an explanation more satisfactory 
than those put forward in Great Britain. Perhaps 
the oddest feature of the ether convulsion is its com- 
paratively recent appearance. Ether was in use a 
number of years before 1912, when the first case was 
reported, and it is impossible to believe that the 
symptom could have escaped notice and description 
by anesthetists of the vast experience and powers of 
observation possessed by Frederic Hewitt, Dudley 
Buxton, Walter Tyrrell, and others of that day. 
From the assumption that it was a new symptom 
came the suggestion that it arises from new methods 
of administration ; yet this will not hold, for in some 
of the recorded cases the ether was given by the 
simple open-drop method. At present we must face 
the fact that ether convulsions, though still a rarity, 
are commoner than they were, and that their 
cause is unknown. | 


RELIEF OF ANGINAL PAIN 


EFFORT angina, and the rarer spasmodic angina 
which comes on at rest but is not dependent on 
coronary occlusion or myocardial infarction, are 
nearly always readily relieved by the quickly acting 
vasodilator drugs. In fact, effort angina may imme- 
diately disappear ‘if at the first warning the patient 
rests; while a tablet of nitroglycerin may enable 
effort to be made in comfort which would otherwise 
be impossible. On the other hand, carefully con- 
trolled observation on many drugs has shown that 
their continuous administration is of no benefit, and 
it is therefore surprising to read a report which claims 
for one of these not only the dramatic relief of 
paroxysmal cardiac pain but also its prevention 
when taken continuously. The drug is Amino- 
phyline or Euphyllin, and Dr. J. F. Quigley 8 describes 
its successful use for angina and also other forms of 
cardiac disturbances—though he makes no clear 
distinction between angina of effort, spasmodic 
angina, and myocardial infarction. The total amount 
of the drug used, in the form of tablets and injections, 
is stated, but not the total number of patients treated ; 
notes on six cases (only four of which appear to have 
had some form of angina) are given, and it is admitted 
that the action in two of these was unfavourable. 
It is difficult to accept the view that a cardiac pain 
which does not respond to amyl nitrite will be relered 
by a much less powerful vasodilator; yet this claim 


"THE LANCET, 1933, i., 95. 
®Prescriber, 1935, Xxix., 197. 


SERUM TREATMENT OF STREPTOCOCCAL INFECTIONS 


[yan. 18, 1936 157 


‘arises from one of the successful cases, in which an 


agonising attack which had lasted an hour was com- 
pletely relieved before the intravenous injection 
of 10 c.cm. of aminophyllin had been completed. 
Dr. Quigley gives some clinical criteria for the dif- 
ferentiation of ‘‘ angina pectoris,’ by which is pre- 
sumably meant effort angina, and ‘‘ coronary disease,” 
which may be taken to mean coronary occlusion or 
myocardial infarction. The description of the former 
as frequently unbearable is somewhat out of date ; 
it would be better to say that it is usually mild ; 
and to say no more of the treatment of myocardial 
infarction by morphia than that it may be of little 
help is rather an understatement of its value. The 
evidence so far available suggests that in the treat- 
ment of angina of effort (including spasmodic angina) 
there is nothing which nearly approaches the nitrites ; 
and for most cases of myocardial infarction morphia 
is of the greatest use. Dr. Quigley’s present report 
does not justify any modification of this generally 
accepted opinion. 


SERUM TREATMENT OF STREPTOCOCCAL 
INFECTIONS 


THE hemolytic streptococci pathogenic for man 
comprise a number of diverse antigenic types. Their 
full number is as yet unknown, but they appear to 
be numerous, for F. Griffith t has already succeeded 
in identifying 27. These streptococci produce disease 
in virtue of two attributes, the ability to elaborate 
toxin and the power to invade the tissues. Some 
strains owe their pathogenicity almost exclusively to 
their ability to produce toxin—the scarlet fever 
strains, for example, Others depend largely, if not 
entirely, on invasiveness. Between these two extremes 
come strains whose pathogenicity is a product of 
both these factors. The truth of this is reflected in 
the results obtained in the treatment of streptococcal 
disease with antitoxic sera. If one excludes scarlet 
fever—in which condition streptococcal antitoxin has 
proved its etlicacy—it has to be admitted that the 
use of this type of serum has given disappointing 
results. In some cases the results have been excellent, 
but in many others the serum has been without 
effect. To combat infections due to the invasive 
type of strain one must use an antibacterial serum, 
and unfortunately eflicient sera of this type are not 
available. The polyvalent streptococcal antisera 
prepared in the past have not been a success; but 
when one remembers the great variety of antigenic 
types presented by the hemolytic streptococci, and 
that a serum of the antibacterial type to be effective 
must possess type-specific antibody, this lack of 
success is not surprising. Whether the future will 
produce a satisfactory serum of this type it is too 
early to predict ; at the moment the logical outcome 
of recent research would seem to indicate a polyvalent 
serum prepared against a very large collection of 
strains. In the meantime, however, we are not 
entirely powerless against this type of streptococal 
infection. A note by Dr. Hendry and Dr. Griffiths, 
appearing elsewhere in this issue, describes a case 
which was successfully treated by immuno-transfusion. 
The patient, a woman infected with a highly invasive 
strain of streptococcus, received four injections of 
streptococeal antitoxin without material benefit. Her 
husband was then immunised with the strain which 
had been isolated and the patient was treated with 
whole blood from the immunised donor. Seven 
injections of 15¢.cm. were given, and on each 


1Griflith, F.: Jour. of Hyg., 1935, xxxiv., 542. 


158 THE LANCET] 


occasion they were followed by great improvement, 
the patient making a good recovery. Admittedly 
this is only one case, and Hendry and Griffiths 
consider that possibly the whole blood was effective 
in virtue of its complement content. In support of 
this contention is the report of good results which 
sometimes follow transfusion with blood from normal 
healthy donors. A recent paper by Stahl? gives his 
experience of this form of treatment. But work by 
Ward and Lyons? in the United States has shown 
that the serum of healthy adults often contains 
antibody which is protective against one or more 
strains of hemolytic streptococcus, so that simple 
transfusions may sometimes be providing the appro- 
priate antibody as well as complement. This work 
suggested the possibility of using donors possessing 
the requisite antibody in the treatment of invasive 
streptococcal infections, and the procedure evolved, 
together with illustrative cases, is given in a paper 
by Lyons which has just been published.‘ Briefly, 
his method consists in matching the donor against 
the streptococcus obtained from the patient. This 
is done by testing sera from a number of prospective 
donors by an in-vitro phagocytic test and selecting 
for donor the one whose serum produces the greatest 
degree of phagocytosis of the patient’s streptococcus. 
And should the patient’s clinical condition suggest 
that toxin is playing some part in the production of 
symptoms, then antitoxin is given as well. Lyons’s 
work is still in its early stages and it will be interesting 
to see what sort of results he obtains with a more 
extended trial. But the method seems sound 
scientifically and well worthy of trial. 


POLIOMYELITIS VACCINATION: A WARNING 


Two forms of poliomyelitis vaccine are on trial 
in the United States.5 One of them, Kolmer’s, is a 
living virus attenuated by treatment with sodium 
ricinoleate ; the other, Brodie’s, is a virus killed 
with formalin, At the annual meeting of the American 
Public Health Association last October ® it was agreed 
that Brodie’s formolised vaccine is safe, though not 
necessarily efficacious. It had been given to 8000 
persons, and though 1 of these had soon afterwards 
developed poliomyelitis there was reason to suppose 
the vaccine innocuous. On the other hand, of 
12,000 persons receiving Kolmer’s living attenuated 
virus aS many as 9 had subsequently developed the 
disease; and, though Kolmer was convinced that 
all of them were already incubating the infection at 
the time of inoculation, his critics were by no means 
satisfied. Their doubts will be increased by a grave 
statement published in the Journal of the American 
Medical Association for Dec. 28th by Dr. J. P. Leake, 
medical director of the United States public health 
service. He summarises 12 cases, reported to the 
service, in which paralytic poliomyelitis has followed, 
at suggestive intervals, the injection of unnamed 
vaccines, A and B. Of the 9 having Vaccine A, 
5 died ; of the 3 having Vaccine B, 1 died: the ages 
of all but one were under ten years, and the deaths 
occurred 6-14 days after a first or second dose. 
Paralytic poliomyelitis was not endemic in any of 
the localities in question, and after estimating the 
probability of its accidental manifestation in vac- 
cinated persons Leake concludes that the likelihood 
of the whole series of cases being due to natural 
causes is extremely small, This likelihood is further 


* Stahl, R.: Med. Klin., Oct. 4th, 1935, p. 1302. 
3? Ward, H. K., and Lyons, C.: Jour. Exp. Med., 1935, lxi., 
515 and 531, 
“Lyons, ©.: Jr. Amer. Med. Assoc.. Dee. 14th, 1935, p. 1972. 
*See THE LANCET, 1935,i., 686; 1935, ii., 1131. 
¢ Ibid., 1935, ii., 1081. 


POLIOMYELITIS VACCINATION: A WARNING 


[san, 18, 1936 


reduced by the fact that in every case in which the 
sequence is known the level of the spinal cord first 
affected corresponds to the extremity into which 
the injection was made; that is to say, if the child 
was inoculated in an arm the paralysis developed in 
an arm, though not necessarily in the same arm. 
This is strong support, Leake adds, to other evidence 
that the virus of poliomyelitis is transmitted along 
nerve-fibres and not through blood or lymph; and 
he thinks the remarkably hich fatality-rate may be 
attributable to close proximity between the part of 
the cord primarily infected and the nuclei corre- 
sponding to the muscles of respiration. His final 
conclusion is that “‘although any one of these cases 
may have been entirely unconnected with the vac- 
cine, the implication of the series as a whole is clear,” 
and many physicians may feel that it ‘‘ renders 
undesirable the further use of poliomyelitis virus for 
human vaccination at present.” 


THE centenary of the University of London will 
be celebrated this year, probably from about 
June 29th to July 3rd, when many visitors from 
overseas will be attending the congress of the uni- 
versities of the empire and the Anglo-American 


_ Historical Conference. 


PUBLIC response to Canon Sheppard’s broadcast 
appeal has ensured the despatch of a second British 
Red Cross Unit to Abyssinia for service on the north- 
western front. The general stores and the medical 
and surgical equipment and comforts will be com- 
pleted by Jan. 18th, and it is anticipated that the 
unit will leave this country in the following week. 


TuE prizes for original research into rheumatism 
offered by the Soviet Government to the council of 
the Ligue Internationale Contre le Rhumatisme have 
been awarded to Dr. G. Kahlmeter (Stockholm), 
Dr. M. P. Weil (Paris), Dr. Ernst Freund (Vienna), 
and Dr. Bernard Schlesinger (London). As the 
prizes were offered by the Russian Government the 
communications submitted by Russian workers were 
not considered for the prizes; but those of Prof. 
Talalaef and Prof. Danischewsky were highly 
commended. 


We publish in another column an appeal for a 
recognition of the practical services of Dr. Rowland 
Fothergill on behalf of the medical profession in 
general. Dr. Fothergill’s activities have been mani- 
fested within the oflicial working of the British 
Medical Association, but his voluntary labours, 
through the Association, have helped to the formation 
of an effective medical organisation under the National 
Insurance Acts. Dr. Fothergill is giving up practice, 
and this is therefore a particularly appropriate time 
at which to make practical acknowledgment of the 
debt due to him from all. A Fothergill Testimonial 
Fund has been opened and subscriptions should be 
directed to the treasurer of the Fund, B.M.A. House, 
Tavistock-square, London, W.C.1. 


SOCIETY OF MEDICAL OFFICERS OF HEALTH.—A 
meoting of the fever hospital medical service group will be 
held at the house of the society, 1, Thornhaugh-street, 
Russell-square, London, W.C.,on Friday, Jan. 3lst,at4 P.M., 
when papers on the scrum treatment of typhoid fever will 
be read by Mr. A. Felix, D.Sc., and Dr. C. J. McSweeney. 

Dr. James Fenton left on Jan. 10th to attend the first 
South African Health Congress to be held at Cape Town, 
from Feb. 3rd to 8th. He represents the Royal Sanitarv 
Institute (of which he is chairman), the Royal College of 
Physicians of London, and the Society of Medical Oflicers 
of Health. 


THE LANCET] 


[gan. 18, 1936 159 


PROGNOSIS 


A Series of Signed Articles contributed by invitation 


LXXXV.—THE PROGNOSIS IN DEAFNESS 


I 

THE causes of deafness may be broadly divided 
into (1) disease and degeneration of the perceptive 
apparatus, the cochlea, auditory nerve, and brain 
centres, the so-called nerve-deafness ; and (2) affections 
of the conducting mechanism, that is, of the external 
auditory meatus and of the tympanum with its 
adnexa. It is with the latter group which is by 
far the more common that we shall deal first. 

Conduction deafness is characterised, in distinction 
to nerve-deafness, by a greater loss of perception of 
low than of high tones of the scale, and by a greater 
loss of perception of sounds transmitted through the 
meatus, air-conduction, than of those transmitted 
by the bones of the skull, bone-conduction. Clinically, 
perception by bone-conduction may even seem to be 
better than normal, i.e., increased, though it appears 
from experiment in a perfectly sound-proof chamber 
that this is never actually the case. When the 
normal relation between air- and bone-conduction is 
so much altered that a tuning-fork is heard longer 
on the skull than at the meatus, Rinné’s test is 
said to be negative; in cases of unilateral deafness 
of this kind, a tuning-fork on the middle line of the 
cranium is usually heard more loudly in the deaf 
ear and Weber’s test is said to be to the affected 
side. But when the affection of the middle ear 
has only caused a slight diminution of hearing, not 
sufficient to invert the usual relation, Rinné’s test 
will still be positive. Again, in middle-ear disease 
of long standing, as well as normally in old people, 
there is a tendency to degeneration of the internal 
ear and bone-conduction becomes shortened. 


Obstruction of the External Auditory Meatus 

This is an obvious cause of deafness. Hearing 
remains unimpaired as long as a small chink remains 
by which air and sound-vibrations can reach the 
drum ; it is for this reason that the slow accumula- 
tion of wax often causes deafness of sudden onset. 
Deafness from obstruction by cerumen or eczematous 
debris is, of course, quickly relieved but, as these 
conditions are often accompanied by some degree of 
myringitis, the hearing does not always return to 
normal at once. The removal of foreign bodies may 
be easy or exceedingly diflicult ; in order to avoid 
the danger of injuring the drum, a general anæs- 
thetic is often advisable, especially for children, 
except in the simplest cases, and a post-aural incision 
may be necessary. The prognosis should not be too 
optimistic until it is seen that the drum is unhurt ; 
atresia may ensue if the meatus has been severely 
damaged. The meatus may be blocked by an exos- 
tosis, which here takes the form of a round peduncu- 
lated tumour ; hearing is fully restored by its removal 
which is usually best performed through a post- 
aural incision. In cases of hyperostosis of the meatus, 
a condition in which three sessile bony outgrowths 
contract the meatus to a Y-shaped slit, the prognosis 
must be very guarded; removal is difficult and 
liable to be followed by stenosis, and the condition 
is apt to be accompanied by signs of nerve-deafness ; 
it is usually wise to be content with keeping the 
meatal passage clear of debris, and fortunately the 
growth is very slow and rarely causes . complete 
obstruction. The dilatation of stenosis due to injury 
is tedious and relapse is common, but it is possible 


to restore a lumen sufficient for normal hearing ; 
when, however, the meatus is completely occluded 
by scarring, the prognosis becomes uncertain, because 
it is impossible to know beforehand to what extent 
the tympanum has been damaged by the original 
traumatism. Congenital absence or atresia of the 
meatus is so often associated with malformation of 
the middle and/or internal ear that it is only worth 
while to attempt to make a meatus by plastic methods 
in the rare cases where the deformity is bilateral and 
bone-conducted sounds are well heard. 


Deafness Due to Inflammatory Causes 


With the exception of otosclerosis, a peculiar form 
of deafness to be considered later, the disease of the 
middle ear which causes deafness is almost always 
of the nature of an inflammation which passes along 
the Eustachian tube from the nasopharynx, and which 
shows an infinite variety of acuteness and virulence. 
The principal site of incidence of the inflammation, 
and of any resulting fibrosis, also varies, so that either 
the Eustachian tube, the drum-membrane, or the 
inner tympanic wall may bear the brunt of the 
damage; a lesion of the first is generally the most 
curable, while fibrosis in the region of the fenestra 
causes the most severe and intractable forms of 
middle-ear deafness. It was formerly considered 
certain that the important path by which sound- 
vibrations are conducted to the cochlea is by way 
of the membrana tympani and chain of ossicles, but 
of recent years considerable doubt has been thrown 
upon this, and the theory has gained ground that 
the chief function of the ossicular chain is to damp 
and regulate the sounds. 


ACUTE SUPPURATIVE OTITIS 


The more virulent forms of inflammation usually 
produce a simple acute suppurative otitis; if 
infection be still more virulent, or be favoured 
by anatomical or constitutional factors, mastoid- 
itis supervenes; in the most severe types, espe- 
cially in those associated with the specific fevers 
such as scarlet fever, measles, or influenza in 
certain epidemics, the severe complications occur: 
sinus-thrombosis, cerebral abscess, meningitis, and 
labyrinthitis, the two latter causing severe deafness 
from damage of the internal ear, and all causing 
danger to life with which we are not here concerned. 
In the great majority of cases acute suppuration 
heals within three or four weeks under proper atten- 
tion, and fortunately often even without it, leaving 
a healed membrane with a barely visible scar and no 
noticeable deafness, though some slight impairment 
compared with the other ear can more often be 
detected by careful tests. By proper attention is 
meant timely incision of the membrane when 
spontaneous perforation is delayed, and strict 
cleanliness of the meatus to avoid secondary infection. 
If the discharge fails to diminish in from two to three 
weeks, any nasopharyngeal infection must be treated, 
and especially should adenoids be removed in children 
and young people, for the ear will often become 
dry in a few days after this operation. If this treat- 
ment fails or is not indicated, and suppuration 
persists undiminished for three or four weeks, the 
simple mastoid operation should undoubtedly be 
performed even in the absence of all other symptoms ; 
apart from the danger to life from the persistence 
of the suppuration (and quite extensive disease is 


160 


THE LANCET] 


THE PROGNOSIS IN DEAFNESS 


[san. 18, 1936 


usually found in these cases) operation at this stage 
may be relied on in nearly all instances to leave an 
ear with an intact drum and little or no impairment 
of hearing. The longer that suppuration persists 
after four weeks, the more likely is deafness to result, 
and the greater probability is there of a permanent 
perforation of the drum which conduces to recurrence 
of the attacks. 


ACUTE CATARRHAL OTITIS 


Acute catarrhal otitis is the result of a less active 
inflammation and may show all grades of severity 
from a tympanum full of serous or mucoid fluid to 
a slight impairment of the patency of the Eustachian 
tube. As pain and constitutional disturbance are 
less marked, deafness is here a more obvious symptom ; 
the patient often complains that his own voice 
echoes or sounds unduly loud, and musical tones are 
frequently heard out of tune which is a serious matter 
for musicians. Clinically, there may be much 
obstruction of the tube with or without secretion in 
the tympanum, or the latter may be full of fluid 
without any great Eustachian obstruction. Inflation 
‘gives marked relief; in young children politzerisa- 
tion must suffice, but in adults inflation with the 
catheter is preferable. This must usually be repeated 
at intervals of one, two, or three days for some six 
to twelve times before cure is obtained. A single 
attack of acute catarrhal otitis nearly always ends 
in complete recovery of hearing, and often without 
treatment, but in some the hearing is left impaired ; 
hence the importance of treating and keeping under 
observation all such cases until restoration is complete. 
Unfortunately attacks are liable to recur and some- 
times to follow every cold, especially in children and 
young adults. This is a very frequent cause of 
chronic deafness, and every effort should be made 
to find and treat any predisposing cause in the nose 
or nasopharynx; adenoids are of all affections the 
most likely to be the source of trouble, but unhealthy 
tonsils, sinusitis, and nasal obstruction must not be 
overlooked. This does not mean that every septal 
deviation or spur should be removed, for here 
considerable judgment is required, but it is all- 
important that a healthy condition: of the nose and 
throat be obtained. Occasionally an acute catarrhal 
otitis fails to clear up and a subacute condition 
remains in which a collection of fluid tends to persist 
in the tympanum. In such cases it is useful to suck 
out the fluid at regular intervals by means of a 
Weber-Liel tube passed along the Eustachian catheter, 
but if this fails to prevent its accumulation, the drum 
should be incised with careful antiseptic precautions 
and the secretion, usually a thick mucus, blown out 
with the catheter. This may seem a drastic form 
of treatment for a non-suppurative condition but, 
if it be allowed to persist, the hearing will be per- 
manently damaged, Although the majority of cases 
of acute middle-ear inflammation recover without 
permanent deafness, the minority who suffer lasting 
damage are sulliciently numerous to form a large and 
important class of the community; frequently this 
is the result of severe destruction caused by scarlet 
fever. Closer attention to the acute forms of aural 
disease has already done much, but can do much 
more, to diminish their number; the public needs 
education on the importance of seeking skilled 
attention in these conditions, and especially on the 
harm which results from neglecting earaches in 
childhood. 

CHRONIC MIDDLE-EAR DEAFNESS 


Chronic middle-ear deafness may be the result of 
damage caused by former suppuration. Its degree 


varies greatly with the site of the principal lesion; 
a perforation of the drum may be attended by surpris- 
ingly little disability, while fibrosis and adhesions 
within the tympanum, especially about the fenestre, 
cause severe deafness. This fibrosis is very similar 
to the state of affairs found in non-suppurative 
chronic middle-ear catarrh, but with this difference, 
that it is usually not progressive. In some large 
perforations an ‘‘artificial drum’’ composed of a 
disc of cotton-wool moistened with liquid paraffin 
gives marked improvement of hearing. After the 
radical mastoid operation has been performed, the 
hearing is always below normal, but the effect of 
the operation is very variable and is difficult to 
estimate beforehand; if deafness is severe before 
operation, and especially when the ear is blocked by 
cholesteatoma or granulations, the hearing will 
probably be somewhat improved but, if the hearing 
has previously been fairly good, it is likely to be made 
worse. It is important, while operating, carefully to 
respect the inner tympanic wall in order to avoid 
Scarring in this region. 


CHRONIC CATARRHAL OTITIS 


The commonest cause of chronic deafness is chronic 
catarrhal otitis, which is sometimes labelled chronic 
hypertrophic or chronic hyperplastic catarrh according 
to whether the principal lesion is thought to be a 
thickening of the mucosa or the formation of fibrous 
tissue; in any case they seem to represent different 
stages of the same process. The affection is probably 
always caused by former, usually repeated, attacks 
of acute or subacute catarrh, but, as the onset is 
very gradual and the normal perception is greater 
than is required in civilised life, patients seldom 
come for treatment until the deafness is advanced, 
while the attacks of otitis which have initiated the 
process frequently have occurred in childhood or 
youth and have been forgotten. The deafness 
usually tends slowly to increase, but there may be 
long intervals, even of many years, without pro- 
gression, making it difficult to evaluate the eflect 
of treatment. Attempts have been made in the 
past to remove scar-tissne and to loosen adherent 
ossicles by operation, but, apart from the danger 
of causing suppuration, results have not been 
permanent and such operations have been aban- 
doned. Indeed, there is as yet no method 
of influencing fibrosis within the tympanum ; 
obstruction in the Eustachian tube can, however, 
be favourably affected and, in some cases, cured by 
such treatment as the use of Eustachian catheters, 
bougies, and topical applications, and not infrequently 
inflation has a beneficial effect on the hearing even 
in the absence of noticeable obstruction. If a short 
tentative course of such treatment is found to produce 
progressive improvement, it should be persevered in 
as long as improvement continues; in this way a 
considerable proportion of eases can be brought to 
a higher level of hearing, and maintained there by 
occasional repetition of treatment. A short trial 
of such methods is always worth while, and some- 
times gives improvement in unexpected cases. 
Mechanical oto-massaye sometimes gives subjective 
rolief, but is seldom found to produce a real or lasting 
improvement. Massage by means of sound waves, as 
produced by the electrophonoide of Ziind-Burguet, is 
warmly advocated by some ; it demands a long course 
of treatment and speedy relapse seems to be frequent. 


ITAROLD BarweE Lu, M.B., F.R.C.S., 


Consulting Surgeon for Diseases of the Throat 
and Ear to St. George’s Hospital. 


(To be coneluded) 


THE LANCET] 


[yan. 18, 1936 161 


SPECIAL ARTICLES | 


ALCOHOLISM AND CRIME 


IN RELATION TO MANIC-DEPRESSIVE 
DISORDER * 


By W. Norwoop East, M.D., F.R.C.P. Lond. 


H.M. COMMISSIONER OF PRISONS 


THE terms mania and melancholia were used 
formerly to differentiate mental states which were 
looked upon as separate disease entities. Later, 
it was recognised that periods of mania and melan- 
cholia, of mental elation and mental depression, 
might occur as two stages in the same disease, and 
Kraepelin in 1896 introduced the concept of a manic- 
depressive disorder. It is unnecessary here to consider 
the various types of mental alienation which Kraepelin 
included in this term. He emphasised the important 
fact that although attacks might occur throughout 
the life of the individual they were not followed by 
pronounced mental enfeeblement. Indeed, the subjects 
of the disorder are frequently of good intelligence. 
Kraepelin associated the condition with symptoms of 
physical deterioration, but Kretschmer, Rehm, and 
others have found themselves unable to accept this 
view. Kretschmer seeks to connect certain physical 
states with psychological types and considers manic- 
depressive disorder to be associated with the pyknic 
physique. 

A hereditary predisposition to mental disorder is an 
important stiological factor in many manic-depressive 
subjects, and cases can be conveniently divided into 
two main groups. 
without any apparent cause; in the other, to be 
determined by a constitutional inability of the patient 
to adjust himself to accidental happenings which 
would present no such difficulty to a normal person. 

The disorder consists of three phases: a state of 
mental depression, of mental exaltation, and a 
subsequent period of normal mental health. These 
phases may occur in variable order and may last 
for varying periods, and occur at irregular intervals. 
In both the depressed and exalted phases three 
fundamental symptoms are to be noted. In the 
depressed phase emotional depression, psychomotor 
retardation, and difficulty in thinking ; in the exalted 
phase, emotional elation, psychomotor activity, and a 
rapid flight of ideas. In the depressed phase the 
patient experiences mental pain, the bodily move- 
ments and thought processes are slow, but conscious- 
ness is retained ; the subject is aware of his surround- 
ings and is often able to appreciate that he is mentally 
il, In the exalted phase the patient has an 
exaggerated sense of well-being; he is over-active, 
restless, excitable, inconsistent, and changeable, 
and may be unable to exercise self-control. Ilis 
memory may be clear, but his judgment is impaired 
and he does not realise that he is ill. 

This brief outline of symptoms will require amend- 
ment if the disorder is present in an aggravated form. 
The most profound degrees of melancholia with 
stupor, delusions, and hallucinations may then be 
present ; and in the alternating phase intense excite- 
ment, violence, and incoherence with delusions and 
hallucinations. On the other hand, the symptoms 
may be so slight in the milder cases as to escape notice 
either by the patient or his friends and associates, 


* 4 paper opening a discussion at the Society for the Study of 
Inebriety on Jan. l4th, 1936. 


In one, the attacks appear to arise | 


and may pass by imperceptible gradations into 
normality. Itis of particular medico-legal importance 
to remember that the temperamental level of many 
normal persons is not constant but rises and falls 
to lesser or greater heights from time to time, and 
it is a common experience to find among our personal 
friends and acquaintances some who for no assignable 
cause have their good and bad days according to the 
measure of their emotional variations. 


Association with Crime 


It will be apparent from these facts that the 
relationship of alcoholism and crime to manic- 
depressive disorder may be clear and unequivocal 
when the abnormal mental state is well-defined, 
but may be determined only by a skilled observer 


when normality is approached. How difficult it may 


be to form a correct opinion in the latter type of case 
was forcibly impressed on my mind many years ago 
when carrying out observations on prisoners who had 
been remanded from the police-courts on charges of 
attempted suicide, and in whom mental depression 
was attributable to external factors and alcohol had 
had been consumed in order to combat the affective 
state. A true assessment of the mental condition 
in such cases is important as a guide to the future, 
because manic-depressive disorder, it will be 
remembered, is recurrent. It should be remembered 
also in this connexion that an attempt at suicide in 
England is a misdemeanour for which a considerable 
sentence of imprisonment may be imposed, Further, 
in pre-war years, particularly it was frequently 
associated with alcoholism. | 
Crime, however, is associated with both major and 
minor manic-depressive states apart from alcoholism. 
Here again prolonged observation may be necessary 
before the mental condition underlying anti-social 
conduct can be disclosed. It must be noted also that 
criminal conduct in a manic-depressive subject may 
be unconnected with the abnormal phases of his life. 


For example, a youth 20 years of age was sentenced 
to detention in a Borstal institution for stealing a motor- 
car. He was of foreign parentage and nothing of medical 
importance in the family history was admitted. He 
stated that his mother died when he was fifteen years 
old, and that he was much depressed at the time in con- 
sequence, and had suffered from at least five attacks of 
depression since then. He went to the United States of 
America and obtained work on a farm but stole a horse 
and was convicted and sent to an industrial school. He 
worked as a labourer on attaining his discharge, but in a 
few months was reconvicted for robbery and returned to 
the school. He was convicted later for stealing a motor- 
car and was deported to England. On arrival he stole 
a car with a man he became acquainted with on the 
voyage; they were arrested, and he received the current 
sentence. Immediately after arrest he came under the 
observation of experienced prison medical officers, and 
his mental condition was considered to be normal. A 
few months later he became rather unusually good- 
tempered and friendly ; he was boisterous and appeared 
to have a surplus of energy. In a few weeks he became 
less aggressively purposeful. As time passed, although 
he continued to work well in the institution, he became 
quiet, disregarded his companions, and was uninterested 
in his surroundings. Two months later he became again 
unsettled, restless, talkative, aggressive, and mischievous. 
His memory at this time was unusually retentive, and a 
press of activity was noticed at work and throughout the 
various duties of the day. This phase passed off in a 
few weeks and he regained his normal mental level. 


So far there has been no evidence to connect the 
criminal conduct directly with the mental disorder. 


162 THE LANCET] 


ALCOHOLISM AND CRIME 


[san. 18, 1936 


But it should be observed that some manic-depressive 
subjects are eccentric and unstable when they have 
attained their normal mental health and are then 
potential delinquents as a result of their mental 
constitution. 

Manic-depressive disorder gives rise to criminal 
conduct apart from alcoholism. In one case a 
strictly abstemious man who had suffered from three 
previous attacks killed his wife in the depressed phase 
of a subsequent attack. The murder was unconnected 
‘with alcohol. The most important point to note 
here is the fact that crimes of violence are more 
frequent in depressed than in exalted states. I 
have pointed out elsewhere? that in a series of 53 
depressed law-breakers 34 committed crimes of 
violence, and in a series of 52 exalted subjects only 
7 were so convicted. Recent figures of insane 
homicides at Broadmoor criminal lunatic asylum 
Show that 62 murders were associated with melan- 
cholia and 28 with mania. 

It is generally accepted by those who are concerned 
with the administration of justice, and with the 
administration of penal institutions, that the propor- 
tion of first offenders who commit crime again is 
relatively small. It is also generally accepted that 
many others soon acquire a habit to commit crime 
which may be unconquerable. A manic-depressive 
subject may pass through phases of the disorder 
without committing any offence although some 
attacks are associated with crime, but personal 
_ experience leads me to believe that when the disorder 
ig associated with alcohol the tendency to commit 
crime is materially increased. Further, the fact 
that crime was repeatedly associated in the same 
subject with manic-depressive disorder would lead 
me to consider whether alcohol was a contributory 
influence. 

When repeated crimes are due to the disorder, and 
alcohol is not an added factor, the intervals of normal 
mental health may be free from the moral degradation 
‘which is to be observed not infrequently when the 
condition is associated with alcohol. A man was 
convicted of assaulting the police and was aggressive, 
offensive, contumacious, boastful, excited, and abusive 
when received into prison. He made false accusations 
against the staff and was unashamed when they were 
proved to be untrue. He appeared to be an 
unscrupulous and revengeful man, but his conduct 
and ethical standards were not inferior to those of his 
class in life when he regained his mental health. 

In marked contrast is the case of a man who has 
been coming to prison for many years. He has been 
under treatment also in mental hospitals and has been 
diagnosed as a case of manic-depressive disorder by 
different alienists. His offences, which include theft, 
false pretences, assault, and drunkenness, have been 
attributable at different times to alcohol, to manic- 
depressive disorder, to both combined, and some- 
times to a now well-established habit to commit 
crime. His reputation is such that those who know 
him are quite unable to place the slightest confidence 
in him at any time. 


Association with Crime and Alcohol 


When manic-depressive disorder is associated with 
alcohol and crime results the evidence of recent 
excessive drinking may be so overwhelming and that 
of the underlying mental disorder so insignificant 
as to escape demonstration. In such cases the past 
history of the individual may assist the diagnosis, 
and if there is reason to believe that previous conduct 
was due to manic-depressive disorder it may be 
desirable for those conducting the defence to call 


medical evidence to support this view at the trial. 
In this event a medical witness will not belittle his 
position or the value of his evidence provided he 
submits his opinion as a possibility and without 
unqualified assurance. I do not mean to convey 
the impression that medical evidence should not be 
given with all the force that circumstances permit, 
but I have no doubt that some witnesses have not 
been as acceptable as they might have anticipated 
because they assumed more than they could sub- 
stantiate and confused assumptions with facts. 


A man was charged with the murder of his sweetheart 
in circumstances which left no doubt that he had com- 
mitted the crime. The dead girl was found with a fatal 
wound in her throat and the accused lay a few yards 
away with a self-inflicted wound across the upper part 
of his neck. On reaching the hospital the house surgeon 
noted the man’s breath smelt of alcohol, and he volun- 
teered the statement that he killed the girl because she 
had been teasing him. This may have been true but 
was an inadequate motive, as indeed must be any motive 
for murder. The accused admitted that he had been 
drinking heavily for some little time before the crime, 
and there was corroboration of this as two days before 
he had been turned out of the girl’s home as he arrived 
there in a drunken state. He was received into prison 
eleven days after the murder and was rational in conduct 
and conversation and showed no evidence of insanity then 
or whilst awaiting trial; but he made varying and con- 
tradictory statements at the medical interviews in order 
to suggest that he was of unsound mind. It is unnecessary 
to enter into these recitals here in detail, suffice it to say 
that it became quite clear that they could not be accepted. 
This conclusion was confirmed long after the trial; the 
prisoner then admitted to me that he had spoken falsely 
when he said he had no recollection of the circumstances 
connected with the crime. There was no evidence to 
support the view that the crime was the result of epilepsy, 
although this was put forward as a defence at the trial, 
apparently because the alleged amnesia was accepted. 
There was, however, reason to believe that the prisoner 
had suffered previously from periods of mental depression 
for which there appeared to be no external cause and 
which led him on one occasion to make an attempt at 
suicide. He combated these attacks by drinking to excess 
in order to gain confidence so that ‘‘ he could feel himself 
as himself.” Certain of his uncorroborated statements, 
if true, supported a diagnosis of alcoholic hallucinations, 
and the view that he was insane at the time of the crime. 
I was unable to go further than this in my evidence at 
the trial. The prisoner was found guilty of murder and 
sentenced to death, and was later reprieved. 


The case presented difficulties inasmuch as the accused 
was clearly malingering insanity ; it was also evident ’ 
that the crime was related to alcohol, but it was less 
certain that it was associated also with manic- 
depressive disorder. I was able to observe the man 
during subsequent years in prison during which he 
passed through phases of mental depression which 
left no doubt that the crime was the result of alcoholic 
excess in a manic-depressive subject. 


Association with Alcohol 


Drunkenness may be associated with other forms 
of mental disease, with, for example, delusional 
insanity, dementia precox, general paralysis of the 
insane, senile dementia, epilepsy, and high-grade 
mental deficiency. This society is chiefly interested 
in the association of manic-depressive disorder and 
alcoholism not involving criminal conduct. It is, 
however, quite impossible to draw any hard-and-fast 
line here as drunkenness, if followed by certain 
conduct, may itself constitute a crime and lead to the 
police-court. 

More than 40 years ago Legrain ? divided alcoholists 
into three classes: drinkers with an abnormal instinct, 


Pe, 


THE LANCET] — 


ALCOHOLISM AND CRIME 


[san. 18, 1936 163 


defective moral sense, and want of moral equilibrium ; 
drinkers with an abnormal tendency, including 
drinkers through taste, weak-mindedness, and want of 
mental equilibrium; and drinkers through impulse. 
In the last class were included dipsomaniacs and 
these were divided into pure dipsomaniacs and pseudo- 
dipsomaniacs, Pure dipsomania was defined as a 
“morbid condition, characterised by the irresistible 
obsession and impulse to drink coming on in attacks 
during which the patients are in a condition of 
impotence of will and manifest great anguish.” 
Legrain observed that an attack of dipsomania 
might remain an isolated event in the life of the 
subject, but usually the attacks were repeated and 
assumed a periodical character. The concept of 
manic-depressive disorder had not been formulated 
at this time, but Legrain referred to the fact that 
Krafft-Ebing and others classified it among the 
periodical insanities, whilst other observers, struck 
by the depressed aspect of the patients especially 
at the commencement of an attack, saw in dipsomania 
a variety of melancholia. Pseudo-dipsomaniacs 
according to Legrain were drunkards who possessed 
a genuine desire to combat their craving, but were 
unable to do so through weakness of will. 

We are concerned in this discussion with the periodic 
drinking associated with manic-depressive disorder, 
the true dipsomania of Legrain in which drinking is 
only an outward manifestation of underlying psycho- 
logical, and perhaps physiological, causes independent 
of habit formation. The advisory committee to the 
Central Control Board in their work on Alcohol? 
stated that : 

“In these relatively infrequent cases, to which the name 
dipsomania is sometimes given, the patient drinks heavily 
for a period ranging in different cases, but usually of 
approximately constant length for the same case, and 
then, when the attack ceases or passes into another phase, 
he returns to sobriety—a fact, it may be noted incident- 
ally, which goes to show that alcohol has no very strong 
habit-forming influence. ” 


Too limited a view may be taken of dipsomania 
if the term is restricted to manic-depressive subjects, 
for some authorities consider that it may be related 
to epilepsy, and may also be the expression of a 
compulsion neurosis. The consumption of alcohol 
in manic-depressive disorder is connected directly 
with the current emotional state; in the depressed 
phase the patient has learnt by past experience its 
comforting effects; in the elated phase he is so 
joyous and expansive that he must share his happiness 
with others in extravagant festivity. In the former 
state the alcohol is consumed in order to avoid reality, 
in the latter to enhance it. 


Segregation in Prisons and Retreats > 


The number of persons annually convicted of 
drunkenness is still considerable and the last figures 
published ¢ show how the year 1933 compares in 
this respect with recent years. 


\ 


Year. Convictions. Year. Convictions. 
Average of ) 1931 45,842 
1925-1929 | 90,858 1932 33,100 

1930 .. 57,131 1933 39,751 


There was a continuous and rapid decrease until 
1932, in 1933 there was a 20 per cent. increase over 
1932, but the 1933 figure was still much below the 
fivure for 1931 and earlier years. The number of 
persons received into prison for drunkenness, &c., 
during the last five years are as follows®: 1929, 
7876; 1930, 8611; 1931, 7484; 1932, 5836; and 
1933, 6631. No figures are available to show the 
number of those persons who are manic-depressive 


subjects. The proportion is probably small, but the 
total may be not inconsiderable. 

Persons are sent to prison as a punishment and 
not to be punished, and although it may seem illogical 
to-day to imprison anyone because his conduct is the 
result of a constitutional disorder over which he has 
no control, it is to be remembered that prisons serve 
also to protect the public, actually during the time 
the lawbreaker is detained, and potentially as the 
result of its deterrent effect. If binding over, fines, 
and probation have no effect on an offender whose 
conduct is a nuisance to society, imprisonment 
may be necessary ultimately even though he is not a 
serious menace to law and order. 

Moreover, imprisonment may be the only means 
of protecting the manic-depressive alcoholist from 
himself. For it will be agreed that a large number are 
not certifiable, or are not certified, under the Lunacy 
Acts, others refuse to accept the provisions of the 
Mental Treatment Act, 1930, and enter a mental 
hospital as a voluntary patient, and others refuse to 
enter a retreat. On reception into prison they come - 
under medical care and supervision and their return 
to normal mental health is expedited, partly as a 
result of medical treatment, partly because the 
orderly life is conducive to recovery, and also because 
alcohol and other causes of mental imbalance are no 
longer operative. It may be hoped that imprisonment 
will act sometimes as a deterrent also, if its imposition 
suggests to the subject that society not only dis- 
approves of his conduct but considers he can amend 
it. However this may be, the patient and the public 
must be protected from the effects of his disordered 
mind, and although it may seem harsh, yet, in our 
present state of knowledge, temporary detention in a 
penal institution may be the only satisfactory method 
of dealing with some of these cases. 

It will be known to the members of this society 
that the number of alcoholists detained in licensed 
retreats under the Habitual Drunkards Act, 1879, 
is almost negligible at the present time. The average 
for the period 1925-1929 was twelve ; the number for 
the year 1930 was nine; for 1931, eight; for 1932, 
one; for 1933, seven; and for 1934, one. My 
experience as inspector under the Inebriate Acts 
leads me to consider that some manic-depressive 
alcoholists are suitable cases to deal with under the 
Act of 1879 if other alternatives are rejected and the 
reluctance of the patient to comply with the statutory 
provisions for admission can be overcome. The 
consequent restrictions may impress the patient with 
the importance of custodial care and encourage him 
to seek and persevere with treatment. There can 
be, of course, no objection to discharge the patient 
in appropriate cases before the full period of detention 
has expired. 

REFERENCES 
. East, W. Norwood: Forensic Psychiatry, London, 1927, 
p. 317. 
. Legrain, M.: Art. Dipsomania, pp. 388 et seq, Dictionary 


of Psychological Medicine, D. Hack-Tuke, London, 1892. 
. Aleohol: Its Action on the Human Organisin, London, 1923, 


p. 106. 

. Criminal Statistics England and Wales, 1933, London, 1935, 
p. 5. 

. Report of the Commissioners of Prisons and Directors of 


Convict Prisons, 1933, London, 1935, pp. 10 and 11. 
. Annual Reports of the Inspector under the Inebriate Acts. ° 


oOo on tm © N m 


MEDICAL Tour OF Morocco.—On April 14th a 
party of medical men and their friends will leave for 
a tour of Morocco, which will include districts only 
recently colonised as well as the more usual sights. 
The party will return to Marseilles on April 21st. Further 
particulars may be had from Dr. R. Bernard, Bruzelles- 
Médical, 29, Boulevard Adolphe Max, Brussels. 


164 THE LANCET] 


MEDICINE AND THE LAW.-——VITAL STATISTICS 


[yan. 18, 1936 


In relation to the huge total of medical practitioners 


MEDICINE AND THE LAW 


Doctors and Dangerous Drugs 


THE Home Office periodically circulates a list of 
medical practitioners, dentists, chemists, and veteri- 
nary surgeons from whom has been withdrawn the 
authority to possess, supply, or prescribe “‘ dangerous 
drugs.” The latest of these lists gives the names 
and addresses of 27 medical practitioners against 
whom the Secretary of State has made an order for 
this purpose during the past 14 years. The list states 
that’ in all but three cases a direction was simul- 
taneously given that it should not be lawful for the 
named doctors to give prescriptions for the purposes 
of the Dangerous Drugs Regulations. Thus we get a 
summary of information (otherwise scattered over 
the arid columns of the London Gazette) as to the 
working of statutory control. The Act of 1920, 
giving permanent effect to certain war-time restric- 
tions, confined the import, export, manufacture, 
sale, distribution, or supply of “ dangerous drugs ”’ 
to persons licensed or authorised. Home Office 
regulations, made under the Act, explain that certain 
classes of persons are authorised for this purpose— 
duly qualified medical practitioners, registered den- 
tists, and veterinary surgeons and research workers 
in approved institutions in particular. This general 
‘authority,’ however, does not entitle these 
privileged classes to possess or supply such drugs 
beyond what is “‘ necessary for the practice or exer- 
cise of the respective professions or employments, 
in their capacity as members of their respective 
classes.” Conviction for an offence under the Act 
of 1920 (or under the customs laws as applied by 
that Act) gives the Home Office a power to with- 
draw a person’s “ authority ° by notice in the Gazette. 
If a doctor, dentist, or veterinary surgeon thus loses 
his ‘‘ authority,” the Home Office may, by lke notice, 
direct that it shall not be lawful for him to prescribe 
dangerous drugs. It will be remembered that in 
1926 a departmental committee on drug addiction 
considered and reported upon possible abuses dis- 
covered through the supply of exceptionally large 
quantities of morphine and heroin to particular 
practitioners or to individual patients on practi- 
tioners’ prescriptions. The committee examined 
evidence tendered by the Home Office, the Ministry 
of Health, and the Director of Public Prosecutions, 
and considered possible remedies. It found the Home 
Office reluctant either to prosecute doctors in the 
police-court for offences against the Dangerous 
Drugs Acts or to bring such cases to the notice of 
the General Medical Council for disciplinary action. 
The reason for this reluctance was the fact that the 
issue would turn largely on questions of medical 
opinion. In the end the committee advised that 
these cases of alleged improper supply should, where 
the conduct of doctors was in question, be referred 
to a special medical tribunal. Regulations of 1928 
gave effect to this suggestion and enacted that, if 
the tribunal so recommended, a doctors “‘ authority ”’ 
might be withdrawn by the Home Office in conse- 
quence of adverse findings. It was a solution by 
no means unsatisfactory to the medical profession 
that the Home Office, accepting the advice of a 
departmental committee consisting entirely of phy- 
sicians and surgeons, should have set up a medical 
tribunal to deal with these difficult allegations 
against professional men of possessing or supplying 
dangerous drugs for medical purposes which are not 
legitimate, So far as is known, no complaint is made 
of the manner in which the tribunal does its duty. 


on the Register, the number of 27 in the recent 
Home Office list is perhaps not a sensational 
proportion. 

Murder by Bacillus 


We must wait for the Indian mail to bring a full 
account of the judgment of the High Court in Calcutta 
on the appeal from the death sentences in the plague 
bacillus case. A rich Bihar land-holder was said to 
have died through plague infection injected into his 
body by a prick inflicted by a passing stranger in 
the waiting-room of a Calcutta railway station in 
November, 1933. Two men, the step-brother of the 
deceased and a doctor, were found guilty of con- 
spiracy to murder. The Appeal Court has described 
the case as unique in the annals of crime. According 
to a telegram in the Times from its Calcutta corre- 
spondent, the death sentences were, on Jan. 10th, 
commuted to transportation for life partly because 
of the exceptional delay in hearing the appeal (the 
appellants having been under sentence of death for 
ten months) and partly because of the circumstantial 
nature of the evidence. It appeared that the two 
accused had conspired to provide some person at 
present unknown with plague culture which ‘could 
not have been obtained except at Bombay. It is 
reported to have been an additional reason for com- 
muting the sentences that this course may lead to 
the discovery of the actual perpetrator of the crime. 


INFECTIOUS DISEASE 
IN ENGLAND AND WALES DURING THE WEEK ENDED 
JAN. 4TH, 1936 


Notifications.—The following cases of infectious 
disease were notified during the week: Small-pox, 0; 
scarlet fever, 2438; diphtheria, 1227; enteric fever, 
25; acute pneumonia (primary or influenzal), 1684 ; 
puerperal fever, 31 ; puerperal pyrexia, 132 ; cerebro- 
spinal fever, 29; acute poliomyelitis, 2; acute 
polio-encephalitis, 1; encephalitis lethargica, 3; 
dysentery, 23; ophthalmia neonatorum, 56. No 
case of cholera, plague, or typhus fever was notified 
during the week. ' 


The number of cases in the Infectious Hospitals of the London 
County Council on Jan. 10th was 3818, which included: Scarlet 
fever, 1102; diphtheria, 1188; measles, 397; whooping- 
cough, 528; puerperal fever, 17 mothers (plus 12 babies); 
encephalitis lJlethargica, 280; poliomyelitis, 3. At St. 
Margaret’s Hospital there were 16 babies (plus 6 mothers) 
with opbhthalmia neonatorum. 


Deaths.—In 121 great towns, including London, 
there was no death from small-pox, 2 (1) from enteric 
fever, 48 (4) from measles, 6 (0) from scarlet fever, 
21 (4) from whooping-cough, 39 (7) from diphtheria, 
45 (12) from diarrhoea and enteritis under two years, 
and 110 (12) from influenza. The figures in paren- 
theses are those for London itself. 


The mortality from intluenza is rising, the total deaths for 
the last five weeks (Working backwards) being 110, 80, 67, 62, 45. 
They are scattered over 62 great towns, Manchester reporting S, 
Birmingham 6, Liverpool 5. Blackburn, Leeds, Bristol, and 
Walsall each 3; no other great town more than 2. Liverpool 
reported 15 deaths from measles, Mnachester 9, no other great 
town more than 2. Liverpool also had 6 deaths from whooping- 


cough, Deaths from diphtheria Were reported from 25 great 
towns: Liverpool 6, Hull. Manchester, Newcastle-upon-Tyne 
each 2. Bradford reported the only death from enteric fever 


outside London, 

The number of stillbirths notified during the week 
was 270 (corresponding to a rate of 38 per 1000 total 
births), including 53 in’ London. : 


SOCIETY FOR THE PROVISION OF BIRTH CONTROL 
Cuinics.—On Friday, Feb. 7th, at 6 p.m., Dr. Gladys Cox 
will give a lecture on the theory and practice of contra - 
ception, which will be followed at 7 P.m. by a practical 
demonstration. The lecture will be given at the Walworth 
Women’s Welfare Centre, 1534, East-street, London, S.E. , 
Tickets should be obtained in advance from the centre. 


THE LANCET] 


(san. 18, 1936 165 


OBITUARY 


ALBERT ALEXANDER GRAY, M.D., 
F.R.F.P.S. Glasg. 


THE death on Jan. 4th at his home in the West 
Highlands of Dr. Albert Gray, at the age of 67 years, 
removes an otologist whose name was known to 
his fellow workers throughout the world. 

Albert Alexander Gray was born at Pollokshields, 
Glasgow, son of William and Margaret Gray (née Pace), 
and was educated at Bootham School, York, Oliver's 
Mount, Scarborough, and Glasgow Academy, quali- 
fying M.B., C.M. Glasg. in 1890. Within the next ten 
years he took the M.D. Glasg. and the fellowship of the 
Faculty, and was elected F.R.S. Edin. After a house 
surgeoncy at the Glasgow Royal Infirmary he spent 
two years in general practice in Blackburn and then 
studied in Leipzig 
and Munich before 
returning to Glas- 
gow to specialise in 
diseases of the ear, 
nose, and throat. 
He was appointed 
aural surgeon to 
the Central Dis- 
pensary and lec- 
turer in the Uni- 
versity on diseases 
of the ear, contri- 
buting regularly to 
the Journal of 
Anatomy and Phy- 
siology, so that even 
before his appoint- 
ment as aural 
surgeon at the 
Infirmary he came 
to be recognised as 
an otological 
authority. 

The story of 
Gray's career as an investigator is part of the history 
of scientific otology. His early work was designed 
to overcome the formidable technical difficulties still 
obscuring many fundamental questions of the ear’s 
finer structure. His first major achievement was a 
notable improvement in the technique of preparing 
casts of the membranous labyrinth (1904). This 
method he proceeded to apply on a wide scale in 
those studies of the comparative anatomy of the 
inner ear, the fruits of which were seen in his first 
classic work, ‘‘The Labyrinth of Animals,” published 
in 1908. The results therein presented display a 
mastery of histological and photographic technique 
which has remained unsurpassed to this day. By 
this early mastery of anatomical method Gray pro- 
vided himself with a weapon the power of which 
was to be continuously demonstrated in the years to 
come. With the instinct of the true biologist, how- 
ever, he regarded anatomy as no more than a means 
of attack upon problems of function. In 1900 he 
published his observations upon the differentiation 
in size and density of the spiral ligament of the 
cochlea, putting forward the theory of maximum 
stimulation which has stood the test of time. Ilis 
views on the physiology of hearing are embodied in 
the “ Mechanism of the Cochlea °? (1924), written in 
collaboration with Mr. G. Wilkinson. His “ Atlas of 
Otology’ (1924 and 1933) displays the same technical 
perfection and sound biology. In the sphere of 


DR. ALBERT GRAY 
(Photograph by Annan 


pathology, apart from his pioneer study of the 
changes in deaf-mutism, Gray was chiefly known for 
his work on otosclerosis. His book with this title 
(1917) combined careful clinical observation and good 
pathological method in a way unusual at the time. 
His more recent work was set out in his Dalby lecture 
(1934), and the book on the treatment of otosclerosis 
published just before his death. Recognition of his 
standing as a scientific otologist came to Gray at 
many periods of his career: it included the Lenval 
prize of the International Congress of Otology 
(Budapest, 1909), the gold medal of the American 
Academy of Ophthalmology and Otology (1911), the 
Guyot prize of the University of Groningen (1929), 
and many others. He was elected president of the 
section of otology of the Royal Society of Medicine in 
1914 and of the International Collegium Otolaryngo- 
logicum Amicitis Sacrum in 1929. 

Dr. Gray had married in 1892 Mabel Henderson 
by whom he had two sons, of whom the elder is now 
head master of Bootham School and the younger is in 
practice at Haslemere. On his wife’s death in 1927 
he gave up his work in Glasgow and retired to 
London where he became librarian and curator to 
the Ferens Institute of Oto-Laryngology at the 
Middlesex Hospital. Of his work there “S. H.” 
writes: “‘ Except for holidays in Scotland, Gray 
spent almost the whole of his time in the Institute, 
often remaining at work until well after midnight, 
because the freedom from traffic and vibration pro- 
vided the best conditions for the high-power micro- 
photography by which he illustrated most of his 
contributions. He soon became the father of the 
laboratory, his counsel and advice being constantly 
sought and freely given. He worked because he 
enjoyed working and his enthusiasm spread to all 
with whom he came in contact. He had in high 
degree the gift of exposition, making a difficult and 
technical subject both clear and interesting, and his 
demonstrations at the Institute and at meetings of 
the otological section and of the collegium were 
appreciated by all who heard them. Gray has done 
more than anyone in this country for scientific 
otology. He has demonstrated that the best, if not 
the only, line of advance lies in the careful study of 
deafness during life followed by high-power magnifi- 
cation of seria] sections after death. It is greatly 
to be regretted that the valuable work on which he 
was still engaged should have come to this abrupt end.”’ 


JAMES WOOD, M.D. Manch., D.P.H. 


Dr. James Wood, who died on Jan. 3rd at the age 
of 62, had been for some time in ill-health but con- 
tinued to discharge his duties as M.O.H. for Chad- 
derton until two years ago. Born at Oldham and 
educated subsequently at Wesley College, Sheffield, 
and the University of Manchester, he graduated as 
M.B., Ch.B. in 1896, and proceeded later to the M.D. 
degree, taking also the diploma of D.P.II. of the 
Irish royal colleges. After holding several resident 
appointments and being for a few years in private 
practice, he was appointed in 1911 assistant M.O.H. 
at Oldham. Two years afterwards he became M.O.H. 
of Chadderton, and discharged the duties to public 
satisfaction until a breakdown in health occurred in 
1934. He was then given leave of absence and 
never resumed duty. Dr. Wood was known in the 
neighbourhood, in addition to his valuable public 
services, as a particularly fine cricketer. 


166 


THE LANCET] 


RONALD GEORGE CANTI, M.D.Camb. 


THE death after long illness of Dr. Canti, 
well-known pathologist, occurred 
Hampstead on Jan. 7th. He was a pioneer in 
scientific research, a popular and effective teacher, 
and an untiring and unselfish worker. His death at 
the age of 52 is a matter of public regret. 

Ronald George Canti was the son of Mr. G. F. 
Canti, and was born in London in 1883. He was 
educated at Charterhouse and entered King’s College, 
Cambridge, in 1902. He received his medical training 
at St. Bartholomew’s Hospital, took the English 
conjoint diploma in 1911 and graduated M.B. Camb. 
in 1915, proceeding later to the M.D. degree. At 
St. Bart.’s, after serving as house physician, he 
became a demonstrator of pathology under the late 
Sir Frederick Andrewes, the starting-point of a 
laboratory career which 
was to develop along lines 
which no one could then 
have foreseen. Over- 
shadowed as they were by 
his subsequent achieve- 
ments, his earher contribu- 
tions to knowledge included 
a number of useful and 
diverse studies, embracing 
such subjects as the urea 
content of the cerebro- 
spinal fluid, the morbid 
anatomy of pulmonary 
tuberculosis in childhood, 
and the bacteriological find- 
ings in cerebro-spinal fever. 
In connexion with these it 
should be observed that he 
was the first English worker 
to demonstrate that the 
urea content of the cerebro- 
Spinal fluid rises with that 
of the blood, the first to 
confirm Ghon’s observation that tuberculosis of 
mediastinal glands is always secondary to a focus 
in the lung, and one of the earliest to recognise that 
meningococci identical with those causing a meningitis 
are to be found in the nasopharynx during the course 
of the disease. 

The work by which Canti is best known began in 
association with the late T. S. P. Strangeways and 
centred on the behaviour of the malignant cell under 
irradiation. Over and above the pursuit of this study 
by in-vitro methods, he undertook with Dr. Malcolm 
Donaldson an exhaustive histological investigation 
of uterine carcinoma at various stages during and 
after irradiation, which is among the earliest and 
most thorough of its kind, But his principal achieve- 
ment was in bringing the behaviour of tissue 
cultures within the range of ordinary vision. 
Direct observation could not be continued over 
such periods as are occupied by the process 
of growth in a tissue culture; photography could 
conceivably take its place, and photographs would 
not merely provide a permanent record, but if 
taken at long intervals and projected at the 
speed of cinema film would condense the pro- 
tracted and sluggish events of perhaps three days’ 
growth into an animated but nevertheless faithful 
reproduction lasting only a few minutes. The 
apparatus by which this result was in fact achieved, 
first built by Canti himself in his own house, was a 
marvel of ingenuity, and the technical excellence 
of its photography excited widespread admiration, 


the 
at his home in 


OBITUARY 


DR, CANTI 


[yan. 18, 1936 


These films enabled many thousands who would 
never otherwise have had more than the vaguest 
conception of the individual living cell to gain a 
vivid idea of its activities. The potentialities of 
this method of observation have perhaps yet to 
be fully explored, but wherever tissue culture 
can serve the purposes of future research the 
machine devised by Canti will remain indispensable 
to its prosecution. 

Among Cantis numerous other interests were his 
scientific secretaryship of the British Empire Cancer 
Campaign, which included the organisation of a highly 
successful conference in December, 1934, and his 
position as chief medical adviser to the London 
Blood Transfusion Service, an organisation which he 
helped very largely to bring to its present size and 
efficiency. His appointments included that of 
lecturer in bacteriology at St. Bart.’s, which he 
relinquished in 1930 to 
become clinical pathologist 
to the hospital and lec- 
turer in clinical pathology, 
those of pathologist to 
the Alexandra Hospital, 
Swanley and to the 
Florence Nightingale Hos- 
pital, and of bacteriologist 
to the City of London. In 
the interstices of this public 
work he‘ was a clinical 
pathologist enjoying a 
reputation in some ways 
unique for acumen and 
soundness of judgment, and 
for his capacity to apply 
the latest available methods 
to the problems of diagnosis 
and treatment. 

Apart from his wide 
and diverse knowledge of 
many ancillary subjects, 
from engineering to pure 
physics, the attribute which served Canti best in his 
principal achievements was a light-hearted courage 
in the face of technical difficulties which no living 
man can have equalled. Behind this was an insatiable 
curiosity and a catholic interest in all things biological. 
To him nothing seemed impossible, and he was ready 
to turn to account in the laboratory a new discovery 
in almost any sphere. His visit to New York in 
1925 to learn a new technique for studying the 
bacteriology of influenza provided a fresh stimulus 
to a mind of rare enterprise, and contributed to that 
ultra-modernity of outlook which was prepared for 
anything in the cause of progress. This imaginative 
capacity and an almost boyish enthusiasm were the 
most striking qualities in a vivid personality. His 
enthusiasm spilled over to the work of others, and 
many junior colleagues are indebted to him for 
unsparing help and stimulating encouragement. Both 
in the laboratory and in his practice he was inex- 
haustibly generous when his services were needed. 
He had a wide circle of international as well as of 
home friendships ; he will be remembered by all as a 
brilliant personality and a supreme technician, and 
by many as a most lovable friend. 

Dr. Canti married in 1912 Clara Eyles, who nursed 
him throughout a long and distressing illness. He 
leaves four children: a daughter, a son who has 
followed his father to King’s College, Cambridge, a 
second son who is a student at the Royal Veterinary 
College, and a third son who is a student at 
St. Bartholomew’s Hospital. 


THE LANCET] 


JOHN GEORGE GRANT, L.R.C.P. Edin. 


Dr. J. G. Grant, of Miavaig, Stornoway, who. died 
on Dec. 26th, had been in ill-health for a long time 
and his premature death was directly connected with 
his arduous work as a medical officer in the High- 
lands and Islands medical service. He received his 
medical education at Anderson College, Glasgow, 
working also in Edinburgh and at the London Hos- 
pital, and took the double diplomas of Edinburgh 
and Glasgow in 1899. He practised for a time in 
Canada, but some 20 years ago he succeeded Dr. 
Donald Murray as M.O.H. for Stornoway and the 
parishes of Uig and Lochs, a district presenting great 
geographical difficulties to the practitioner. The 
discharge of his onerous duties, complicated by the 
bad conditions of transport, especially in winter, 
tried Grant, but relief was obtained by the division 
„of his area during the latter part of his life. He 
was now responsible for West Uig only, while the 
opening of a new high road eased the water journeys. 
But by this time he had practically broken down 
under the strain, and a lingering invalidism led to his 
death at the age of 60. 


MABYN READ, M.D., D.P.H.Camb. 


Dr. Mabyn Read, whose death occurred on Jan. 2nd, 
was for many years M.O.H. for the city of Worcester. 
As he became connected with the public health of 
Worcester nearly half a century ago he saw the 
whole of modern sanitary administration develop 
in the cathedral city. 

Born at Falmouth he went to Christ’s College, 
Cambridge, as a natural science scholar, and graduated 
with honours in the Natural Sciences Tripos in 1876. 
He proceeded to St. Bartholomew’s Hospital for 
his medical education, and graduated as M.B. Camb. 
in 1880, later taking the diploma of D.P.H. and the 
M.D. degree. He acted as house physician both at 
St. Bartholomew’s Hospital and Great Ormond-street 
Children’s Hospital, and in 1891 was appointed 
M.O.H. of Worcester ; as this was, as usual at that 
date, a part-time appointment, for the first 20 years 
of his residence in Worcester Dr. Read carried on 
private practice, but in 1912 he became a full-time 
oflicer and held the post for 17 years, retiring in 
1929. As will be seen by these dates, the main 
evolution of modern sanitation went on under his 
eyes and largely under his administration, the official 
care of infants, the school medical and tuberculosis 
services all being initiated during his term of office. 
He was particularly interested in maternity and 
child welfare activities, and was rewarded by seeing 
the infant death-rate of the city substantially reduced, 
a practical issue to his enthusiastic labours. 


CLEMENT JOHN GOODHUGH WHITE, M.B., 
B.Chir. Camb. 


Tue sudden death occurred on Jan. 6th of Dr. 
John White, resident surgical oflicer at St. Bartho- 
lomew`s Hospital, Rochester. He was found dead 
in the hospital in circumstances that necessitated an 
inquest, which has been adjourned in order that 
certain analyses may be performed. 

C. J. G. White was the son of Dr. Clement White, 
honorary surgeon at St. Bartholomew’s Hospital, 
rochester, and was 27 years of age. He was educated 
at Felsted and Christ's College, Cambridge, where 
his father had been before him, and graduated in 
arts with honours in the Natural Sciences Tripos, 
proceeding for his medical education to the Middlesex 


OBITUARY 


fran. 18, 1936 167 


Hospital. He took the English conjoint diplomas in 
1933, and graduated as M.B., B.Chir. Camb. in 1935. 
At the hospital he served as house physician and 
resident officer in the ear, nose, and throat, and in 
the orthopædic departments, and in his work showed 
himself diligent, conscientious, and possessing sound 
judgment. His geniality and good nature combined 
with his clinical insight enabled him to fill his resi- 
dent posts with unusual success, while his qualities 
as a sportsman further added to his popularity, for 
while at Middlesex he was secretary and captain of 
the hockey club. After leaving Middlesex Hospital 
he acted as obstetric and gynecological house surgeon 
at Queen Mary’s Hospital, Stratford, and then, after 
six months’ experience as a ship’s doctor, he obtained 
the post of resident surgical officer to St. Bartho- 
lomew’s Hospital, Rochester. The reasons of his 
sudden death are now under inquiry, but none of 
the evidence given at the inquest pointed to anything 
but a fatal accident, for he was to all appearance a 
perfectly happy young man, successful in his career, 
in excellent health, and with no financial or other 
private trouble. We have received from the Middle- 
sex Hospital medical school an eloquent tribute to 
his popularity at the Middlesex Hospital: “Jack 
White will always be remembered by those who 
knew him for his cheerfulness, good nature, enthu- 
siasm, and other personal qualities which go to the 
making of a most kindly and understanding doctor.” 


JEREMIAH REIDY, M.D., D.P.H. 


Dr. Jeremiah Reidy, who died on Jan. 6th at his 
home in Blackheath Park, practised in Stepney for 
30 years, and was well known in both public and 
professional capacities. 

Jeremiah Reidy was born at Gardenfield, Limerick, 
and was educated at University College, Cork, pro- 
ceeding for his medical studies to Dublin and Glasgow. 
He took the double Scottish diploma in 1898 “and 
attended classes at the London Hospital, after which 
he became clinical assistant at the Royal Eye Hos- 
pital, Southwark, the Royal Chest Hospital, and the 
Blackfriars Hospital for Diseases of the Skin. He 
then graduated as M.B., B.Ch. R.U.I., taking also 
the D.P.H. in 1912. Two years later he proceeded 
to the M.D. degree, when he secured the gold medal 
in ' medicine. He had now been established for 
some time in Stepney and was conducting a large 
practice, while he was also surgeon to the H Division 
of the Metropolitan and Thames Police. In the year 
1917-18 he was mayor of Stepney and was appointed 
a J.P. of the County of London. In Dr. Reidy the 
profession has lost an able practitioner and the 
public a useful servant. 


NEw HOSPITAL AT EAST GRINSTEAD.—East Grin- 
stead’s new hospital was opened on Jan. 8th by 
Princess Helena Victoria, and received its first patients 
on Jan. 14th. The hospital is situated on the Fast 
Grinstead-Holtye road, not far from the town, and it 
will meet the great need which has been felt for many 
years, It replaces the Queen Victoria Cottage Hospital 
which was opened as amemorial of a former Royal Jubilee, 
and which only contained 12 beds for adults, 3 cots for 
children, and one room for a paying patient. The new 
hospital, which cost about £29,000, has accommodation 
for 12 men, 12 women, 6 cots for children in their own 
ward, and 6 paying patients; it also contains an operating 
theatre, X ray room, and accommodation for the staff. 
After the opening ceremony and the dedication service 
conducted by the Bishop of Chichester, the Princess 
received purses from 150 children. 


168 THE LANCET] 


[san. 18, 1936 


el 


CORRESPONDENCE 


NN ooo 


THE CONTROL OF MEASLES 
To the Editor of THE LANCET 


Sir,—In his interesting paper in your last issue 
(p. 103) Dr. J. A. H. Brincker states that the first 
attempt to modify measles was made by L. Weiss- 
becker 40 years ago. As a similar statement was 
made in an editorial article in the Journal of the 
American Medical Association of August 17th, 1935, 
it is well to emphasise the fact that inoculation 
against measles was first carried out nearly two 
centuries ago by Frances Home (1719-1813), first 
professor of materia medica in Edinburgh, who is 
best known for his ‘‘ Inquiry into Nature, Cause, 
and Cure of the Croup ” (1765). In an article in his 
« Medical Facts and Experiments ” (1759), entitled 
Of the Measles as they appeared 1758 and of their 
Inoculation, Home wrote: ‘I thought that I should 
do no small service to mankind if I could render the 
disease more mild and safe in the same way as the 
Turks have taught us to mitigate the small-pox.”’ 
Home’s method was as follows : A superficial incision 
was made where the eruption of measles was thickest, 
and the blood was received on cotton-wool which 
was applied to incisions on both arms of the child 
to be protected and allowed to remain on three days. 
Of 12 children, aged from 7 months to 13 years, in 
whom this method was employed three had no rash 
at all and were regarded by Home as failures, though 
' we should probably regard them as examples of 
complete protection, while in nine the attack was 
much milder than usual. 

Home’s method was subsequently employed by 
observers in different countries with varying results. 
In 1789 Thomas Percival (‘‘ Essays Medical, Philo- 
sophical, and Experimental,’ 1789, ii., 69), after 
alluding to Home’s method, stated that “the mor- 
billous matter has since been ingrafted by means of 
lint wet with the tears from the eyes in the fresh 
stages of the disorder.” Percival however did not 
give any information as to the success of this experi- 
ment. Von Jürgensen (Nothnagel’s Encyclopædia 
of Practical Medicine, 1902, art. measles), who is 
sceptical as to the success of Home’s experiments, 
quotes Thomassen à Thuessink, who attended 
Home’s clinic in the Edinburgh Hospital in 1784-5, 
and failed to see the successful results described. 
According to Guersant and Blache (Dictionnaire de 
Médecine, 1832-1846, art. Rougeole) Home’s experi- 
ments were repeated at the Philadelphia Hospital 
in 1801 but without success, although trials were 
made with blood, tears, and nasal and bronchial 
mucus, and with a similar result by Locatelli. On 
the other hand, Prof. Speranza of Mantua (Jour. 
der pract. Heilk., 1827, lxiv., 124) in 1822 inoculated 
six boys and himself, aud a mild attack of measles 
resulted in each case. Home’s method, however, 
was carried out on the largest scale by a Hungarian 
physician, Michael von Katona (Österreich. med. 
Woch., 1842, No. 29, p. 697), who stated that during 
a malignant epidemic of measles he had successfully 
inoculated 1122 individuals, 7 per cent. escaped 
an attack altogether, and in the rest it was very 
mild. 

An interval of nearly 50 years elapsed between 
the publication of Katona’s paper and the appear- 
ance of another communication on the same subject. 
In a paper read before the Glasgow Medico-Chirur- 
gical Society on March 21st, 1890 (Glas. Med. Jour., 
1890, xxxiii., 420), entitled Inoculation, with sug- 


gestions for its further application in medicine, 
especially in mitigating the severity of measles, 
Dr. Hugh Thomson, vaccinator to the Faculty of 
Physicians and Surgeons, Glasgow, and to the Glasgow 
Royal Infirmary, after giving an account of Home’s, 
Speranza’s and Katona’s experiments, recorded his 
personal experience of two cases in which he employed 
Home’s method. As no eruption ensued, but only 
slight catarrhal symptoms, Thomson regarded his 
cases as failures, but like the three cases of Home 
previously mentioned they were probably examples 
of what would now be called an attenuated attack. 
Further information about Frances Home will be 
found in a paper (Proc. Roy. Soc. Med., 1927-8, xxi., 
1013) by his descendant the late Fleet-Surgeon 
W. E. Home, a frequent contributor to your columns. © 


I am, Sir, yours faithfully, 


J. D. ROLLESTON. 
London, S.W., Jan. lith. 


GASTRIC ACIDITY AND ITS SIGNIFICANCE 
To the Editor of THE LANCET 


Sir,—Prof. F. L. Apperly’s paper on gastric 
acidity in your issue of Jan. 4th is of great interest, 
but some of his conclusions to which you refer in 
your annotation are certainly erroneous. 


I have analysed the data obtained in a consecutive 
series of 41 anemic patients at New Lodge Clinic 
who had both a blood count and a test-meal in the 
few days preceding a transfusion. No less than 
33 secreted free hydrochloric acid, including 17 with 
acidity above normal. They included 21 cases of 
anemia following hemorrhage from an ulcer. Some 
of the others were cases of very chronic anzmia, 
including 1 of Hodgkin’s disease and 3 of aplastic 
anemia. In one patient with aplastic anemia, who 
has led a fairly active and comfortable life as a result 
of having about 250 transfusions in the course of eight 
years, hyperchlorhydria is still present, though his 
hemoglobin rarely exceeds 50 and has been as low 
as 26 per cent. In seven cases the hemoglobin per- 
centage was under 30, in six between 31 and 40, in 
nine between 41 and 50, in seven between 51 and 60, 
and in the remainder between 61 and 66—all having 
a degree of anæmia which, according to Prof. Apperly, 
should give rise to achlorhydria. 

Only 8 of the 41 patients had achlorhydria ; of 
these 3 had Addison’s anemia, 3 carcinoma of the 
stomach, 1 polyposis and carcinoma of the colon, 
and 1 microcytic anemia which appeared to be a 
sequel of achlorhydria following gastro-jejunostomy. 
Certainly in 6 and probably in all of these cases the 
achlorhydria preceded the development of the 
anemia. In an unselected series of 41 ansemic 
patients there was thus no single case which gives 
any support to Prof. Apperly’s statement that achlor- 
hydria is likely to result when the hemoglobin falls 
below 66 per cent. of the normal. 

Prof. Apperly suggests that it is necessary to dis- 
tinguish between achlorhydric anemia and his hypo- 
thetical anæmic achlorhydria, but I believe that all 
cases in which anemia is associated with achlor- 
hydria the anzemia is either a result of the gastritis, 
which also causes the achlorhydria as in Addison‘s 
anemia (Faber, Castle), or the, anemia is a result of 
deficient utilisation of the iron in the food owing to the 
achlorhydria or the associated enteritis (Faber, Witts). 
Prof. Apperly also suggests that asthma will be found 


THE LANCET] 


MATERNITY NURSES AND MIDWIVES 


(san. 18, 1936 169 


to raise the gastric acidity. But Glanvill and Cosin 
found that in 15 of my cases at Guy’s Hospital and 
52 at New Lodge Clinic curves below the average 
normal occurred 20 per cent. more frequently than 
among normal people, 12 per cent. having achlor- 
hydria. Marjorie Gillespie in a series of 109 asthmatic 
patients found that 51-5 per cent. had acidity below 
normal, compared with 19 per cent. of 2448 cases 
collected by Hartfall from New Lodge Clinic, and 
15-5 per cent. had achlorhydria. Low acidity is still 
more frequent among children; thus Bray found 
that 9 per cent. of 200 children had achlorhydria, 
48 per cent. hypochlorhydria, and 23 low normal 
curves, I am, Sir, yours faithfully, 

. ARTHUR F. HURST. 

New Lodge Clinic, Windsor Forest, Jan. 11th. 


MATERNITY NURSES AND MIDWIVES 
To the Editor of THE LANCET 


Srrz,—In your issue of Nov. 16th, 1935, appeared a 
letter from Dame Janet Campbell in which various 
problems connected with the proposed salaried mid- 
wifery service were offered for solution. Among 
these, the most urgent would seem to be: How are 
the competing claims of the medical student and 
pupil midwife for the use of clinical facilities to be 
reconciled ? When medical authorities are urged to 
improve the training in obstetrics of medical students, 
they invariably reply that the chief obstacle is the 
comparative scarcity of material, the cases which 
they so greatly need being absorbed by the training 
of over 3000 pupils annually, for the Central Mid- 
wives Board examination. Of these, more than 
50 per cent. do not propose to practise midwifery, 
and the experience to be gained by, at the lowest 
computation, 30,000 of these all-important maternity 
cases is being thrown away on candidates already 
dedicated to a totally different branch of service. 

A medical student and a pupil midwife may not 
count the same case in their obligatory roll of 20. 
This rule does not, for obvious reasons, apply to the 
training of maternity nurses. If, therefore, as Dame 
Janet suggests, England were to copy the example of 
Holland—already well ahead of her in this matter— 
and were to institute a registered service of maternity 
nurses, the legitimate aspirations of our hospital 
nurses, to learn how to care for mothers and their 
infants during and after childbirth, would be satisfied, 
and the gain to medical students and pupil midwives 
greater than is at present realised. Simultaneously, 
the training of the latter might with advantage be 
lengthened to a two years’ course—already current in 
many, if not most, European countries. This would 
automatically reduce the number of midwifery pupils 
to a very large extent, their place being taken in 
hospital wards by the pupil maternity nurses. 

In Holland maternity nurses who already possess 
State registration for general nursing are allowed to 
take a six months’ course, twelve months being 
prescribed for those without this qualification, and 
this has been proved to answer admirably. It is 
sometimes urged that the only way to abolish the 
dangerous “handy woman ” is to penalise the care 
of motherhood to all but certified midwives, but it 
is obvious that a class of registered maternity nurses 
would answer the same purpose, perhaps even more 
effectually. 


I am, Sir, yours faithfully, 


ALICE S. GREGORY, 


Hon. Secretary, British Hospital for Mothers 


Jan. 13th. and Babies, Woolwich. 


WHOOPING-COUGH AND VACCINE 
To the Editor of THE LANCET 


Sm,—I should like to thank Dr. Begg and Dr. 
Coveney for the way in which they have, in your 
issue of Jan. llth, set out the data of their vaccine 
treatment of whooping-cough. Sufficient details are 
given to enable the reader to criticise. Often enough 
no notes of dose or preparation of vaccine are given, 
so that when failures are reported, one is left wonder- 
ra oer it was indeed the vaccine which was at 
ault. 

Knowing nothing of the vaccine treatment of 
whooping-cough, I assume that it can be compared 
to that of any other disease of a mildly chronic type, 
a disease, moreover, which may begin acutely and 
then pass through a subacute stage. The authors 
of the above paper make the following statement : 
“ It is generally agreed that, if success is to follow 
vaccine therapy, the initial injections must be given 
early in the disease, large doses must be injected. . . .” 
Treatment along these lines is justified, as has been 
shown by W. H. Wynn (Brit. Med. Jour., Jan. 11th, 
1936) in his treatment of pneumonia, but large 
doses may only be given before the patient is sensitised 
to pneumococci, which, according to Wynn, begins 
to happen on the fourth or fifth day. On their own 
showing, however, the whooping-cough cases treated 
by Dr. Begg and his colleague had already reached 
the paroxysmal stage of the disease. In order to 
justify the large doses of vaccine used, it would be 
necessary to show that no specific antibodies had 
already been formed—i.e., that the cells had not 
become sensitised. In any case, the doses advocated 
by Wynn (60 to 600 million) are less than a twentieth 
of those given to the children (all under the age of ten). 

A few years ago I made some estimations of the 
dried weight of bacterial vaccine. Roughly 4000- 
5000 million dried coliforms weighed 1 mg., or 5000- 
6000 million streptococci or staphylococci. Probably 
the very small B. pertussis might run to higher figures, 
but certainly not more than 8000 million. Drs. Begg 
and Coveney in 14 days gave children doses up to 
2 mg. and, in all, the equivalent of 6 mg. of dried 
bacterial substance. Compare this with tuberculin, 
as Wynn aptly does in the paper quoted above; 
l c.cm. (containing 1 mg. ?) would not affect a normal 
child, but 0-000001 c.cm. might cause reaction in an 
infected person. Translated into terms of pertussis 
vaccine :— 


Eight thousand million to a normal person=reaction _ 
Hight thousand only to an infected person =reaction + 


Comparable too with tuberculosis is the vaccine 
treatment of chronic rheumatism. At the Charter- 
house Rheumatism Clinic, in order to minimise 


‘reaction, amounts varying from under 1000 up to 


about 200,000 organisms are given. This range of 
dosage was also recommended by the B.M.A. com- 
mittee on arthritis, when referring to my vaccine. 
For estimating dosage, perhaps we may assume that 
whooping-cough in the paroxysmal stage lies between 
the extreme of acute pneumonia on the one hand 
and chronic arthritis on the other. Optimum doses 
might reasonably be considered to range from (say) 
50,000 to 500,000 or one million. Drs. Begg and 
Coveney envisage a further investigation. Let them 
try such a range and use their present method as a 
control. 

To the unbiased reader the surprising thing is 
that the vaccine cases so closely approximated to the 
controls. Here must have supervened the mechanism 
which a merciful Providence seems to have provided 
whereby the reaction from a heroic dose of vaccine 


170 THE LANCET] 


ŒDEMA OF THE ANKLES AND AIR TRAVEL 


[gan. 18, 1936 


I I III aan 


can only be the maximum and that any bacterial 
substance in excess of the amount necessary to 
provoke this does no further harm, beyond perhaps 
immediately neutralising the antibodies produced. 
I am, Sir, yours faithfully, 
London, W., Jan. 13th. H. WARREN CROWE. 


THE UNDESCENDED TESTICLE 
To the Editor of THE LANCET 

Sır, —I have been discussing the question of 
medical and surgical undescended testicles with Dr. 
Spence and Dr. Scowen, and we have decided to 
break away from professional tradition and have a 
look at some of each other’s cases. I hope to convince 
them that the arguments on which I submit cases to 
operation are not entirely irrational, and that the 
results are much better than they imagine them 
to be. On the other hand, if they convert a case 
for which I should recommend operation into one for 
which I should not, I shall most willingly admit it 
as a postscript to their next report. : 

I am, Sir, yours faithfully, 
Queen Anne-street, W., Jan. 13th. DENIS BROWNE. 


A VASOVAGAL ATTACK 
To the Editor of THE LANCET 
Str,—I was interested in Dr. Gumpert’s note 
published in to-day’s issue of TUE LANCET because 
I recently had a similar experience. | 
A middle-aged patient was brought to me on 
Dec. 21st, 1935, by Mr. J. Ross McNeill, of Norbury, 
with a history of fainting attacks associated with 
bradycardia. Just as I was preparing to take a 
tracing he suddenly had a faint, and the electro- 
cardiogram, as in Dr. Gumpert’s case, showed a 
slow rhythm (40) with complete absence of P-waves. 
A second tracing taken about a quarter of an hour 
later showed a normal rhythm. 
I am, Sir, yours faithfully, 
Queen Anne-street, W., Jan. 11th. T. W. PRESTON. 
A BOOK REVIEW 
To the Editor of THE LANCET 
Sır, —I have read with much interest the review 
(THE Lancet, Nov. 23rd, 1935, p. 1183) of the new 
edition of Jelliffe and White and especially the 
remark that too great a proportion of the book has 
been given to the vegetative nervous system (supra- 
renals et al.) as compared with neurosurgery, for 
example, i.e., tumours of the spinal cord, radio- 
graphy, &c. Dr. White and I believe that suprarenal 
difficulties are strictly neurological problems ; especi- 
ally asthenic states are more frequent and important 


than spinal cord tumours, hence a greater space is 


given to them. One of our special problems was this 
statistical one of proportionate involvement of this 
or that organ or organic function—i.e., disease—and 
we have tried to follow such a balanced programme 


‘in our book. 


We think your reviewer distinctly in error when he 
says we give only “six words” to the subject of 
encephalography in the diagnosis of cerebral tumours, 
no doubt referring to the six words on p. 785. How 
about the 20 words on p. 778? and I might refer 
to a number of places throughout the book where 
Röntgen ray methods are emphasised. As this work 
ig not one on neurosurgery this type of special study 
is naturally only mentioned as desirable or necessary. 
The roentgenologist does most of the film interpreting 
for spinal cord tumours, brain tumours, &e. 

When further your reviewer states that “ subacute 
combined sclerosis ” is not clearly differentiated from 
a motley group of “ combined scleroses,”’ is this true ? 
And when he says it is ‘‘ mainly in the realm of recent 


developments in neurology that the shortcomings 
of the book are to be found,’ would it not have 
been of service and as evidence of good faith to 
mention some of these that are omitted ? 
I am, Sir, yours faithfully, 
New York, Dec. 20th, 1935. SMITH ELY JELLIFFE. 


ŒDEMA OF THE ANKLES AND AIR TRAVEL 
To the Editor of THE LANCET 

Sir,—On a recent visit to England by air I was 
rather startled to find that by the time we had 
reached Brindisi my ankles had become very 
edematous. I was feeling at the time particularly 
fit and there was no sign of any renal or cardiac 
mischief. On inquiring from my fellow travellers, 
I was relieved to find that the majority also had some 
degree of oedema of the ankles. Moreover, not all 
the passengers had started from Johannesburg. 
Some of them had joined up in British East Africa 
and the Soudan. The oedema passed off after the 
first few days in London, but on the return trip my 
ankles again became oedematous. Inquiry also 
showed that some of the other passengers again had 
edematous ankles. As quite a number of the 
passengers on the return trip were non-English 
speaking, it was difficult to- get percentages or details 
of their physical conditions. Several of the pilots 
whom I questioned informed me that their ankles 
did not become odematous. The most likely 
explanation for the œdema is that in the heat of 
the tropics the prolonged inactivity, with dependent 
position of the legs, causes stasis. 

I am, Sir, yours faithfully, 
Johannesburg, Dec. 29th, 1935. M. WEINBREN. 


INFIBULATION 
i To the Editor of THE LANCET 

Sır —I should like to add a little to what was 
written by Mr. John M. Melly in your issue of 
Nov. 30th, 1935, about female circumcision, under 
the title infibulation, which is very popular 
in Egypt, not less than 80 per cent. of our girls being 
submitted to it. No one can give a date when this 
habit started; but it is now so adhered to by all 
classes of Egyptians as to be regarded as shameful: 
to leave a girl uncircumcised. 

The operation is done usually by old women who 
have gained a wide experience through long practice. 
As Mr. Melly says, the girl is usually about the age 
of 7 years, but may be much older ; some are circum- 
cised just before marriage, others after they have 
given birth to their first child. The way in which 
it is done in Egypt seems to differ from that in Somali- 
land because here its only purpose is to lessen desire, 
not to create a physical obstruction to intercourse. 
Some, however, believe that it is a form of toilet to 
the external genitals. The clitoris and the labia 
minora are removed in one sweep of a razor, ethyl 
alcohol and sometimes brandy being used for asepsis 
before the operation and to secure hemostasis after- 
wards. No stitches are applied and no anesthetic 
is used. The girl’s legs are not bound together and 
the stump of each labium heals separately. Some- 
times cases are referred to hospital with severe 
bleeding from the dorsal artery of the clitoris, for 
which we ligature the stump of the clitoris; occa- 
sionally one meets with retention of urine, relieved 
by a hot hip bath. I have never seen any cases of 
sepsis. The raw surface mostly heals by first inten- 
tion ; if infection occurs, it must be very rare. , 

I am, Sir, yours faithfully, 
- B. GIRGIS, 


. House Surgeon, King Fouad Ist Children Hospital, 
Jan. 3rd. ; Cairo, Egypt. 


THE LANCET] 


THE VOLUNTARY HOSPITALS COMMISSION 


(san. 18, 1936 171 


TESTIMONIAL TO DR. ROWLAND 
FOTHERGILL 


| To the Editor of Toe LANCET © 


Sır —For over 33 years Dr. E. R. Fothergill has 
been prominent in British Medical Association affairs, 
and there are few members of the Association who 
are better known to those who take an interest in it. 
First in Wandsworth, then in Brighton, he has been 
an indefatigable local worker. For 22 years he 
has been a member of the representative body, for 
25 years ou the council, and for 22 years a repre- 
sentative on the panel conference. 

It is impossible in the limits of this letter to detail 
the extent and importance of Dr. Fothergill’s 
voluntary services to the medical profession through 
the Association, but his work on the Insurance Acts 
Committee and on the body which preceded it, and 
also on the Hospitals and Medico-Political Committees 
stands out pre-eminently. It was he who suggested 
and promoted the first conference of local medical 
and panel committees at Brighton in 1913, which 
led to the adoption by these committees of the British 
Medical Association as the body to which they should 
look for central organisation and support. His 
fertility of ideas, his persistence, and his loyalty to 
principle and to the interests of the Association have 
justly given him a unique position in it which was 
recognised in 1931 by his election as a vice-president. 
His advocacy at all times of the dignity and the rights 
of the medical practitioner is well known. 

In recent years he has been compelled by reasons 
of health to give up general practice, and this has 
severely strained his resources. ‘This seems to us 
therefore an appropriate time to give to the members 
of the profession an opportunity to mark in a tan- 
gible way their appreciation of Dr. Fothergill’s work, 
and of the sacrifices he has made in doing that work. 
We hope for a prompt and generous response to 
this appeal, not only from individuals but from local 
medical and panel committees. Subscriptions should 


be sent to the treasurer, Fothergill Testimonial Fund, — 


B.M.A. House, Tavistock-square, W.C.1. 
We are, Sir, yours faithfully, 


HELEN Boye (Hove) DAWSON OF PENN 

A. C. GEMMELL (Hove), (London), 

DonaLD Harr (Hove), J. D’Ewart (Manchester), 

H. NETHERSOLE FLETCHER W.McApbam ECCLES 
(Hove), (London), 

L. A. Parry (Hove), C. E. S. FLEMMING 

J. ARMSTRONG (Ballymena, (Bradford-on-Avon), 
Antrim), N. Bisnor HARMAN 


J. W. BıceER (Dublin), (London), 

R. A. Boram (Newcastle- C. O. HAWTHORNE 
on-Tyne), (London), 

J. W. Boxe (Luton), E. Kaye LE FLEMING 

H. B. BRACKENBURY .(Wimborne), 
(Hendon), EWEN MacLean (Cardiff), 

R. C. Buist (Dundee), HuMPHRY ROLLESTON 

A. H. BURGESS (Haslemere), 


H. S. Souttar (London), 
W. E. THomas (Ystrad- 
Rhondda). 


(Manchester). 
ALFRED Cox (London), 
H. G. Darn (Birmingham), 


Jan. 13th. 


ROYAL MEDICAL BENEVOLENT FUND SOCIETY OF 
IRELAND.—At ameeting of the Belfast and County Antrim 
branch of this society on Jan. 8th a unanimous resolution 
was passed expressing thanks to Dr. V. G. L. Fielden for his 
invaluable services as honorary secretary and treasurer 
for the past 28 years. Dr. Robert Marshall was appointed 
Dr. Fielden’s successor, and future subscriptions should 
be sent to him at 9, College-gardens, Belfast. 


or to 


THE VOLUNTARY HOSPITALS 
COMMISSION 


THE first meeting of the new commission was 
held on Wednesday at the headquarters of the 
British Hospitals Association with Lord Sankey 
presiding. It will be remembered that the appoint- 
ment of such a commission was resolved at the 
annual conference of the B.H.A., held at Leamington 
in June, 1935, with the instruction to consider the 
present position of the voluntary hospitals and to 
inquire whether recent legislative and social develop- 
ments had made it desirable. to take steps whether 
to promote their interests, to develop their policy, 
safeguard their future. The commission 
consists of the following ten members: Lord Cozens- 
Hardy ; Alderman Miss H. Bartleet, J.P.; Sir Henry 
Brackenbury, M.D.; Alderman Alan Davies, J.P.; 
Prof. L. S. Dudgeon, F.R.C.P.; Mr. H. L. H. Hill; 
Colonel D. J. Mackintosh, M.B.; Miss E. M. Musson, 
R.R.C.; Sir Reginald Poole; Prof. A. W. Sheen, 
F.R.C.S. It will be seen to be of a highly repre- 
sentative character, including experts on nursing, 
accountancy, and legal procedure, besides men and 
women who know the technique of hospital adminis- 
tration inside and’ out and who have been in touch 
with problems of amalgamation and association. 
Lord Cozens-Hardy has already done for Liverpool 
hospitals what it is now proposed to do for the 
hospitals of the country ; he found twenty different | 
hospitals with similar interests, but with no single 
body authorised to speak on behalf of them all; 
and the matter has been put right.. The problems 
have been well stated by Sir Charles Harris in the 
Nineteenth Century and After for May, 1935. In the 
general stocktaking of the position which is now 
necessary he instanced (1) the working relations 
which should exist between different units and 
especially the proper functions of the cottage hospital ; 
(2) the question of modifying the time-honoured 
principle of unpaid visiting staffs; (3) economy in 
hospital administration and better team-work in 
general, If the voluntary principle is to hold its 
ground it is necessary, he said, fur its adherents to 
demonstrate that in these as in national matters 
the intelligent codperation of free men can achieve 
better results than bureaucracy or any form of 
dictatorship, The conundrum of to-day is to create 
voluntarily a machinery for effective combined 
action before it is too late; for, as Prof. W. Blair- 
Bell pointed out in the September issue of the same 
journal, the extraordinarily rapid march of State 
service in five years leaves no doubt of the urgency 
of the matter. Any person or body desiring to give 
evidence before the commission should communicate 
with the secretary, Mr. R. H. P. Orde, at 12, Grosvenor- 
crescent, London, S.W. 1. 


IRELAND 


(FROM OUR OWN CORRESPONDENT) 


A “f PROTECTED ’? MEDICAL SERVICE 


Ir is stated that the Ministry of Home Affairs for 
Northern Ireland has issued a circular to local 
authorities intimating that medical practitioners 
who ın future seek positions as dispensary medical 
officers in Northern Ireland must be of British 
parentage, and must have at least five years’ resi- 
dential qualification in Great Britain or Northern 


172 THE LANCET] 


MEDICAL NEWS 


(yan. 18, 1936 


Ireland. From the newspaper reports it is not clear 
whether the Minister has framed a regulation to 
this effect, or has merely intimated that unless his 
wishes are met by the local authorities he will refuse 
his sanction to those whom they elect. Hitherto 
throughout the area of the British Isles—both before 
and since the establishment of the Irish Free State as 
a dominion—the appearance of the candidate’s name 
in the register of the appropriate area, without refer- 
ence to either birth or residence, has been the only 
qualification required for public appointments. The 
establishment of a medical register for the Irish 
Free State did not impose any bar, since any medical 
man holding British qualifications can enter his 


name on that register, and conversely anyone holding 
Irish Free State qualifications can enter his name on 
the register of the General Medical Council. As a 
matter of fact in recent years there must be very 
few medical men, other than those with local ties, 
who seek to enter the dispensary service in Northern 
Ireland as the service is less well paid than in the 
Irish Free State. It would be unfortunate if this 
decision were to give rise to retaliatory measures on 
the part of the Irish Free State. Many of the most 
capable officers in all branches of the public service 
in the Irish Free State are in fact natives of Northern 
Ireland, and particularly is this the case in the 
recently appointed public health service. 


MEDICAL NEWS 


Royal College of Surgeons of England 


A meeting of the council of the college was held on 
Jan. 9th with Sir Cuthbert Wallace, the president, in the 
chair, at which a report was received from the board of 
examiners in anatomy and physiology for the fellowship 
stating that, at the examination held in December, 228 
candidates were examined, of whom 70 were approved 
and 158 rejected, that the Hallett prize was awarded to 
Robert Sutherland Lawson, of the University of Mel- 
bourne. At the recent primary fellowship examination 
held in Calcutta, 54 candidates were examined, of whom 
12 were approved. 


It was reported that Mr. F. H. Bentley and Dr. David 
Slome had been elected Mackenzie-Mackinnon research 
fellows for one year. Mr. Hugh Lett was appointed 
Bradshaw lecturer for the year 1936, and Dr. George W. 
Corner, professor of anatomy in the University of Rochester, 
U.S.A., was appointed as the next Thomas Vicary lecturer. 
Mr. L. R. Braithwaite was elected representative of the 
college on the medical advisory committee of the British 
Health Resorts Association for one year, and Mr. Victor 
Bonney was re-elected representative on the Central 
Midwives Board. 


A diploma of fellowship was granted to Kenneth Christie 
Eden, of University College Hospital, and the following 
diplomas were granted Jointly with the Royal College of 
Physicians of London :— l 

Tropical Medicine and Hygiene: W. K. Cheng, Anastasio 
D’Souza, J. S. Gibson, Kalidas Mitra, and V. T. Vagh. 

Psychological Medicine: J. L. Bates, A. J. Galbraith, J. F. 
Galloway, 5. L. Last, S. A. Mackcith, W. H. McMenemey, 
K. R. Masani, J. A. Smeal, Alfred Torrie, Rosalind Vacher, 
and J. H. Watkin. 


Laryngology and Otology: B. T. Bernstein, G. B. Ludlam, 
R. F. J. Martin, Narayana Srinivasan, T. G. Swinburne, and 
W. E. Williams. 


The following hospitals were approved, with the posts 
specified, for the six months’ surgical practice required 
of candidates for the final fellowship examination : 

Warneford, Leamington, and South Warwickshire General 
Hospital, Leamington Spa (resident house surgeon till July 31st, 
1937); Manchester, Victoria Memorial Jewish Hospital (resident 
surgical ofiicer); Newcastle Hospital, New South Wales (resi- 
dent medical officer, 1 house surgeon, surgical registrar and 
superintendent); Southend-on-Sea General Hospital (surgical 
registrar, 2 house surgeons); Sunderland Royal Infirmary 
(resident medical officer, 4 house surgeons); the Royal Hospital, 


Wolverhampton (resident assistant surgeon, surgical registrar, 
and 3 house surgeons). 


Medical Research Scholarships 


The Grocers’ Company Scholarships.—To encourage 
original medical research the Grocers’ Company offer 
three scholarships, each of £300 a year. The next election 
will be held in May, but applications should be sent to 
the clerk, Grocers’ Hall, London, E C.2, before the end 
of April. 

Aldrich-Blake Travelling Scholarship.—The trustees of 
the Aldrich-Blake memorial fund will shortly award a 
travelling scholarship to a medical woman. Applications 
should be sent to the secretary of the trust, 8, Hunter- 
street, London, W.C. 


Further particulars of both these awards will be found 
in our advertisement columns. 


University of London 


At University College, on Mondays from Jan. 20th to 
Feb. 24th, Mr. H. R. Ing, Ph.D., will lecture on chemical 
structure and pharmacological action, and on Tuesdays, 
beginning on Jan. 2Ist, Mr. G. P. Wells will give ten 
lectures on comparative physiology. All the lectures 
will be at 5 P.M., and no ticket is needed. 


Prof. C. R. Harington, F.R.S., has been appointed 
acting director of the Charles Graham medical research 
laboratories at University College Hospital medical school, 
and Dr. A. M. H. Gray, chairman of the Graham 
Legacy committee. 


International Congress of Physical Medicine 


The sixth international congress of physical medicine 
will be held in London from May 12th to 16th. The 
meetings of the congress will be held under the following 
sections: kinesitherapy, physical education, hydro- 
therapy and climatotherapy, electrotherapy, actino- 
therapy, and radiotherapy and radium therapy. The hon. 
secretary of the British section is Dr. Albert Eidinow, 
4, Upper Wimpole-street, London, W. 1. 


London School of Hygiene 


A course of lectures on publie health, open to all medical 
practitioners, is in progress at the London School of 
Hygiene and Tropical Medicine, Keppel-street, W.C. 
At the next lecture, at 3 P.M. on Jan, 22nd, Dr. W. G. 
Savage will discuss bovine tuberculosis, and on Jan. 31st 
and Feb, 7th, at 11 a.m.,Mr. H. E. Magee, D.Sc., will speak 
on nutrition. Other subjects in the course are venereal 
disease (Col. L. W. Harrison, Feb. Sth, 10th, and 12th, at 
3 P.M.), infant feeding (Dr. A. G. Maitland-Jones, Feb. 14th, 
at 11 a.m.), food poisoning (Dr. W. G. Savage, Feb. 21st, 
at 11 a.m), shell-fish (Prof. J. W. H. Eyre, March 9th, at 
3 P.M.), and the marketing of fish and production of clean 
milk, 


Royal Medical Benevolent Fund 


This is the centenary year of the fund and a special 
appeal is being made for new subscribers to carry on the 
work and for donations. At a recent meeting of the 
committee 64 grants were voted amounting to £1329. 
The following particulars of a few of the cases helped 
indicate the kind of work undertaken. 


Daughter, aged 73, of M.R.C.S. She has lived for many 
years in Italy lecturing and acting as guide to English visitors 
in Rome. Owing to the prospect of there being less Work in 
the future she has decided to leave Italy. On ber arrival in 
England she will have only £70 per annum to live on. Fund 
voted her an allowance of £36 per annum. 

Daughter. aged 52, of M.R.C.S., who used to look after her 
mother, aged 87, who is also a beneficiary of the fund, and take 
paying guests ; owing to a recent breakdown in healthis unable 
to continue this work. The fund by contributing £638 (of which 
£26 is an allowance to the daughter) has raised the income of 
these two ladies to £137 per annum, f ; 

Daughter, aged 79, of a naval surgeon, maintained herself 
until eight years ago in the nursing profession. She then joined 
her sister and was able to manage till her sister’s death recently. 
Although now living rent free this lady has only the old age 
pension of 10s. a week. The fund voted an allowance of £36 
and will consider what further help may be needed. 


Cheques should be addressed to the honorary treasurer, 
of the fund, 11, Chandos-street, Cavendish-square, 
London, W.1. 


THE LANCET] 


Scottish Board of Control 


Dr. Francis Sutherland has been appointed a deputy 
commissioner of the General Board of Control for Scotland. 


National Hospital for Diseases of the Heart 


A course of lectures, open to members of the medical 
profession, without fee, will be given at this hospital at 
5.30 P.M. on Tuesdays from Feb. 4th to April 28th. The 
lecturers and their subjects will be announced weekly in 
our Medical Diary. 


Conference on Social Work 


The third International Conference on Social Work 
will be held at Bedford College, Regent’s Park, London, 
N.W., from July 12th to 18th. The general subject of 
the meeting is social work and the community. Dr. 
René Sand, counsellor of the League of Red Cross Societies, 
is president of the executive board of the permanent 
committee, and Dr. Ralph Crowley, formerly senior medical 
officer of the Board of Education for England and Wales, 
is chairman of the advisory committee in Great Britain. 
The secretary-general is Mr. Alexander Farquharson, 
Le Play House, 35, Gordon-square, London, W.C.1. . 


Fellowship of Medicine and Post-Graduate Medical 

Association 

The following courses will be given in February: in 
proctology at the St. Mark’s Hospital (Feb. 3rd to 8th) ; 
in neurology at the West End Hospital for Nervous 
Diseases (Feb. 3rd to 8th) ; in chest diseases at the Bromp- 
ton Hospital (Feb. 10th to 15th); and in gynecology at 
the Chelsea Hospital for Women (Feb. 10th to 22nd). A 
week-end course in physical medicine will take place at 
the St. John Clinic and Institute for Physical Medicine 
(Feb. 8th and 9th) and in children’s diseases at the Princess 
Elizabeth Hospital (Feb. 22nd and 23rd). A series of 
lecture-demonstrations in anatomy and physiology, speci- 
ally intended for F.R.C.S. (primary) candidates, will be 
given at the Infants Hospital at 8 p.m. on Mondays, 
Wednesdays, and Fridays from Feb. 24th to April 24th. 
For further particulars application should be made to 
the secretary of the fellowship, 1, Wimpole-street, London, 
W.1. 


Births, Marriages, and Deaths 


BIRTHS 


BricG.—On Jan. 10th, at ay Dae ae Norton, the wife of D. A. 
Brigg, M.B., B.S. Lond., of a 

MARSHALL.—On "Dec. 29th, 1933, at "Sheffield, the wife of Dr. 
G. G. Marshall, of a son. 

SHERIDAN.—On Jan. lst, at Greenock, Scotland, the wife of 
Captain A. M. Sheridan, I.M.S., of a son. 

Witcox.—On Jan. 5th, at Lilongwe, Nyasaland, the wife of 
Dr. R. N. Wilcox, of @& son. 


MARRIAGES 


MORRAH—DAY.—On Jan. 9th, at All Saints’, Foots Cray, 
Michael C. M. Morrah, only son of the late Major J. H. 
Morrah, The King’s Own Regiment, to Catherine Day, 
M.B., B. S. Lond., of Sidcup, Kent. 

OLIVER— MICHIE. —On Jan. dtu, at St. Andrew’s, Frognal, 
N.W., Surg.-Licut. John Widdicombe Oliver, R.N., to 
Isobel Margaret, elder daughter of Mr. Charles E. Michie 
Finchley, N. 

SPRIGGS—M ACINTOSH.— On Jan. 14th, at St. John’s Parish 
Church, Perth, Sir Edmund Spriggs, K.C.V.O D., 
F.R.C. P., to Miss J. M. D Tntochi eldest daunt of the 
late William MacIntosh, M.V.O., and Mrs. MacIntosh. 
The Old Farsonaga, Dunning, Perthshire. 

WILLIAMSON 10th, at the Chapel of the 
Savoy, Bruce Williamson, M. D. Edin., to Margaret, only 
daughter of the late William Gibson and Mrs. Gibson, 


Egerton-terrace, S.W. 
DEATHS 


BaLri.—On Jan. 7th, the result of a motor accident, Dr. Norman 
Dryer Ball, younger son of the late James Dy er Ball, of 
Hong- Kong, and husband of Dr. Doris Bell Ball. 

CantTi.—On Jan. 7th, at Hampstead, Ronald George Canti, 


M.D. Camb., aged 52. 
1935, Walter Fisher, M.R.C.S. 


FisHer.—On. Dec. 30th, 
Eng., of Kaletie Hil, N. Rhodesia, ror 46 years a medical 
Perthshire, 
R.N. 


missionary in Central Africa, aged 

MATTHEW. —On Jan. llth, at Craigmakerran, 

Charles Geekie Matthew, M.B. Edin., Surg.-Capt. 
(retired). 

SAUNDERS.—On Jan. 12th, at Pembroke Dock, Edward Argent 
Saunders, M.R.C.S. Eng., M.O. and school medical 
otticer. Borough of Pembroke, aged 50. 

WYLIE.—On Jan. 7th, at a nursing-home, E David 
Thomas Wylie, M. D. Durh., of Oxford, aged 73 


N.B.—A fee of 18. 6d. is charged for the insertion of Notices of 
Births, Marriages, and Deaths. 


BIRTHS, MARRIAGES, AND DEATHS.—THE SERVICES 


[yan. 18, 1936 173 


THE SERVICES 


ROYAL NAVAL MEDICAL SERVICE 


' Surg. Comdr. A. G. Bee to Defiance. 

Surg. Lt.-Cmdr. J. G. Holmes to President for course. 

Surg. Lt.-Cmdr. (D.) A. A. Gardner to Drake for R.N.B. 

Surg. Lts. J. L. S. Steele-Perkins to Victory for R.N.B., 
N. S. Hepburn to Gannet, T. McCarthy to Furious, D. W. 
Walker to Pembroke for R.M. Infirmary, Deal, M. A. 
Rugg-Gunn to Pembroke for R.N. Hosp., Chatham, and 
T. F. Crean to Pembroke for R.N.B. 

Surg. Lt. (D.) W. G. Finnie to Ganges. 

Appointments as Admiralty Surgeon and Agent: 
Mr. J. M. Stuart, Ilford ; Mr. A. S. Addison, M.C., Harrow ; 
Mr. J. A. Edward, Barking ; Mr. J. R. Buchanan, Watford ; 
Mr. R. Vincent Howell, Bournemouth; and Mr. P. N. 
Grinling, Sheffield. 


ROYAL ARMY MEDICAL CORPS 

Major-Gen. O. L. Robinson, C.B., C.M.G., Colonel 
Commandant, R.A.M.C., will be Representative Colonel 
Commandant during 1936. 

Short Servico Commissions: Lts. R. H. Wheeler and 
J. J. C. Rainsbury to be Capts. 

ARMY DENTAL CORPS 

The name of Capt. O. E. Howell is as now described and 
not as shown in the London Gazette of Dec. 27th, 1935 
(vide THE LANCET, Jan. 4th, 1936, p. 42). 

TERRITORIAL ARMY 

Hon. Maj.-Gen. Sir Cuthbert S. Wallace, K.C.M.G., 
C.B., relinquishes the appt. of Hon. Col. R.A.M.C. Units, 
47th (2nd Lond.) Div. 

Lt.-Col. and Bt. Col. A. R. Laurie, from Gen. List, 
R.A.M.C., to be Col., and is apptd. A.D.M.S., 46th 
(N. Midland) Div., vice Col. F. G. Lescher, M.C., vacated. 

Maj. T. E. A. Carr to be Lt.-Col. and to comd. the 
137th (N. Midland) Fd. Amb., vice Lt.-Col. and Bt. Col. 
A. R. Laurie, vacated. 

Capts. R. Pollok and H. S. Ward to be Majs. 

M. K. Braybrooke to be Lt. 

Supernumerary for Service with O.T.C. : Lts. L. C. 
Bousfield and N. Heath (empld. Univ. of Lond. Contgt. 
(Med. Unit), Sen. Div., O.T.C.) to be Capts. 


ROYAL AIR FORCE 

Squadron Leader T. J. X. Canton to No. 1 Flying 
Training School, Leuchars, for duty as medical officer. 

Flight Lt. H. C. S. Pimblett to R.A.F. Hospital, Cranwell. 

Flying Officer J. B. Wallace to No. 10 Flying Training 
School, Ternhill. 

INDIAN MEDICAL SERVICE 

Majs. to be Lt.-Cols.: C. M. Nicol and D. R. Thomas, 

B.E. 


O.B 
To be Lts. (on prob.): W. McN. Niblock, H. J. 
Gibson, P. A. Hubbard, T. P. Mulcahy, F. E. McLaughlin, 
and E. H. Wallace. 
The undermentioned have vacated appts. in India :— 
A.D.M.S.—Col. E. C. Hodgson, D.S.O., K.H.P., I.M.S. 
D.A.D.P.—Capt. J. R. Dogra, M.D., LM.S. 
The undermentioned appts. have been made in India :— 
A.D.M.S.—Col. R. P. Lewis, D.S.O., Brit. Serv. 
D.A.D.P.—Capt. S. S. Bhatnagar, M.D., I.M.S. 
Col. A. C. Amy, D.S.O., is vacating the appointment of 
Deputy-Director of Hygiene and Pathology at Army H.Q., 
and proceeds on eight months’ leave from Feb. 17th. 


DEATHS IN THE SERVICES 
The death occurred on Jan. llth, at Craigmakerran, 
Perthshire, of Surg.-Captain CHARLES GEEKIE MATTHEW, 
R.N., retired. He qualified M.B., C.M. Edin., 1885, and 
was then for a time in the P. and O. Steam Navigation 
Company’s service at Edinburgh, later joining the Royal 
Navy. As surgeon of Sparrow he was present on 
August 27th, 1896, at the bombardment and capture by 
Rear-Admiral H. H. Rawson’s squadron of the Sultan of 
Zanzibar’s palace which had been seized by Seyyid Khaled. 
He became Surg.-Commander in 1905, and Surg.-Captain 

in 1918, after his retirement from the Service. 


Sir James Purves-Stewart has been elected an 
honorary member of the New York Neurological Society. 


174 THE LANCET] 


MEDICAL DIARY.—APPOINTMENTS 


[JAN. 18, 1936 


Medical Diary 


SOCIETIES 
ROYAL SOCIETY OF MEDICINE, 1, Wimpole-strect, W. 


TUESDAY, Jan. 21st. 
5.30 P.M. Ballot for Election 


General Meeting of Fellows. 
to the Fellowship. 
WEDNESDAY. 
Comparative Medicine. 5 P.M. Dr. G. Marsball Findlay 
and Mr. I. A. Galloway: The Routes of Infection 
aud Paths of Transmission of Viruses. 


THURSDAY, 

Urology. 8.30 P.M. Dr. J. Leon Jona: The Kidney, 
Pelvis—its Normal and Pathological Phy siology (cine- 
matograph). 

FRIDAY. 

Disease in Children. 5 P.M. (Cases at 4.30 P.M.) Dr. 

E. P. Poulton and Mr. T. W. Adams; Metabolism, 


General Nutrition, and Growth in Infancy and Child- 
hood. Dr. W. 5. C. Copeman: 1 and 2. Still’s Disease 
Cured by Gold Injections. Mr. David Levi: 3. Addi- 
tional Prehensile Big Toes. Mr. H. J. Seddon: 4. 
Auiyloid Disease Secondary to Bone Tuberculosis. 
Dr. Bernard Schlesinger and Dr. Annie Flew: 5. Arach- 
hodactyly. Dr. E. A. Cockayne and Dr. G. H. Newns: 

6. Speciinens from a Case of Schiller-Christian Syn- 
drome. Dr. R. Wilon (for Dr. R. Lightwood): 


T. Ptyalism. 
Epidemiology and State Medicine. 8.15 P.M. Dr. H. J. 
Stallybrass, Dr. J. D. Rolleston, and 


Parish, Dr. C. O. 
Surgeon- Capt. S5. F. Dudley: Use and Abuse of the 
Swab in Combating Diphtheria. 
Physicial Medicine. 8.30 P.M. Dr. Douglas A. Robert- 
son: The Cathode Ray Oscillograph Applied to Bio- 
electric Problems. 
EUGENICS SOCIETY. 

TUESDAY, Jan. 21st.—5.15 P.M. (the Rooms of tbe Linnean 
Socicty, Burlington House, Piceadilly, W.) Dr. 8. 
Zuckerman: The Physiology of Fertility in Man 

and Monkey. 
MEDICO- LEGAL SOCIE TY. 

THURSDAY, Jan. 23rd.—8.30 P.M. (Manson Tlouse, 26, 
Portland- -place, W.), Mr. J. B. Montagu: The Develop- 
ment in Criminal Law and Penology since 1910. 

CHELSEA CLINICAL SOCIETY. 

TUESDAY, Jan. 21st.—8.30 P.M. (Hotel Rembrandt, Thurloe- 

place, S.W.), Sir Harold Gillies: Plastic Surgery. 
HUNTERIAN SOCIETY, 

MONDAY, Jan, 2Uth.—9 P.M. (Mansion House, E.C.), Dr. 
sven Ingvar: The Physical Basis of Psychoncurosis 
(Hunterian lecture. ) 

ASSOCIATION OF INDUSTRIAL: MEDICAL OFFICERS. 

FRIDAY, Jan. 24th.—5.15 P.M. (London School of Hygiene 
and Tropical Medicine, Keppel-street, W.C.), Air Vice- 


Marshal Sir David Munro: Physical Standards in 
Industry. 
SATURDAY.—10 A.M., Dr. T. O. Garland: The Relation 


between the Industrial Medical Officer and the General 
Practitioner. 
BRITISH PSYCHOLOGICAL SOCIETY. 
WEDNESDAY, Jan. 22nd.—8.30 P.M. (11, Chandos-strect, 
W.) Dr. Sylvia Payne: Post-war Social Activities 
and Advances in Psychotherapy. (Medical Section.) 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 


ROYAL COLLEGE OF SURGEONS OF ENGLAND, Lincoln’s 
Inn-fields, W.C. 

Monbay, Jan, 20th.—5 P.M., Dr. E. W. Twining: A Radio- 
logical Study of the Third Ventricle. 

WEDNESDAY, —5 P.M.. Mr. Arthur Bullecid: The Assess- 
ment of Dental Sepsis as a Factor Affecting Medical 
and Surgical Procedures. 

FRIDAY. .M., Mr. John Gilmour: Adolescent Defor- 
mities of the Acetabulumi. 

UNIVERSITY OF LONDON. 

MoNpay, Jan. 20th.—5 P.M. (University College, Gewer- 
street, W.C.), Mr. H. R. Ing, Ph.D.: Chemical Struc- 
ture ‘and Pharmacological Action. (dirst of six 


lectures. a) 
TUESDAY.—5 P.M., Mr. G. P. Wells: 
(First of ten lectures.) 


logy. 
(London School of Wygiene and 


Comparative Physio- 


WEDNESDAY.—3 P.M. 
Tropical Medicine, Keppel-street, W.C.), Dr. W. G. 
Savage: Bovine Tuberculosis. 

WEST LONDON HOSPITAL POST-GRADUATE COLLEGE, 
Hanimersimith, W. 
MONDAY, Jan. 20th.—10 A.M., skin clinic, medical wards. 
1 A.M., surgical wards. 2 P.M., surgical and pynieco- 
logical wards, gynecological and eye clinics. 

TURSDAY.—10 A.M., medical wards. 11 A.M., surgical 
wards. 2 Pa throat clinic. 4.15 P.M., Dr. Scott 
Pinchin: The Development aud Diagnosis of Pul- 
monary Tuberculosis. 

WEDNESDAY.—L10 A.M., children’s wards and clinice, medical 
wards. 2 P.M., eye clinic. 4.15 P.M., Mr. J. K. Hasler: 
Anesthesia, g 

THURSDAY.—10 A.M., neurological and gynæcological 
clinics. Noon, fracture clinic. 2 P.M., cye and genito- 
urinary clinics. 4 P.M., venereal diseases, 

FribDAY.—10 A.M., skin clinic. Noon, lecture on treatment. 
2 P.M., throat clinic. 

SATURDAY. —10 A.M., children’s and surgical clinics, medical 
wards, 

The lectures at 4.15 P.M. arc 
tioners without fee. 

Operations, īmncdical and surgical clinies daily at 2 P.M. 


open to all medical practi- 


NATIONAL COUNCIL FOR MENTAL HYGIENE. 
THURSDAY, Jan. 23rd, to SaTURDAY.—Fourth Biennial 
Conference on Mental Health at the Central Hall, 
Westminster, S.W. 
HOSPITAL FOR SICK CHILDREN, Great Ormond-street, 


W.C. 

WEDNESDAY, Jan. 22nd.—2 P.M., Dr. E. A. Cockayne: 
Pneumonia. 3 P.M., Dr. D. N. Nabarro : The Bacterio- 
logy of Acute Pulmonary Diseases. 

Out-patient Clinics daily at 10 A.M. and ward visits (except 
on Wednesday) at 2 P.M. 

HO SROS SCHOOL OF DERMATOLOGY, 5, Lisle-street, 

TUESDAY, Jan, 21st.—5 P.M., Dr. R. T. Brain : Erythemato- 
squamous Eruptions. 

THURSDAY.—5 P.M., Dr. L. Forman: Sycosis. 

an FOR EPILEPSY AND PARALYSIS, Maida 
ale, ; 

THURSDAY, Jan. 23rd.—3 P.M., Dr. Golla : Demonstration. 

ST. JOHN CLINIC, Ranelagh- road, S.W. 

FRIDAY, Jan. 24th.—4.30 P.M. . Mr. A. G. Timbrell-Fisher : 

Manipulative Methods in Physical Medicine. 
FELLOWSHIP OF MEDICINE AND POST-GRADUATE 
MEDICAL ASSOCIATION, 1, Wimpole-street, W. 

MONDAY, Jan. 20th, to SATURDAY, Jan. 25th.—ST. JOHN’S 
HOSPITAL, 5, Lisle- street, W iC. Afternoon course in 
dermatology (open to non-members).— NATIONAL 
HosrITAL FOR DISEASES OF THE HEART, Westmor- 
Jand-street, W. <AJl-day course in cardiology (open to 
non-members ;).— ST. PETER’S HOSPITAL, Henrietta- 
street, W.C. All-day course in urology.—NATIONAL 
TEMPERANCE HospiTaL, Hampstead-road, N.W. Tues., 
8.30 P.M., Mr. C. A. Joll: Thyroid. Thurs., 8.30 P.M., 
Mr. R. C Brock: Injuries to Bones. 

Courses arranged by the Fellowship are open only to 
members, 

LEEDS GENERAL INFIRMARY. 

TUESDAY, Jan. 21st. —3.30 P.M., Mr. Black: Ocular Com- 

plications of Some General Conditions, 
LEEDS PUBLIC DISPENSARY AND HOSPITAL. 


WEDNESDAY, Jan. 22nd.—4 P.M., Dr. H. H. Moll: Chronic 
Bronchitis. $ 
UNIVERSITY OF DURHAM. 
SUNDAY, Jan. 26th.—10.30 A.M. (Newcastle General 


Hospital), Mr. T. Clav : Surgical Cases of Interest. 
GLASGOW POST-GRADUATE ASSOCIATION. 
WEDNESDAY, Jan. 22nd.—4.15 P.M. (Royal Infirmary), 
Dr. Jobn Henderson: Hypertension and Nephritis. 


Appointments 


Buack, J. I. MUNRO, M.B. Durh., F.R.C.S. Eng., has been 
appointed Assistant Radiwn Ollicer to the Neweastle- 
upon-Tyne National Radium Centre. 

BLAIKLEY, J. B., M.B. Lond., F.R.C.s. Eng., M.C.0.G., Surgeon 
to Out- -patients at the Chelsea Hospital for Women. 

Brewis, B. G., M.D. Durh., M.R.C.P. Lond., D.P.H., Assistant 
Maternity and Child Welfare Medical Otlicer for Newcastle- 
upon-Tyne. 

BRIDGEMAN, G. J. O., M.B. Camb., F.R.C.S. Eng., Hon. Assis- 
tant Surgeon to the Western Ophthalmic Hospital, London. 

COLEMAN, N. M., M.R.C.S. Eng., D.P.M., Deputy Medical 
Superintendent of Renwell Hospital, E ŠSex. 

EVANS, GEOFFREY, M.D. Camb., F.R.C.P. Lond., Physician 
to St. Bartholomew's Hospital, London. 

KEON-COHEN, B. T., M.B. Melb.. F.R.C.S. Eng., Resident 
Surgical Ojlieer at the Robert Jones and Agnes Hunt 
Orthopiedic Hospital, Oswestry. 

LUKE, J. C., M.D. Montreal, FRCS. Eng., Resident Surgical 
Otlicer at the Hudderstield Royal Intirmary. 

OLIVER, L. C., F.R.C.S. Eng.. Resident Surgical Officer and 
Registrar to the Bristol General Hospital. 

ROBERTS, G. J., M.D. Edin.. D.P.H., Deputy County Medical 
Otlicer of Health’ and Deputy School Medical Officer for 
the county of Denbigh. 

SUANKS, HELENA, M.B. Glasg., D.P.H., Assistant Medical 
Otlicer of Health (Maternity ‘and C hild Welfare) for Walsall. 

TATHAM, R. C., FRCS. Eng., Resident Surgical Ollicer at the 
Hull Royal Intirmary. 

WILLIAMS, BRYAN, M.D., F.R.C.S. Edin., M.C.O.G., Senior 
Resident Assistant Medical Otlicer (Obstetrical and Gynwco- 
logical) at the Walton Hospital, Liverpool. 

WITHERS, A., M.R.C.S. bug., D.P.H., D.M.R. C., Chief Assistant 
to the N Ray Diagnostic Department, St. Bartholomew ’s 
Hospital, London. 

New Queen Victoria Cottage Hospital, East Grinstead.—The 
following appointments are announced :— 

ROWNTREE, CEOIL, M.B. Lond., F.R.C.S. Eng.. Surgeon ; 
SCoTT-BROWN, W. G., M.D. Edin., F.R.C.S. Eng., Surgeon 
to the Kar, Nose, and Throat Department ; 


GARDINER-LEILL, H., M.D. Camb., F.R.C.P. Lond., Phy- 
sician; and 

FRANKLIN, JOUN, M.D. Camb., M.R.C.P. Lond., Derma- 
tologist. 


Certifying Surgeons under the Factory and Workshop Acts: 
Dr. W. A, LocHIEAD (Bingley District, York, West Riding); 
Dr. K. M. McCracken (Kelso District, Roxburgh); Dr, 
A, M. McMaster (Rochdale District, ’ Lancashire) : Dr. 
S. L. SMITH (St. Annes-on-the-Sca District, Lancashire); 
and Dr. S5. Wirson (Rochford District, Essex); Dr. 
ISOBEL C. ARMSTRONG (Kirkintilloch, Dumbarton); Dr. 
R. D. BRIDGER (Biggleswade, Bedford). 

Medical Referee under the Workmen’s Compensation Act, 
1925: Dr. R. W. WILLCOCKS, for the Braintree, Brent- 
wood, Chelmsford, Colchester, Clacton and Halstead, 
Harwich and Maldon County Court Districts (Circuit 
No. 33). 


THE LANCET 


NOTES, COMMENTS, AND ABSTRACTS 


S 


[JaN. 18, 1936 175 


THE PRESENT POSITION OF 
MEDICAL PSYCHOLOGY * 


By R. MACDONALD LADELL, M.B. Vict. 


LATE MEDICAL OFFICER, MINISTRY OF PENSIONS NEUROLOGICAL 
CLINIC, BIRMINGHAM, AND NEUROLOGIST, 
HOLLYMOOR HOSPITAL 


THIRTY years ago when I first read a paper on the 
problem of hysteria and its treatment by hypnotic 
suggestion, I had the feeling that it was scarcely 
respectable to spend time on imaginary ailments, 
or in such an apparently unscientific method of 
treatment. When Freud brought forward his theory 
of a dynamic unconscious and showed that the 
symptoms of a neurosis were the expression of a 
compromise between two conflicting mental trends 
and that they therefore had a meaning to the patient, 
I felt myself to be on more solid scientific ground. 
I still, however, had the feeling of being on the wrong 
side of the fence, since the acceptance of Freud’s 
theories involved a consideration of the sex instinct 
both in the child and in the adult. One had to 
overcome one’s own resistances before one could 
manage to look upon sex in a perfectly objective 
way, and those who did not succeed in this were 
apt to think of one as nasty-minded. 

Since then the Great War, in providing an outlet 
for primitive hate and aggression, inevitably broke 
down our taboos, and sex expression both in word and 
deed broke through all artificial restraints, and it 
has been found impossible. to replace Jack in his 
Box. Sex is universally recognised as one of the 
great driving forces of human nature, and one which 
can legitimately be studied. Then, too, the problem 
of the war neuroses brought medical psychology 
from its mystic cave into the full glare of publicity. 
Psychology became an important part of our national 
defences and could no longer be ignored. It was 
upsetting to those who conceived of illness as 
necessarily due to some organic lesion, to find that 
men could be blind, deaf, dumb, or paralysed, 
through purely mental processes; but the fact 
that they could be cured by purely mental processes 
proved that this was so. Materialistic medicine 
which tended to regard illness as something which 
could be studied in terms of somatic changes only, 
has never recovered from the shock. It is now 
realised that whatever the nature of the illness, one 
is not dealing with disease of the mind or the body, 
but that mind and body always interact, so that the 
mentality of the patient allects the course and 
symptoms of disease. 


Interaction of Mind and Body | 


The discovery of X rays, radium, and light therapy 
has accustomed men’s minds to the idea that matter, 
both organic and inorganic, can be altered by powerful 
agents which are normally unsuspected by our five 
senses. Indeed, under the analysis of the physicist, 
matter itself is seen to be nothing but a balance of 
electric forces ‘and the distinction between organic 
and inorganic is being broken down. One is therefore 
no longer afraid of being regarded as a superstitious 
quack when one suggests that the mind plays a part 
in all disease and even that the mind may initiate 
disease. To do so is not to deny the verm theory 
of disease, but merely to draw attention from the 


*A paper read at the Midland Medical Socicty on Dec. 18th, 1935. 


seed to the soil. The study of the endocrine glands 
has revealed to us the profound influence these have 
on the chemistry and metabolism of the body, and 
we know, moreover, that the lever they respond to 
is the emotional situation. 

We are therefore well on the way to understanding 
how worry and anxiety, which mean chronic fear, 
may break down the natural defences of the body 
and provide a suitable breeding-ground for hostile 
micro-organisms, or possibly change the nature 
of the micro-organism itself from benign to hostile. 
What is true of overt fear and anxiety is just as 
true of emotional states which have been repressed 
into the unconscious and since such repressions 
mostly take place in infancy and childhood, it follows 
that the happy child is likely to be a healthy child 
and vice versa. One need not evoke the œdipus 
complex in order to explain the delicate child. 
Usually he is the product of fussy parents whose 
anxiety as to health is reflected in a constant series 
of prohibitions which not only rob the youngster 
of its natural spontaneity and joy of life, but fill 
its mind with fear which finds danger all around. 
We can see the adult product in the health enthusiast 
who is always seeking health but never finding it. 
He believes he is cultivating health, but it is illness 
which dominates his mind. Health, as a natural 
state of things, is unknown to him; he believes it 
can only be found by taking thought and running 
after strange doctrines. His anxiety betrays him 
and he falls a ready victim to illness under circum- 
stances which would leave his care-free neighbour 
immune. 


Responsibility of the Family Doctor 


This conception of health throws the responsibility 
of the medical profession further and further back. 
The family doctor must see himself as the real medical 
officer of health and not simply a healer. Prevention 
from the beginning should be his aim, and so I 
contend that his training should be directed to that 
end, and that his status in the profession should 
be in the topmost notch. Early in his career the 
student should undergo vocational tests to find out 
if he has the natural abilities for such an onerous 
and distinguished responsibility as general practice. 
If not, he should be allowed to concentrate on one 
of the numerous specialties which are more of the 
nature of pure science, whilst the embryo general 
practitioner should be relieved of much of the exact 
knowledge of technique in examination and treat- 
ment which now crowd his curriculum, leaving the 
field clear for a study of child psychology and sociology 
without which he will find himself ill-equipped. 
To advocate that specialists should be trained from 
the beginning ad-hoc is not to deny my thesis that 
in illness it is the whole individual who must be 
considered and not a part. A woman’s aphonia 
may be due to some conflict in her sex or domestic 
life, but if the G.P. discovers it to be due to a growth 
on the vocal cords the actual job of removing it Is 
not his business. Similarly there are many other 
procedures in radiology, electrotherapeutics, chemistry 
of the blood and secretions, which it is enough for 
him to know of, without himself being able to carry out. 

Naturally I do not propose to abolish the specialist 
medical psychologist, but his work would be halved 
and the remainder made easier if the family doctor 
had the knowledge required and used his authority 
to procure the right environmental influences for 
the child from the start. There are mothers who 


176 


should never be allowed to suckle their children, 
since their nervous handling provokes fear at the 
outset. There are the fussy parents who implant 
dread of illness. The ultra-scientific parents whose 
science swallows up their common sense and makes 
life appear a dangerous burden; the authoritative 
whose “do not do this” render the child afraid of 
any natural form of activity ; the possessive mother 
who sees in the child something to minister to her 
own ego and never lets it grow away from her. The 
general practitioner should be able to detect and deal 
with all these obvious causes of maladjustment, 
and he should certainly take as his province the 
field of sexology so as to be able to give advice to 
those who are married, those who intend to marry, 
and those who want to get married but cannot. The 
doctor should be consulted, too, on the selection of 
suitable schools and should be able to give his views 
for or against co-education in any given case. 


THE LANCET] 


Problems for the Specialist 


Although by these means it would be possible to 
cut down the supply of ill-adjusted individuals 
from the source, many would still slip through the 
net and, at one stage or another, provide a problem 
for the specialist. Every practitioner should be 
something of a psychologist, but few have the 
knowledge or leisure to deal with a patient on psycho- 
analytic lines. Psycho-analysis is essentially a 
technique for overcoming mental resistances so 
that tendencies and conflicts which have become 
unconscious but which still exert an influence are 
made conscious. Actually the term psycho-analyst 
should be restricted to those who agree to adhere 
strictly to the methods of technique and interpreta- 
tion initiated by Freud. Their numbers are very 
few in this country. The majority of practising 
psychologists whilst realising that Freud’s. doctrine 
of a dynamic unconscious with its corollary of 
repressions and resistances must remain the funda- 
mental conception in dealing with neurotics, have 
nevertheless allowed themselves some modification 
of technique and interpretation based on their 
experiences in practice. Some of them find Jung’s 
somewhat mystical outlook of real value. Others 
are content with the somewhat rough-and-ready 
“will to power’”’ psychology of Adler. Some borrow 
freely from all schools and try to preserve an open 
mind. An adequate adjustment of the personality 
can be secured at different levels and by varying 
methods; but I think if one feels the need of a 
really scientific basis for psychological theory and 
practice one finds it in Freud, though, personally, 
I find the actual Freudian technique too restricted. 
Freud himself, however, does not claim to have 
revealed the whole truth and nothing but the truth, 
and many workers, both at home and abroad, are 
adding to and altering his structure. 

The late Ian Suttie’s book, published after his 
death, on the “ Origins of Love and Hate,” is an 


example of this kind of criticism and shows the 


change which has come over psycho-analytic thought. 
He believes that Freud’s work is dominated too 
much by the idea of the influence of the father, 
owing to Freud’s own unconscious trends, and that 
in attributing so much to the œdipus situation he 
has ignored the earlier need of the child to make 
adjustments to its mother. Since this earlier adjust- 
ment is one of reciprocity, the child needs its mother, 
the mother needs the child, we have here the germs 
of social relationship. Suttie shifts the emphasis 
from sensory gratification as the prime need of life 
to the need of feeling wanted and evoking tenderness, 


NOTES, COMMENTS, AND ABSTRACTS 


[san. 18, 1936 


In other words, he finds that there is a natural urge 
to social relations before the natural urge to purely 
sensory pleasure. It is interesting to find that 
Suttie’s theory receives confirmation from another 
angle. Gerald Heard, in a recent book “ The Source 
of Civilization,” reviews the history of the evolution 
of men in the light of recent research, and concludes 
that the ancestors of man survived and evolved, not, 
as we used to be taught, owing to their superior 
aggressiveness, but to their refusal to specialise in 
defence and by retaining to a high degree sensitive- 
ness and awareness. These latter qualities are what 
make for understanding our fellows, they imply an 
innate sense of at-one-ment with others; and so 
Heard, like Suttie, finds a social instinct at the 
bottom of man’s activities. This changed emphasis 
which is beginning to show in analytic psychology 
does not mean, of course, that the sex life either of 
the child or adult is unimportant, but it regards 
maladjustment in this sphere as evidence of a deeper 
maladjustment to social life. One illustration may 
perhaps make my meaning clear. A man whose wife 
is frigid may become neurotic from that cause, but 
his neurosis is not due to the lack of sensual grati- 
fication which he might get from a more tempera- 
mental partner, but to the sense of guilt engendered 
by the fact that his need to feel at one with her is 
frustrated. There is more in sexual intercourse than 
the satisfaction of an appetite and the use of that 
phrase rather than coitus indicates where the difference 
lies. 
Adjustments to Life 


The psychologist then has to deal with the neurotic, 
and the neurotic person is one who has failed to 
make adequate adjustments to life in one or more 
of three spheres as Adler has pointed out. The three 
spheres are those of economics, sex, and society. 
Economic adjustment does not, of course, mean that 
a man must strive to accumulate riches but that he 
must in some way assume responsibility for his food 
and shelter. Nor does his adjustment to sex imply 
that he must necessarily indulge in heterosexual 
practices. He is at liberty to remain virgin but he 
must be fully aware of his natural sex needs and not 
attempt to repress them by substituting childish 
fantasy. Adjustment to society means that he must 
respect himself as a worth-while individual and be 
willing to codperate with others. 

The symptoms of a neurotic can usually be 
interpreted as an attempt to achieve by fantasy 
and on a childish level what he is unable to gain in 
reality. One might sum him up by saying that his 
attitude to life is either that of “‘let’s pretend ” or 
“shan't play.” The main difference between the 
neurotic and the psychotic is that the former is 
aware throughout of some personality defect and 
wishes to be like others. The psychotic, on the 
other hand, has entered so thoroughly into the realm 
of “make believe” that he has lost touch with 
reality. That some psychoses have an origin in 
organic disease of the brain as in syphilitic lesions or 
are due to toxemia from acute or chronic sepsis is, 
of course, undeniable, but in many cases there is a 
borderline where the neurotic imperceptibly merges 
into the psychotic. Schizophrenia or dementia 
precox I believe to be a case in point. There is a 
progessive withdrawal of interest from people and 
from things which leads as we all know to absolute 
dementia. Yet there is an early stage of emotional 
unbalance where contact with reality is still complete 
and the patient is able to justify himself. We 
have been too apt in the past to think of the disease 


THE LANCET] 


in terms of its final results and consequently to 
believe that once the diagnosis is made there is 
nothing to be done but to tuck the patient away 
out of sight to await the appointed end. This 
attitude I believe to be too pessimistic. Early cases 
with which I have been associated have proved 
to have underlying mental conflicts similar to 
the neurotic, and I believe equally amenable to 
psychotherapy. 

Unfortunately the early schizophrenic is impatient 
with all discipline and convention, and so creates 
disturbances which make it impossible to keep him 
in his home or to board him out with ordinary people. 
Sooner or later his conduct 1s considered so scandalous 
that he is hastily interned and, once he feels his 
freedom curtailed, he appears to give up the struggle 


and withdraw within himself more and more; thus 


folowing what has been believed to be his destiny. 
To me there is nothing more pathetic than to come 
across these border cases. They seem as if they 
were swept on by a rushing current, but seeking all 
the time for something to cling to which might save 
them. One gets a grip and the boy’s relief and 
gratitude is obvious; then comes a relapse which 
possibly, in an appropriate environment, could be 
dealt with—and the current sweeps him on to be 
lost in the whirlpool. I ask myself whether it is not 
possible to provide the environment for these often 
briliant youngsters which would enable the psycho- 
logist to keep in close touch with them whilst allow- 
ing them freedom for self-expression. The kind of 
thing I have in mind would be an open-air colony—a 
sort of perpetual camp where each could have his 
own hut and yet the opportunity to share in a com- 
munal life with the minimum of discipline and 
routine. With such an environment I believe the 
psychologist’s work need not be in vain, and that 
many of these troubled souls could be won back to 
peace and usefulness. 


Prevalence of Neurotic Illness 


From what I have said of the need for the individual 
to make his adaptations to life it is easy to under- 
stand the prevalence of neurotic illness. Society 
grows increasingly complex. There is nothing left 
of the easy going laissez-faire of Victorian days. 
Science continually springs new marvels on us, 
man’s power of control over natural forces grows 
day by day—yet there seems no meaning or purpose 
in anything. God seems no longer in his Heaven 
and all right with the world as Browning was able 
to believe. Everywhere there is questioning and 
seeking. In such a world it is very hard to retain 
the sense of security which should be the foundation 
on which to build life. Economic and social adjust- 
ments are equally difficult in this age of machinery 
and specialisation. The individual either feels himself 


to be a mere cog in the vast machine—or, worse still,. 


he finds himself unwanted and on the scrap heap 
before he has settled down to his task. Sexual 
difficulties are increased by the fact that economic 
pressure tends to make marriage impossible in early 
youth—and nowhere is there an adequate outlet 
for the tremendous creative urge without which man 
would be no better than a brute. 

Society is waking up to the fact that it is manu- 
facturing misfits and a real attempt is being made 
to deal with the situation. Nursery schools and child 
guidance clinics are doing splendid work in providing 
the infant with the right environment and in readjust- 
ment. Psychology has found its way into the class- 
room and schools are being run on sounder lines. 
The juvenile criminal, too, is being given his chance 


NOTES, COMMENTS, AND ABSTRACTS 


[san. 18, 1936 177 


and his need for treatment and not punishment is 
recognised. All these are hopeful signs that society 
does recognise its responsibilities—but the need for 
such institutions is still far greater than the supply. 
It is splendid that so much is being done, and by 
providing for the children society is starting at the 
right end. The picture is not so good when we 
look to see what is being done for the adult neurotic 
who cannot possibly afford to pay for his treatment. 
I doubt whether there is even in the psychological 
clinic established in connexion with the Birmingham 
hospitals sufficient staff to permit of enough time 
being devoted to each case to bring about the necessary 
rapport between physician and patient. As far as 
I know the Tavistock Clinic in London is the only 
one which provides adequate facilities for psycho- 
therapy on analytic lines and at the same time gives 
training to medical men in psychological methods. 
The need for the extension of such clinics is obvious. 
Neurotic illness accounts for a very large proportion 
of disability under the Health Insurance Act, but 
both facilities for treatment and trained psychologists 
are ‘lacking. Both must be provided in the near 
future. 

Psychology deals with human nature, but it is 
human nature trying to adapt itself to a certain 
social environment. It may be we are making the 
task too difficult. Looking around the world as it is 
to-day, we seem to be in a nursery of quarrelsome 
children. Can we wonder at the psychotic who takes 
one look at us and: then retires into a world of his 
own rather than choosing to play a part in this ? 
I believe that coöperation is a more integral part of 
human nature than aggression, which is the quality 
our civilisation has developed most. I believe that 
in the future the psychologist will be asked to take 
a leading part in planning a social order in which 
coöperation will be the keynote. Only then, I 
believe, will the problem of the neurotic be solved. 


INCOME-TAX IN GENERAL PRACTICE 


THE Paddington Medical Society were addressed 
by Mr. G. G. Turner on Jan. 14th on the subject of 
income-tax in general practice. He said that the 
taxation of a doctor’s income differs from that of 
any other citizen only in the peculiar but confusing 
fact that practice is conducted from a private residence. 
The chief difficulty is to decide the proportion of 
personal to business expenditure, though here also 
it is only a matter of correctly applying the broad 
principles of the law. In dealing with income as 
opposed to expenditure the position is clearer. All 
profits, including the fees received from societies, 
panel, and public appointments. are assessed under 
the ordinary Schedule D “ trades and professions,” 
with which the practitioner is mainly concerned. 
If, however, he receives a salary for a whole-time 
work, he is taxed under the Schedule E relating 
to salaries. The doctor is entitled to select the 
closing date of his annual accounts, but he is taxed 
for his financial year ending before April 5th. If 
the basis of his assessment is the ‘‘ cash system ”’ 
the assessment is made only on the income received 
and expenses paid during the year, excluding all 
unpaid debts or credits. The better method, Mr. 
Turner insisted, is the ‘* earnings system ” in which all 
amounts earned and expenses incurred during the 
year are assessed whether there was actual payment 
or not; an adjustment is made for unpaid bills in 
the following year. A record of accounts is not 
compulsory, but it is strongly recommended that 
one should be kept to control the assessment, for 
all expenses due to the practice itself are exempt 
from taxation. Some doctors do not realise that 
among the deductions allowed from the gross profit 
are subscriptions to recognised societies and charities, 


178 THE LANCET] i VACANCIES [san. 18, 1936 


the fees, cost, and board of a locum tenens or assistant 
for sickness or holiday relief, the salaries of servants 
employed solely for the practice; the maintenance 
of equipment and repairs, decorations, and literature 
for the waiting-room and surgery ; and the cost of pro- 
fessional literature. Insurance premiums can be 
deducted only if sick benefits are declared as income. 

Expenses due both to practice and to private life 
are assessed in the proportions in which they apply 
to each; for example, the rent of the house, allowance 
being made if the practice is in an expensive locality 
or if the best room in the house has to be used for a 
surgery. Repairs, decorations, and depreciation 
have to be apportioned, also running expenses, 
cost of renewal and wear and tear of cars and electrical 
apparatus, and the wages of servants. In conclusion, 
Mr. Turner emphasised the desirability in the practi- 
tioner’s own interest, of keeping detailed accounts 
and of consulting an expert accountant. 


UNDESIRABLE, BUT WANTED 


IF any of our readers receive a call from a man 
who gives his name as Captain MacDonald or Captain 
MacDouall, and who answers to the police description 
which follows, the visitor should be detained under 
some pretext until the police, who desire to hear 
about him, can be communicated with. The descrip- 
tion furnished to us of ‘‘the captain” is detailed. 
He appears to be a little over 60 and stands 5 ft. 8 in. 
He is white-haired, baldish, and has a white waxed 
military moustache. He is of military bearing, 
has a ruddy complexion, officially described as 
“ bloated,” and when last seen was wearing a dark 
overcoat, a bowler hat, a bow tie, and spats. He 
speaks plausibly and may allude to having been at 
an old public school. He has obtained money from 
medical practitioners by claiming acquaintance with 
them or with a common friend, naming the friend, 
such conversations having led to loans. A coup of 
this sort he brought off in Harley-street on Dec. 17th 
last, in a distinctly ingenious way. ‘“ Captain 
MacDonald ” is now wanted by the C.I. Departments 
of Marylebone-lane (Welbeck 2824) and Bow-street 
(Temple Bar 6400) police stations. 


GUIDE TO LECTURES 


Messrs. H. K. Lewis and Co.. Ltd., are issuing with the 
bi-monthly list of books added to their lending library 
a list of lectures on medical, scientific, and technical 
subjects to be given in London during the same 
period. They believe, and we think rightly, that 
such a list may be of use to their subscribers. The 
lectures enumerated are given in the schools of 
London University and other places which are open 
to interested persons, and the list illustrates the 
wide range of first-hand information available to 
the inquiring mind. Suggestions for making the 
list more complete may be addressed to the com- 
piler, Guide to Lectures, c/o Messrs, If. I. Lewis and 
Co., Ltd., 136, Gower-street, London, W.C.1. 


V acancies 


For further information refer to the advertisement columns 
Aberdeen City District Mental Lospital.—Jun,. Asst. M.O. €300. 
Aldrich-Blake Memorial Trust, 8, llunter-street, W.C.—Scholar- 
ship. 200 guineas. 

Ayr Royal Burgh.—M.O.H. £800, 

Barry Surgical Hospital.—Res. Sure. O. £350. 

Bedford County Hospital.—sSecond I.S. At rate of £150. 

Birmingham and Midland kye Hospital.mRes. Surg. O. £200. 

Rirmingham, Romstley Hill Sanatorium —Res. Asst. M.O. £240. 

BORO Sellu Oak Hospital.— Jun. M.O.’s. Each at rate 
of £200. 

Blackburn, Brockhall Institution for Mental Defectives, Langho.— 
Jun. Asst. M.O. £500. 

Bootle General Hospital.—H.P., two H.S.’s. Also Cas. O. Each 
at rate of £150. 

Bristol Royal Infirmary.—l1.P.’s, H.S.’s, &e. Each at rate of 
£80. Also Sen. Obstet. Surg. At rate of £100. 

Carshalton, Surrey, Queen Mary's Hospital for Children.—Asst. 
M.O. £250. 

Charing Cross Hospital, W.C.—Hon. Anesthetist. 

Chelsea Hospital for Women, Arthur-street.S }V.—Pathologist. £40. 

Chester Royal Infirmary.—H.P. and H.S. Each £150, 

Cily of London Hospital for Diseases of the Heart and Lungs, 
Victoria Park, #.—H.P. At rato of £100, 

Colindale Hospital, Colindale, N.IV.—mAsst. M.O. £350. 

County Hall, Westminster Bridge, S.fé.—Asst. M.O. £600. 


Coventry and Warwickshire Ilospital.—H.S. At rate of £125. 

Croydon Mental Hospital, Upper Warlingham,—Asst. M.O. £350. 

Dorset County Council.—Asst. County M.O. £500. Education 
Committee: Asst. Dental Officer. £450. 

Eastern Fever Hospital. Homerton-qrove, E.—Asst. M.O. £250. 

East Ham Memorial Hospital, Shrewsbury-road, E.—H.P. t 
rate of £150. 

Elizabeth Garrett Anderson Hospital, Euston-road, N.W.—Asst. 
Radiologist. £100. _ 

Evelina Hospital for Sick Children, Southwark, S.E.—Dental 
Surgeon. 50 guineas. s 

Glasgow U nirersity.—liarry Stewart Hutchison Prize. £50. 

Gloucestershire Ronal Infirmary, 'e.—H.S. At rate of £150. 

Grimsby and District Hospital.—Sen. H.S. £200. Also Jun. 
H.S. and H.P. Each £150. 

Grocers COUUNENY,; Grocers’ Hall, E.C.—Scholarships. Each 
£31 


Hampstead General and N.W. London Hospital, Haverstock Hill, 
VJIV.M—H.P. At rate of £100. 

Hertford County Hospital.—sen. H.S. £200. Also H.P. At 
rate of £150. 

Leicester City General Hospital. —Two Res. M.O.’s. Each £300. 

Liverpool and District Hospilal for Diseases of Heart.—H.P. 
At rate of £100. 

Liverpool Sanatorium, Delamere Forest, Frodsham.—Med. Supt. 
£200, 

L.C.C. Group Laboratory, Archway Hospital, Archway-road, N .— 
Asst. Pathologist. £650, 

London County Council.—Asst. M.O.’s for Mental Hospital. 
Each £470. 

London Hosnital, E.— Hon. Asst. Surgeon. 

London School of Clinical Medicine, Dreadnought Hospital, 
Greenwich, S.f4.—Jun. Pathologist. £400. 

Maidstone, Kent County Ophthalmic and Aural Hospital,— 
H.S. to Ear, Nose, and Throat Dept. At rate of £200. 

Manchester, Ancoats Hospital.—Two H.s.’s. Each at rate of 
£100. Also Med. Reg. £50. 

Manchester ar Hospital, Grosvenor-square, All Saints’,—H.S. 
At rate of £150. 

Manchester Royal Infirmary.—H.S. to Orthopwdic Dept. At 
rate of £50. 

Middlesbrough County Borough.—Deputy M.O.H. £450. 

Middlesex County Council,—aAsst. M.O. £600, 

NEUT nee LUG, Hospital for Sick Children.—Res. Surg. O. 
2230, 

Noweustle-upon-Tyne, Royal Victoria Infirmary.—Jun. Surg. 
Reg. £150. 

Oldham, Boundary Park Municipal Hospital.—Res. Asst. M.O. 
At rate of €200. 

Oswestry, Ltobert Jones and Agnes Hunt Orthopedic Hospital.— 
H.S. At rate of £200. 

Paddington Metropolitan Borough.—Visiting M.O. 14 guineas 
per attendance. 

Papworth Village Settlement, Surgical Unit.—H.s. £200. 

Pinewood Sanatorium, Wokingham, Berks.—Asst. M.O. £250. 

Plymouth City.—Deputy M.O.H. £750. 

Plymouth, Mount Gold Orthopedic and Tuberculosis Hospital.— 
Asst. Res. M.O. £350. 

Portsmouth Royal Hospital,—U.S. At rate of £130. 

Preston, Biddulph Grange Orthopedic Hospital.—Sen. H.S. At 
rate of £250. 

Princess Louise Kensington Hospital for Children, St. Quintin- 
avenue, W.—H.P. At rate of £100, 

Royal Eye Hospital, St. George’s-circus, Southwark, S.E.—Hon. 
Asst. Surgeon. 

Royal Masonic Hospital, Ravenscourt Park, W.—Surgeon. 

St. John's Hospital, Lewisham, S.E.—Res. H.P. At rate of £100, 

Salford Ronal Hospital.—Orthopmdice Reg. £100. 

Salisbury General Infirmary.—tU.s. At rate of £125. 

Smethwick, St. Chad's Hospital.—Res. Obstet. Otlicer. £350. 

Somerset and Bath Mental Hospital, Cotford, near Launton,— 
Sen. Asst. M.O. £650. 

Southend-on-Sea General Hospital.—Cas. O. At rate of £100. 

Stirling District Mental Hospital, Larbert.—Jun, Asst. M.O. £300, 

Stoke-on-Trent. Stanfield Sanatorium — Res. M.O. £250, 

West End Hospital for Nervous Diseases, 73, Welbeck-street, W .— 
Two Res. H.P.’s. iach £125. 
Westminster Hospital, Broad Sanctuary, S.W.—Asst. Obstet. 
Surgeon. Also House Anesthetist. At rate of £100, 
Worcester County Council.—County Analyst and Bacteriologist. 
£800. 

Worcester Royal Infirmary.—H.S. and H.P. Each at rate of 
£1060. 

The Chief Inspector of Factories announces vacancies for 
Certifying Factory Surgeons at North Walsham (Norfolk), 
Bangor (Caernarvon), and Ruthin (Denbigh). 


Corrigendum. —In the L.C.C. advertisement for Assistant 
Medical Otticers which appeared in our advertisement 
columns of Jan. 11th (p. 48) the allowance of £60 to holders 
of D.P.M. should have been given as £50, The advertise- 
ment, as amended, is repeated in our present issue.! 


ASSOCIATION OF INDUSTRIAL MEDICAL OFFICERS,— 
Tho second meeting of this association will be held in 
the London School of Hygiene and Tropical Medicine, 
Keppel-street, W.C., on Friday, Jan. 24th, at 5.15 P.m., 
and on Saturday at 10 a.m. Discussions will be opened 
on physical standards in industry by Air Vice-Marshal 
Sir David Munro, secretary of the Industrial Health 
Research Board, and on the relation between the industrial 
medical officer and tho general practitioner by Dr. T. O. 
Garland, medical officor of Carreras, Limited. The hon. 
secrotary of the association is Dr. Donald Stewart, I.C.I. 
Metals, Ltd., Kynoch Works, Witton, Birmingham 6. 


THE LANCET] [Jan. 25, 193645: : | 
yim 


Fn a so Geis see ia ee On en ee Se ae — 


CLINICAL MEDICINE 


A FAREWELL LECTURE ! 


By LORD HORDER, K.C.V.O., M.D., F.R.C.P.Lond. 


In place of the customary ‘‘Gentlemen” with 
which these lectures are prefaced I am to-day privi- 
leged to address you as “‘ Colleagues and gentlemen.” 
The compliment paid to me by the presence of so 
many of my fellow teachers is both graceful and 
touching. It is also, as compliments are wont to 
be, expensive, since the occasion which determines 
it costs me a great deal. Swan songs are prone to 
be sententious—a quality which I always try to 
avoid, whether in speech or in action. Personalities 
I dislike just as much as I dislike sententiousness. 
I will allow myself one brief deviation from my 
practice in respect of each of these two antipathies. 
I admit that if, after all these years, I had no sort 
of message for those who follow me, I should feel 
heartily ashamed. I also admit that this, my last 
clinical lecture at Bart.’s, far from leaving my withers 
unwrung, strains them to their utmost. 

The occasion justifies a departure from custom in 
regard to these lectures. To-day I am not bringing 
before you a “difficult case,” unravelling its com- 
plications as best I can, and trying to make clear 
the mental process by which this may be done, and 


thereby invite that drowsiness which, in these cir- . 


cumstances, tends to steal over my audience (pardon- 
able only in the case of my house physician, for has 
he not already been “‘ bored stiff” by my previous 
rehearsals in the ward ?). Nor am I bringing a more 
simple case, which may be taken as a peg upon 
which to hang a list of causes or symptoms of disease, 
and thereby stimulate those who scent the possi- 
bility of something which is of potential use in another 
place, a stimulus which extends at times even to a 
little hurried note-taking (for I have never mis- 
construed this brief spurt of active, rather than 
passive, attention on the part of the less frugal 
minded of my audience). Instead of doing either 
of these things I propose to say something about 
clinical medicine itself—that is, about that part of 
the physician’s work to which these lectures are a 
running commentary. 


‘© TOUJOURS LES MALADES ” 


Whatever may be the special branch of medicine 
that attracts us, it is commonly accepted that it is 
at the bedside where, on the one hand, the vital expres- 
sions of diseases are manifested and where, on the 
other, the contributions made by the laboratory, 
both to diagnosis and to therapy, must eventually 
be tested. “Les malades, toujours les malades.” 
But medicine provides such a large field for human 
interest and activity that there are many points at 
which a man may branch off into a whole life’s work 
of relatively detached scientific effort. Any one of 
these digressions may take him so far away from the 
patient that, quite joyfully and quite successfully, 
he may make valuable contributions to what becomes, 
in effect, pure science. He may then be tempted 
to consider clinical medicine but a poor affair, 
scarcely worth the pursuit of a trained intelligence. 
Whereas I regard it as a very inviting field for the 
most highly cultivated minds—a field in which 
t With acknowledgments to St. Bartholomew’s Hospital 
Journal, 

5865 


| ADDRESSES AND ORIGINAL ARTICLES  .: 


meagre achievement, far from indicating an esgfat 
poverty in the soil that is being tilled, signifiese 
that the husbandman is not always as alert aml ṣẹ 
equipped as he might be. However, what I sa¥4his 
morning is not intended as an apologia for the Nig 
cian so much as a brief survey of his place in medicing 
and how his functions are, in my judgment, best 
performed. 

In the view of some people the clinician has not 
advanced, or developed, proportionately with those 
of his colleagues who are primarily concerned with 
the ancillary subjects of surgical technique, bacterio- 
logy, and biochemistry. I cannot accept this esti- 
mate, and I think it is due to a false, or a forgotten, 
conception of the clinician’s function. Though this 
remains what it fundamentally always was—the 
collection and evaluation of all available data which 
are pertinent to the diagnosis and the treatment 
of the sick person—TI believe that the growth of the 
means by which this function is achieved has been 
even greater in the case of the clinician than in the 
case of any one of his colleagues, for the reason that 
the whole of their combined knowledge is available 
for him if he is familiar with it and cares to use it. 


THREE GREAT ADVANCES 


In my own time I have witnessed three great 
advances in the science and art of clinical medicine, 
and (though “‘I speak as a fool”) these advances 
have seemed to me to make the clinician of much 
greater potential service to the patient than he was 
before they took place. How much he is actually of 
greater service depends upon himself, and the degree 
to which he has absorbed these advances and trans- 
muted them into his practical work. 

The function of the old clinicians was not inaptly 
termed “walking the wards,” an expression which 
has its modern counterpart in “ going round.” Our 
predecessors made large observations rather than 
small, and they acquired a facility in diagnosis and 
in prognosis which seemed to many quite uncanny. 
This facility was really due to the fact that they 
had trained themselves to make a greater number of 
observations than they were actually aware of. 
Their eyes and ears and touch and smell were unaided 
by instruments of precision, and the pitch ,of excel- 
lence to which their senses perforcee—and at long 
last—arrived was very astonishing. But their 
exactness stopped short at the point where their 
unaided senses could pierce the mystery no farther 
and this in many cases was stopping too short to 
enable them to give the help which the patient 
needed. Forexample, septicemia was only septiczemia, 
ae heart disease, for the most part, was only heart 

sease. 


THE LESSONS OF THE POST-MORTEM ROOM 


Then came the first great advance. With the 
increased frequency of, and greater thoroughness in, 
post-mortem examinations, the clinician began to 
think morbid-anatomically. This was a notable 
move forward. He was able to visualise the diseased 
organs as they actually existed during life, and this 
visualisation gave his clinical methods a clearer 
purpose and direction. This habit of correlation of 
the clinical features of the case with post-mortem 
experience remains, and must of necessity remain, 
one of the most valuable aids to diagnosis and prog- 
nosis. The clinician who relaxes in a punctilious 
attendance at the post-mortems upon his patients, 
or upon patients of his colleagues, thinking the time 

D 


180 THE LANCET] 


LORD HORDER :: CLINICAL MEDICINE 


[JAN. 25, 1936 


could be better spent in the wards or in the out- 
patient rooms, is not only denying himself the chief 
correction to his exuberance and to his vanity, he is 
departing from the bed-rock of medicine itself. 
What he says at the bedside may, or may not be, 
the truth ; what he sees in the post-mortem room is 
the truth. In this connexion I should like to enter 
a plea against too much reservation of post-mortem 
material for deferred examination. Some such 
reservation is at times desirable and even necessary, 
but it should be upon the decision of the pathologist 
and of the clinician jointly, each having regard to 
the claims of the other. Be it remembered that 
diseased organs that are opened at the time of the 
post-mortem examination, and are seen in relation 
to the rest of the body, nearly always throw light 
upon the obscurity that has perhaps been in the 
minds of those who have seen the “case” during 
life. Whereas organs that are dissected by the aid 
of the pathologist’s midnight oil may, or may not, 
illumine his own individual darkness. 


LABORATORY METHODS 


The second advance came with the development 
of laboratory methods, since in these the clinician 
found new and invaluable aids to his work. The 
study of the patient qua patient was supplemented 
by the study of materials derived from the patient. 
Thus we saw the birth of clinical pathology. The 
past 30 years have witnessed this lusty babe grow 
up to a vigorous manhood. As is wont with the 
virile adolescent, there have been times when he 
thought himself more important than he really was, 
when he sought to bestride the whole world of medical 
knowledge, when he firmly believed he was medicine 
rather than merely making his contribution to medi- 
cine. His incursion into the sick room was apt to 
be somewhat brusque, not to say at times truculent. 
Cuckoo-like, he jostled and pushed and oft-times 
succeeded in ousting his more timid and gentle 
colleague from the latter's legitimate sphere. He 
took to describing himself in the telephone directory 
as “physician,” and he invited the credulous sick 
to consult him. The public, with its child-like con- 
fidence in machinery, loved him, welcoming his 
advent as signalling the millennium of exact medicine, 
and unaware that the human brain is the best machine 
of all. <A catalogue of the flora of the fauces and/or 
of the faces, a complete blood count, a chemical 
analysis of the urine to the third place of decimals : 
“What further may be sought for or declared ? ” 
Not only was the new gospel about to dispel the 
darkness that shrouded diagnosis, it was about to 
ilumine the therapeutic field also. The ‘‘ opsonic 
index” for an exact diagnosis, the hypodermic 
syringe, charged with the appropriate antigen, for 
effective treatment, and medicine was ‘“‘taped”’ at 
last. The clinician came to be regarded by some 
with amused tolerance ; by others, even less generously 
minded, as obstructive to real progress. Nosology 
disappeared and pathology contracted down to the 
name of the infecting agent; patients no longer 
suffered from diseases but from micro-organisms. 
‘What is the matter with the man in bed 4?” 
ant Ie) E eens a 

But fortunately for the patient, for whom, like 
the soul of Faustus, the powers of good and evil 
were fighting, some clinicians kept their heads. 
They absorbed what was good in these clinico- 
pathological advances, seeing in them important 
supplemental aids to their methods rather than a 
substitution for them. But the older and cruder 
notions of infection had to be entirely revised; and 


gaps in the knowledge of metabolism had to be 
filled. Not only was it necessary that the clinician 
should think morbid-anatomically, it was necessary 
that he should think bacteriologically and bio- 
chemically also. 

RONTGENOLOGY 


Then came the third great advance, and by means 
of an entirely new tool. I refer to the arrival of 
roentgenology. Though useful from the first, it has 
taken a good many years to improve the technique 
and to get the method under control, but to-day 
there is probably no more useful addition to the 
clinician’s methods. The exercise of forbearance 
in interpretation on the diagnostic side, and of 
moderation in claims on the therapeutic side, have 
become an important part of the clinician’s work. 


ESSENTIAL DATA 


I said just now that the fundamental function of 
the clinician is to collect and to evaluate data. But 
what data? The clinician is not a mere collector 
of data. If he were, diagnosis would be as easy for 
one man as for another. Nor is he a mere recorder 
of cases seen. If he were, the palm would go to the 
panel practitioner or to the junior casualty physician, 
though this consideration waives a fact of which 
we are well aware—that it is possible, nay easy, to 
see a great number of patients and yet not see their 
diseases. It is the essential data that we want, not 
the unessential. It is data that are associated, not 
data that are dissociated. The capacity to neglect 
is a8 important as the capacity to take notice. True, 
the more obscure the case the less we can afford, in 
the first survey, to omit any examination; but 
after a time there comes what may seem to some an 
almost astounding negligence. This is not forget- 
fulness, nor a lapse from good methods; it is the 
ability safely to omit. Patients’ dossiers are apt, in 
these days, to be so full and so heterogeneous that. 
the courage to say of some of the reports, “ noted, 
nothing doing,” is often the first step in the elucida- 
tion of the problem. It falls to the clinician alone 
to become familiar with the range of health, to be 
sensitive to what lies within it, and to what lies 
outside it. The exercise of this sensitiveness in any 
particular case becomes more and more essential 
the more meticulously exact the reports of the 
experts may be. And these reports tend to be more 
and more meticulously exact with the increasing 
tendency to specialism and the myopia which goes 
with it. The number of patients whose hearts are 
healthy is in inverse proportion to the number of 
cardiologists they consult, and the frequency with 
which they are “ electrocardiographed.” An upper 
respiratory tract which is passed as “normal” by 
a careful “nose and throat man ” will soon be so 
rare as to merit demonstration at the Royal Society 
of Medicine. 

BEDSIDE OBSERVATIONS 


It has been during the recent period of intensive 
laboratory investigations on the clinico-pathological 
side of diagnosis that the notion has arisen that the 
clinician’s observations are not really scientific, 
that they are of the nature of guess-work, whereas 
everything that happens in the laboratory 1s controlled 
by the infallible rules of logic. The test-tube and 
the microscope cannot lie. But God alone knows if 
what the physician thinks is an enlarged spleen 
is the spleen ; or if rose spots are not “ any old spots ” ; 
or the association of a soft and infrequent pulse with 
a continued high fever is not some odd trick of Nature 
designed to intrigue the curious-minded ; and why 


THE LANCET] 


should not a week of intense headache pass away 
somewhat suddenly and be replaced by a muttering 
delirium ; and an unexplained deafness appear ? 
Funny things like these do happen to people who 
suffer from a disease of microbic origin. But the 
one certain thing is that the disease isn’t typhoid 
fever, or any infection in the T.A.B. group, because 
there is no agglutination of the laboratory stains of 
those organisms by the patient’s serum. Strange, 
this idea that facts have a different value according 
as they are observed at the bedside or in the laboratory. 
Stranger still, the idea that one negative observation 
in the laboratory should, by responsible clinicians, 
be regarded as more important than six positive 
observations at the bedside. ‘‘ We can never, by a 
single experiment, prove the non-existence of a 
supposed effect.” If ‘‘science arises from the 
discovery of identity amidst diversity ” then it matters 
not if the identity be discovered by careful observation 
of the patient clinically or pathologically. The whole 
question is, is it a true identity ? But this, in the 
last resort, depends upon the critical judgment of 
the observer. Granted that the exercise of judgment 
at the bedside is more difficult than it is in the 
laboratory, mistakes in judgment are not confined 
to the bedside. We have only to send a specimen of 
the same stool to two, or even to six, bacteriologists, 
equally expert, to find that failure to ‘“ discover 
identity ” is by no means only a bedside difficulty. 
Here the question of criteria is involved, as we know, 
and criteria are not always uniform even amongst 
laboratory workers. Their results are therefore, of 
necessity, not always comparable. Now the clinician’s 
criteria are, in general, less exact than the pathologist’s, 
norcan they be made so exact very easily ; but if they 
are made severe, as they should be—if nothing is 
termed positive which is only doubtfully positive; if 
the clinician’s judgment concerning his observations 
is controlled by reliable technique; if discovered 
identities are unequivocal—then his “facts” are 
as scientific and as logical as are those of the patho- 
logist. The truth is that clear thinking, with for- 
bearance, is essential to the satisfactory solution of 
a diagnostic problem whether the contribution comes 
from the laboratory or from the bedside. 


MENTAL TECHNIQUE 

There is a technique of the mind as well as of the 
eye and of the hand, and the former is quite as 
essential as the latter. It is not only what you find 
at the bedside, it is also what you bring to the bedside. 
The eye sees what it takes with it the power of 
seeing: it is the mind that sees. And surely it is 
the same in the laboratory ? In both spheres there 
comes to some—slowly, painfully, towards the end 
(alas !)—facility born by patient practice out of time. 
Clinician and pathologist are more akin than they 
sometimes realise. Each of them takes a pride (which 
the other regards as excessive) in his small discoveries, 
and each of them lacks humility (or so the other 
thinks) in face of the certain fact that every day, 
whether it be in the ward or in the laboratory, 
momentous things are happening under their very 
eyes, yet they see them not, for they are both under 
the same ban—they cannot live out of their 
generation. 

CLINICAL RESEARCH 


If, looking back, I can feel satisfaction with any 
modest effort of my own in the diagnostic field, it is 
in opposing the tendency of the past two decades 
towards the divorce of clinical from laboratory 
methods. In this hospital this divorce has really 
never occurred. Kanthack and Andrewes and Gordon 


LORD HORDER : CLINICAL MEDICINE ` 


[san. 25, 1936 181 


and Kettle and Canti have been too wise not to see 
that pathological processes have a unity which centres 
itself in the patient and that without careful study 
at the bedside only one part of these processes can 
be elucidated. It is the close coöperation of both 
observers, and this alone, that can lead to results 
that are helpful. We at Bart.’s have been fortunate 
in this matter, and I hasten to add that any mud 
strictures of mine refer not to our school, but to a 
part of the greater world of medicine outside. | 

But clinical medicine in this greater world is just 
now coming back into its own. The prince has taken 
notice of the neglected charms of our modest 
Cinderella. A marriage is being arranged. Professors 
are leading her to the altar, and the name of her 
bridegroom is Research. There is just time for 
me, as an interested end loving uncle, to give the 
pair my blessing. 

“ Let me not to the marriage of true minds 

Admit impedimente. Love is not love 

Which alters when it alteration finds, 

Or bends with the remover to remove: 

O, no! itis an ever fixed mark 

That looks on tempests and is never shaken ; 

It is the star to every wandering bark, 

Whose worth’s unknown, although his height be taken.” 
And so is resumed afresh the long line of clinical 
observers which has been lit by the genius of Hippo- 
crates, of Sydenham, of ,Trousseau, of Osler, and of 
many others—masters in clinical research. 


CLINICAL TEACHING 


A few words about clinical teaching before I close. 
Time has not led me to change my view that the best 
help the clinician can give his pupils during the early 
part of their career is to insist that they use their 
words carefully, exactly, and without ambiguity. 
Next to this, but only by means of this, he can help 
them to think clearly. This is important, too, for 
as Thomas Hobbes said “as men abound in copious- 
nesse of language; 80 they become more wise, or 
more mad than ordinary.” I may be forgiven for 
repeating myself and saying that the first text- book 
of medicine should be Jevons’ ‘‘ Primer of Logic.” 
It costs one shilling but is worth untold gold. Note- 
taking must never be scamped. What is written 
about the facts of a case demands the same care as 
what is said about them. If to these things can be 
added a thorough drilling in methods of clinical 
examination we have really accomplished a great 
deal in the first three months. Be it never forgotten 
that to watch the teacher’s own methods is of greater 
help in the earlier stages of clerking than to try to 
understand what he is talking about. Efforts to 
teach medicine, however tempting, should be resisted. 
The keen student will teach himself medicine if he 
is properly trained in these important preliminaries. 


THE CURRICULUM 


I wish something could be done to save the clerk’s 
valuable time in the wards by introducing into the pre- 
clinical studies a number of examinations and methods 
which have really to do with anatomy and physiology. © 
I have often dealt with this matter, but I make no 
excuse for referring to it again. The fundus oculi 
and the membrana tympani are normal anatomical 
structures, yet few clinical clerks have ever seen them 
before they enter the wards and, largely as the 
result of this fact, some have not seen them clearly 
even when they leave. We could profitably exchange 
the time spent over theories of colour vision and the 
intimate structure of the organ of Corti for these 
important matters. The blood-cells are a part of 
normal histology but they have rarely been counted, 
or, if they have, it has only been during the 

D2 


182 THE LANCET] 


demonstration of the Thoma-Zeiss pipette. The 
contours of the abdomen, the reflexes and tendon- 
jerks, the normal gait, the surface markings of the 
lungs, the deposits that may occur in urine apart 
from disease, the flora of the feces in health ... is it 
really economical that the time of the clinicians— 
and of the senior clinicians—should be taken up in 
teaching about these things? Mr. Dean, we have 
praised you, though not more than you deserve, 
on account of the magnificent laboratories and 
equipment which you have assembled on the Merchant 
Taylors’ site. Here is another piece of work for 
you and your colleagues—this adjustment of the 
pre-clinical studies so that they conform more to 
the requirements of men who are going to be doctors, 
and valuable time may be saved for the later years of 
the curriculum. | 
VALE | 

Well, I must bid you good-bye. It has all been, 
in schoolboy phraseology, ‘‘ great fun’’ and I have 
thoroughly enjoyed it. The clinician’s material 
has not been confined to the patients in their beds. 
For there have been the clerks themselves . . . and 
the rest of the ‘‘ firm”... and the nursing staff... 
and the porters whistling outside the ward, under the 
echoing shaft of the lift ... and the buzzer that calls 
for the anesthetist who is never there . . . and this 
lecture theatre. More than all this, there has been 
the world outside—the domestic circle, the market 
place, the forum. There has been the whole human 
comedy as seen by Shakespeare and Moliére and 
Cervantes and the other great clinical observers. 
I hope I have not put too many of you, whom I 
have been privileged to teach, out of your stride. 
I trust my methods, and my teaching, have conformed 
in some measure to the great traditions of this place. 
But they have been largely, and of necessity, myself : 

‘fay, there’s the rub.” 


So now I doff my ward coat and hand it to you, 
Evans, my friend. Gow and you have been loyal, 
inspiring, and very charitable colleagues, and I tender 
you my most sincere thanks. God bless you, and God 
help you! 


EXOPHTHALMOS 


FOLLOWING THE ADMINISTRATION OF 
THYROID EXTRACT * 


By W. RussELL Brain, D.M. Oxon., F.R.C.P. Lond. 


PHYSICIAN WITH CHARGE OF OUT-PATIENTS TO THE LONDON 
HOSPITAL; PHYSICIAN TO THE ROYAL LONDON OPHTHALMIC 
HOSPITAL AND THE HOSPITAL FOR EPILEPSY AND 
PARALYSIS, MAIDA VALE 


ONE of the most puzzling of the many problems 
arising out of the state of thyrotoxicosis is the mode 
of production of exophthalmos. There is at present 
no satisfactory explanation either of the nature of 
the changes in the orbit which lead to exophthalmos, 
nor of the way in which these changes are associated 
with thyrotoxicosis. The difficulty of explaining the 
exophthalmos is enhanced by the fact, which is 
generally admitted, that the administration of 
thyroxine or of thyroid extract, whether experi- 
mentally to animals or therapeutically to man, does 
not as a rule lead to exophthalmos. The rarity of 
this event in man may be gauged from the fact that 
not more than about twenty instances have been 
reported. The, development of progressive exoph- 


* From the neurological department of the London Hospital, 
and the Royal London Ophthalmic Hospital. 


DR. RUSSELL BRAIN : EXOPHTHALMOS AND THYROID EXTRACT 


[yan. 25, 1936 
thalmos in patients who have previously undergone 
subtotal thyroidectomy for thyrotoxicosis is a closely 
related phenomenon, since this may be precipitated 
by the administration of thyroid extract to correct 
post-operative hypothyroidism. The object of this 
paper is to report a new case of exophthalmos fol- 
lowing the administration of thyroid extract. The 
significance of this sequence of events is discussed 
in the light of this and previously reported cases and 
of recent experimental work on exophthalmos. 


AUTHOR'S CASE 


An unmarried Hebrew woman, aged 38, was referred 
to me from Sir Stewart Duke-Elder’s clinic at the 
Royal London Ophthalmic Hospital on May 14th, 
1934. Since the age of 5 she had suffered from 
epileptic fits, which were mainly nocturnal, and - 
occurred almost every night during her sleep, though 
in addition she used to have one or two every week — 
during the day. Her menstrual history was normal. 


In October, 1923, in addition to bromide and iodide 
she was given thyroid tablets, grs. 2, twice a day for three 
months. In 1926 she had a further course of thyroid 
extract for three months and again in 1928. .In 1929 
she again took thyroid extract until February, 1930. 
In October, 1930, she started to take } grain of thyroid 
extract, and then 1 grain, twice daily, and had taken the 
thyroid almost continuously ever since. During the 
whole of this period she had been taking bromides almost 
constantly and occasionally Luminal. During the three 
and a half years before she came under observation she 
must have taken approximately 2000 grains of thyroid 
extract. 

In the middle of April, 1934, the left eye was first noticed 
to be prominent. When she first attended the Royal 
London Ophthalmic Hospital her condition was as follows. 
Of somewhat retarded mentaldevelopment. Rather obese. 
Weight llst.6lb, (Average weight 8st. 10 1b.) Height 
4ft.ll4in. Thick, dark hair on scalp. Heavy eyebrows. 
Growth of hair on lips and chin, shaved. Thyroid not 
visibly or palpably enlarged. Pulse regular, rate varying 
between 90 and 104. Blood pressure 135/80. Fine 
tremor of hands. The left eye protruded 4 to 5mm. 
in front of the right and the left upper lid was retracted. 
No orbital irregularity was discovered. The ocular 
fundi were normal and visual acuity was 6/6 in both 
eyes. Central nervous system, heart, lungs, and abdomen 
were normal. The urine contained a trace of albumin 
and no sugar. | 

The administration of thyroid extract was at once 
suspended. By July 23rd the patient’s pulse-rate had 
dropped to from 80 to 84. The state of her eve at this 
time is shown in Figs. ] and 2. . 

She was admitted to the London Hospital on Oct. 4th, 
1934 (No. 41578). The exophthalmos had now diminished 
considerably (Figs. 3 and 4) and her weight was 11 st. 
12} 1b. Radiograms of the skull showed no abnormality. 
Her basal metabolic rate on Oct. 19th was plus 9-2 per cent. 
and on Oct. 21st plus 4 per cent. Her blood Wassermann 
reaction was negative. While in hospital she had six 
epileptic fits. She was discharged from hospital on’ 
Oct. 23rd, 1934, and has since been under observation 
as an out-patient. The exophthalmos steadily diminished 
(Figs. 5 and 6) until in April, 1935, the left eye was only | 
l mm. in front of the right. The difference in November, 
1935, was scarcely perceptible (Figs. 7 and 8). After the. 
withdrawal of the thyroid extract her weight steadily | 
increased until in May, 1935, it was 12 st. 8 lb., since when 
she has been on a reducing diet. Her epileptic fits have 
responded well to luminal and bromide, but she still has 
an attack occasionally. 


In this patient, therefore, the ater exoph- 
thalmos, which followed the prolonged but inter- 
mittent administration of thyroid extract, subsided. 
almost completely within a year of the withdrawal . 
of thyroid. It is noteworthy that the patient showed . 
signs of endocrine abnormality—namely, obesity and 
excessive hairiness, 


DR. RUSSELL BRAIN : EXOPHTHALMOS AND THYROID EXTRACT 


[san. 25, 1936 183 


FIGS. 1 and 2.—The patient on July 25th, 1934. 


PREVIOUSLY REPORTED CASES 


Bélére’s Case (1894).1—Female, aged 34. Had been 
treated for myxcedema by means of thyroid gland. By 
mistake she took 92 grammes of thyroid gland in eleven 
days. After this she developed exophthalmos and a 
staring expression, tremor of the arms, tachycardia, 
instability of pulse, elevation of the temperature, insomnia, 
agitation, polyuria, glycosuria, albuminuria, and para- 
plegia. The paraplegia, in view of a history of previous 
hysterical symptoms, was regarded as hysterical. 

von Notthafft’s Case (1894).2*—Male, aged 43. Suffered 
from increasing obesity and treated himself with ‘thyroid. 
Within about five weeks he took nearly a thousand tablets 
of 0:3 gramme Burroughs Wellcome’s thyroid preparation. 
During the five weeks he lost 28 lb. in weight, from 220 lb. 
to 192 lb. During the third week he began to develop 
symptoms. At the end of five weeks he showed moderate 
exophthalmos, with lid lag. His face was flushed and the 
whole skin moist. There was a gross tremor, most severe 
inthe hands. The pulse-rate was 120.. The thyroid was 
not visibly or palpably enlarged. 

Lawford’s Case (1900).1°—Female, aged 34. Had suffered 
from myxcedema for five years. Thyroid extract 
administered, dose not stated. As she benefited greatly, 
the treatment was interrupted but was resumed 44 years 
later. After one week the eyes became prominent and the 
exophthalmos steadily increased. She did not complain 
of palpitation and was not emotional. The thyroid gland 
was scarcely felt, so was not enlarged. 


Ulrich’s Case (1900).25—Female, aged 46. Had suffered 
from myxcedema for ten years. On thyroid treatment 
(0-05 x 2) there was rapid improvement and her hair 
grew again, but she developed exophthalmos, tachycardia, 
excessive sweating, and progressive wasting, resembling 
& patient with Basedow’s disease. 

Stegmann’s Case (1906).24—Female, aged 14. Had 
suffered from her fourth year from slight swelling of the 
neck, which gradually increased in size. She was given 


14 Thyroidin tablets per day. She rapidly developed severe 
palpitations and the treatment was discontinued. There 
was, however, only temporary improvement and three 
months after taking the thyroid she began to suffer from 
palpitations and, a month later, protrusion of the eyes 
began to develop. Eight months after the beginning of 
the treatment her weight had fallen from 64 to 46-7 kg. 
She exhibited gross exophthalmos and a diffuse, soft, 
visibly pulsating enlargement of the thyroid, very severe 
tremor, and a pulse which was very irregular and lay 
between 130 and 150 in rate. The heart was slightly 
enlarged. Her general condition improved greatly follow- 
ing X ray irradiation of the thyroid. 

Pulawski’s Case (1912).?!—Female, aged 47. Had had 
a goitre for 18 years. As it began to increase in size she 
was ordered to take thyroidin. During four weeks she 
took 38 tablets (Poehl). She began to lose weight and 
suffered from palpitations. Four months after beginning 
to take the thyroid she had slight exophthalmos and 
Stellwag’s sign was positive. She was emaciated and 
nervous and tremulous, with a pulse-rate of 120. The 
goitre was firm but did not pulsate. The patient refused 
operation but improved slightly on medical treatment. 


Holbéll’s Case (1927).5—Female, aged 46. Increased 
steadily in weight after the menopause. For 50 days 
she took thyroid gland tablets (Medix, strength. No. 4, 
1 tablet a day). She began to suffer from nervousness, 
tremor, and palpitation and, later, exophthalmos, sweating, 
and enlargement of the thyroid developed. The loss of 
weight was progressive. Four months after beginning 
to take the thyroid extract the typical picture of exoph- 
thalmic goitre was present. The pulse-rate ranged between 
100 and 140. The basal metabolic rate was 157 per cent. 
She became delirious and died one month later. ‘There 
was no autopsy. ` 

H. U. Meoller’s Case (1928).1°—Female, aged 49. Had 
been taking thyroid preparation for seven years. She 
developed unilateral exophthalmos, for which no local 


FIGS. 5 and 6.—Dcc. 31st, 1934. 


FIGS. 7 and 8.— Nov. 28tb. 1935. 


184 


THE LANCET] 


cause could be found on ophthalmological and X ray 
examination. She also showed tachycardia, tremor, 


goitre, glycosuria, fasting hyperglycemia (0-137 per cent.). 


The thyroid administration was discontinued. Six months 
later the goitre and exophthalmos persisted but the pulse- 
rate was normal. The diabetes proved to be of a very 
benign character. 


E. Moller’s Case 1 (1930).15—Female, aged 49. Artificial 
menopause induced four years previously with X rays, 
owing to uterine fibroids. After this there was some 
increase in weight and she began to take thyroid extract. 
In the course of six weeks she took between 110 and 120 
thyroid gland tablets (Medix, strength No. 1, three tablets 
a day). She developed nervousness, insomnia, tremor, 
palpitation, dyspnoea, diarrhea, profuse sweating, thirst, 
and faintness. Goitre appeared and exophthalmos was 
noted. She lost 21 kg. in weight during three months. 
The basal metabolic rate was 152 per cent. and the patient 
was regarded as a typical example of severe thyrotoxic 
goitre. She became delirious and later comatose and died 
seven months after beginning to take the thyroid. 

Post-mortem examination. The thyroid gland was 
enlarged, without cysts or hemorrhages. Microscopically, 
the follicles were of very unequal size. The epithelium 
was flat, cubical, or cylindrical. In most follicles 
papillomatous excrescences were found consisting of thin 
septa of fibrous tissue covered with flat or cubical epithelial 
cells. No colloid was found anywhere and there was no 
leucocytic or lymphocytic infiltration. Vascularisation 
was normal. The brain, cerebellum, and medulla 
oblongata were microscopically normal and sections from 
the cerebral cortex, optic thalamus and caudate nucleus, 
cerebellum, and from the borderline between the pons and 
medulla were all normal, except for a mild degree of 
hyperemia. : 

E. Moller’s Case 2 (1930).1’—Male, aged 49. Developed 
myxæœdemaąa in 1913. From 1916 until 1924 thyroid 
extract was given in an average dose of 4 centigrammes 
daily. This removed all the symptoms and the patient 
was very well and able to work. In 1924, without any 
discoverable cause, palpitation, nervousness, feeling of 
heat,increased sweating, and tremor of the hands developed. 
The pulse-rate rose to about 90 and slight exophthalmos 
was noted. At the beginning of 1930 there was glycosuria. 
At this time there was bilateral exophthalmos with slight 
cedema of the eyelids and weakness of ocular convergence. 
Pulse-rate ranged between 90 and 100. There was slight 
rapid tremor of the hands. The thyroid was not markedly 
palpable. The urine was normal, except for an occasional, 
slight alimentary glycosuria. The blood-sugar was 
normal. The patient was nervous and restless. The 
basal metabolic rate was plus 78 per cent. The exophthal- 
mometer measured: right 25 mm., left 24mm. 


Moorhead’s Case (1931).18—Female, aged 54. In 1924 
was considered to be suffering from myxcdema and 
thyroid extract was prescribed, with much benefit. At 
the beginning of 1926 the dose of thyroid extract was 
increased to grs. 12} daily and this dose was taken con- 
tinuously throughout that year. Early in 1927 it was 
noted that her right eye was much more prominent than 
her left. At this time the right eye was extremely 
prominent and showed well-marked von Graefe’s sign, 
while the left appeared normal. The patient was extremely 
nervous and restless and suffered from insomnia and loss 
of weight. The pulse was rapid, the rate being 140. The 
thyroid gland could not be felt. The administration of 
thyroid extract was stopped and the patient was put to 
bed and treated with bromides. In two months the 
symptoms had largely disappeared and after six months 
the patient was practically well. As the general symptoms 
subsided the exophthalmos diminished but 18 months 
after the onset of hyperthyroidism the right eye was 
still somewhat more prominent than the left. 


Hurxthal’s Cases (1931).@—Hurxthal states that he was 
able to find 40 cases in which there seemed to be a history 
of dieting or the use of thyroid extract in patients suffering 
from exophthalmic goitre. Of this number, however, 
only 9 could be selected in which it was folt that there 
was no question as to the onset of exophthalmic goitre 
following one or other of these procedures. Of these 9 
patients 7 had taken thyroid extract. | l 


DR. RUSSELL BRAIN : EXOPHTHALMOS AND THYROID EXTRACT 


[JAN. 25, 1936 


Hurxthal’s Case 1.—Female, aged 33. In order to 
reduce weight took an unknown dose of thyroid extract 
for one year. Her weight fell from 180 to 1301b. She 
developed typical exophthalmic goitre, with pulse of 92, 
basal metabolic, rate plus 36. Subtotal thyroidectomy 
was performed and one year later weight was 162 lb., 
pulse-rate 68, basal metabolic rate plus 20. 


Hurzthal’s Case 2.—Female, aged 51. Took 1 grain 
of thyroid extract daily for six months. Weight fell 
from 164 to 1391b. She developed exophthalmie goitre. 
Pulse-rate was 76, basal metabolic rate (after Lugol’s 
solution) plus 19. Subtotal thyroidectomy was per- 
formed. One year later pulse-rate was 68, weight 146 lb., 
basal metabolic rate minus 6. 


Hurzxthal’s Case 3.—Female, aged 43. Took an unknown 
dose of thyroid extract for five months, in order to reduce 
weight. Weight fell from 162 to 131 1b. She developed 
a swelling of the neck and presented a picture of typical 
exophthalmic goitre with pulse-rate of 108 and basal 
metabolic rate plus 45. Subtotal thyroidectomy was 
performed and later the weight was 138 lb., pulse-rate 78, 
and the basal metabolic rate minus 12. 


Hurxthal’s Case 4.—Female, aged 38. Took thyroid 
extract in unknown dosage for three months. Weight 
fell from 165 to 135]b. She developed typical exoph- 
thalmic goitre, with pulse-rate of 118, basal metabolic rate 
plus 18. Subtotal thyroidectomy was performed. Basal 
metabolic rate one year later was plus 5, pulse-rate 92, 
weight 145 lb. 

Hurxthal’s Case 5.—Female, aged 19. For two months 
took one tablet of thvroid extract three times a day in 
order to reduce weight. Weight fell from 180 to 165 lb. 
She developed a typical exophthalmic goitre, with marked 
exophthalmos, a large hyperplastic thyroid gland; the 
basal metabolic rate was plus 19, the pulse-rate 104. Sub- 
total thyroidectomy was performed. Six months later 
pulse-rate was 58, weight 187} lb. and the basal metabolic 
rate minus 1l. 

Hurxthal’s Case 6.—Female, aged 55. Took 2 grains 
of thyroid extract three times a day for seven months and 
lost weight from 191? to 158}? 1b. This patient developed 
the typical picture of toxic adenoma of the thyroid with 
a small firm gland, containing small adenoma and no 
exophthalmos. Her basal metabolic rate was plus 36, 
her pulse-rate 106. 

Hurxthal’s Case 7.—Female, aged 54. In order to 
reduce weight first took a restricted diet for six months. 
She lost 20]b. and was then given thyroid extract for 
about six months. Six months after stopping the thyroid 
extract she presented the picture of severe exophthalmic 
goitre, with congestive heart failure and auricular fibrilla- 
tion. Her weight was 142 1b., her pulse-rate 116, and her 
basal metabolic rate plus 58. Subtotal thyroidectomy was 
performed in two stages and one year later her weight was 
1483 lb., her pulse-rate 96 and regular, and her basal 
metabolic rate minus 1. 


It will be seen that exophthalmos is specifically 
mentioned as being present in only 1 of Hurxthal’s 
7 cases. It is noted as having been absent in 1 case 
and in the 5 remaining cases the condition was said 
to be one of exophthalmic goitre or typical exoph- 
thalmic goitre. It may reasonably be presumed that 
exophthalmos was present in these cases also. 
Hurxthal states that with the exception of one 
patient, who was not operated on, the typical patho- 
logical picture of hyperplasia of the thyroid was 
found, the glands being in all eases enlarged clinically 
and diffusely hyperplastic. 

In the 19 reported cases thyroid extract was 
taken for obesity in 10, for myxedema in 6, for goitre 
in 2, and for epilepsy in 1. In most cases the adminis- 
tration of thyroid extract appears to have initiated a 
condition closely resembling if not identical with 
exophthalmic goitre, which persisted or grew worse 
after withdrawal of the thyroid extract. In ‘one 
case, E. Moller’s Case 1, it proved fatal; in Hurxthal’s 
cases it was treated by subtotal thyroidectomy, and 


THE LANCET] 


DR. RUSSELL BRAIN: EXOPHTHALMOS AND THYROID EXTRACT 


[JaN. 25, 1936 185 


in Stegmann’s case it was relieved by X ray irradia- 
tion of the thyroid. Pathological changes in the fatal 
case and in Hurxthal’s cases appear to have been 
those of typical exophthalmic goitre. In 2 cases no 
mention is made of enlargement of the thyroid, and 


in 2 other cases there was a goitre before thyroid 


extract was administered. In the remaining cases 
the thyroid. became enlarged in 10, while no enlarge- 
ment was noticed in 5. In 2 cases in which the 
thyroid was not found to be enlarged, Moorhead’s 
case and my case, the condition differed from typical 
exophthalmic goitre in that the patient began to 
improve as soon as the thyroid extract was with- 
drawn and made a recovery which was complete 
except for very slight residual exophthalmos. In 
3 of the 19 cases the exophthalmos was noted as 


unilateral. 


ROLE OF THYROXINE IN THE PRODUCTION OF 
EXOPHTHALMOS 


Since a very large number of persons take thyroid 
extract for long periods, some even in excessive doses, 
without developing exophthalmos, and since thyroxine 
fails to produce exophthalmos when given experi- 
mentally to normal animals, it seems probable that 
some other factor than the ingestion of thyroid 
extract or thyroxine is necessary in order that exoph- 
thalmos may develop. Recent experimental work 
yields some support for this view. Justin-Besancon, 
Kohler, Schiff-Wertheimer, and Soulié,? working with 
dogs, have found it possible to produce exophthalmos 
by means of various drugs which stimulate the 
sympathetic nervous system. These workers have 
shown that such drugs differ from one another in 
their relative influence upon the eye and upon other 
structures innervated by the sympathetic. Thus the 
least doses of substances of the adrenaline group 
which had a powerful vasoconstrictor effect led to 
only a feeble exophthalmos. On the other hand, 
other sympathomimetic drugs, such as ephedrine or 
ephedrone, caused a very marked exophthalmos in 
doses which produced a rise of blood pressure equal 
to, or even less than, those obtained with adrenaline. 
Other drugs, such as tyramine, phenylethylamine 
and paramethylethylamine, fell between these two 
groups in their relative influence on the arterial 
pressure and on protrusion of the eyeballs. The 
same workers were unable to produce exophthalmos 
in dogs by means of thyroxine, even when given in 
large and repeated doses sufficient to cause rapid 
emaciation and a marked tachycardia. They found, 
however, that thyroxine appeared to sensitise the 
eye to sympathomimetic drugs, and that when 
thyroxine was given either before or after the adminis- 
tration of such a drug it was possible to’ produce 
exophthalmos by means of a dose of a sympatho- 
mimetic drug previously inadequate to do sọ or 
to obtain a much greater degree of exophthalmos 
than could be evoked by the sympathomimetic drug 
alone. Labbé, Vilaret, Justin-Besancon, and Soulié ® 
have investigated this synergic effect of thyroxine 
upon sympathomimetic drugs in a patient who, in 
order to reduce her weight, took 10 mg. of thyroxine 
daily by the mouth. The patient soon presented 
signs of hyperthyroidism : severe and rapid emacia- 
tion, tachycardia, insomnia, and rise of basal meta- 
bolic rate, but at no time was there exophthalmos. 
They were able to produce a transitory exophthalmos, 
however, by giving to this patient on one occasion 
ephedrine and on another occasion ephedrone in 
combination with thyroxine. The same workers 
claim to have produced: exophthalmos in a patient 
suffering from spontaneous hyperthyroidism but 


without showing this symptom by the administra- 
tion of ephedrine, and they quote an observation of 
Sainton ?? on a myxcedematous patient who developed 
exophthalmos when treated with thyroxine and 
adrenaline in combination. 

These observations suggest that thyroxine while 
unable to produce exophthalmos alone can do so in 
combination with a substance capable of stimulating 
the sympathetic. 


ROLE OF THE THYROTROPIC HORMONE OF THE PITUITARY 
IN THE PRODUCTION OF EXOPHTHALMOS 


The discovery of the thyrotropic hormone of the 
pituitary has opened a new road of approach to the 
problem of the pathogenesis of exophthalmos. Marine 
and his collaborators }1~14 jn a series of experiments first 
found that bilateral exophthalmos could be produced 
in rabbits maintained on a diet of alfalfa hay and 
oats by means of the daily intramuscular injection 
of methyl cyanide. In such animals the exoph- 
thalmos was associated with thyroid hyperplasia, 
but the same workers found that exophthalmos was- 
more easily produced and more marked in rabbits 
from which the thyroid had been removed. They 
next succeeded in producing exophthalmos in guinea- 
pigs by means of the administration of the thyro- 
tropic hormone of the pituitary and found that 
exophthalmos occurred as readily and usually earlier 
in thyroidectomised than in intact animals. 

Marine and Rosen conclude from: these experi- 
ments that ‘‘the exophthalmos was brought about 
by the stimulating action of the thyrotropic factor 
of the anterior pituitary and that the thyroid gland 
took no positive part in causation.” They consider 
that thyroidectomy stimulates the anterior pituitary 
to secrete more thyrotropic hormone. They found 
that removal of the superior cervical ganglion of the 
sympathetic abolished exophthalmos, whether caused 
by methyl cyanide or by the thyrotropic hormone 
of the pituitary, and conclude from this that the 
thyrotropic hormone causes exophthalmos by acting 
through a nervous mechanism. 

Friedgood‘4 has observed the development of exoph- 
thalmos in 9 guinea-pigs out of 30 injected with 
anterior pituitary extract. In the first period follow- 
ing the beginning of daily injection of the extract, 
a prompt increase in the basal metabolic rate, asso- 
ciated with an increase in the basal pulse-rate and 
a decrease in the basal weight, was observed. The 
basal metabolic rate reached its maximum between 
the seventh and fourteenth day of treatment. After 
this the animal passed into a second period distin- 
guished by a striking refractory state or remission, 
during which the basal metabolic rate returned to 
normal or might even fall below normal. Although 
slight prominence of the eyes occurred in several 
guinea-pigs towards the tenth day of the experi- 
mental period, when the basal metabolic rate was 
approaching its highest level, the exophthalmos was 
much more marked when it developed after the 
animal had entered the refractory period, and a 
striking exophthalmos was seen only in those animals 
which were injected over a period of several months, 
and especially in those which finally developed 
abnormally low basal metabolic rates. Friedgood 
concludes that these experiments indicate that the 
exophthalmos is produced independently of the 
thyroid secretion which causes the elevation of the 
basal metabolic rate, and that the anterior pituitary 
extract is more capable of inducing exophthalmos 
when the animal is not under the influence of hyper- 
thyroidism but rather in a hypothyroid state. Scowen 
and Spence 23 also observed exophthalmos in 3 out of 


186 THE LANCET] 


14 guinea-pigs treated with the thyrotropic hormone 
of the pituitary. 


ROLE OF IYPOTIHYROIDISM IN THE PRODUCTION OF 
EXOPHTHALMOS 


The observation that hypothyroidism might, in 
certain circumstances, predispose to the occurrence 
of exophthalmos seems first to have been made by 
Kunde,’ who noted that although exophthalmos 
could not be produced in dogs by feeding with thyroid 
and only questionably in normal rabbits, marked 
exophthalmos developed when thyroid was fed to 
rabbits which had been rendered myxcedematous by 
thyroidectomy. Marine and his collaborators and 
TFriedgood, in the experiments described in the 
previous section, observed that hypothyroidism 
exercised a similar predisposing influence on the 
production of exophthalmos by methyl cyanide and 
the thyrotropic hormone of the pituitary. The rare 
occurrence in man of progressive exophthalmos 
developing after subtotal thyroidectomy appears to 
be in some respects similar. Burch? has recently 
reported one case of this, Zimmerman 2’ 8 cases, Naff- 
ziger !? one case, and Earnest and Serger? one case. 
Naffziger and Jones?® have discussed the surgical 
treatment of the condition. All these cases have 
been observed in the United States. I have seen 
two examples in “this country. This condition will 
not be discussed in detail now as it is proposed to 
do this in a later communication. Its interest, for 
the present purpose, lies in the association between 
the development of exophthalmos and hypo- 
thyroidism. The usual sequence of events is as follows. 
A patient: suffering from hyperthyroidism, with or 
without exophthalmos, undergoes subtotal thyroid- 
ectomy. Several months after the operation pro- 
‘gressive exophthalmos develops, associated with 
ophthalmoplegia and, in some cases, with papill- 
edema and visual failure. This may occur when 
the patient is suffering from postoperative hypo- 
thyroidism as indicated by a subnormal basal 
metabolic rate, and it has sometimes followed the 
administration of thyroid extract in an attempt to 
correct postoperative hypothyroidism. Progressive 
exophthalmos occurring during postoperative hypo- 
thyroidism, recalls the experimental observation of 
Marine and his collaborators, and Friedgood, that 
exophthalmos could be produced by the thyrotropic 
hormone of the pituitary in animals that had been 
deprived of their thyroid glands or during a phase 
of relative hypothyroidism. Nevertheless, in some 
instances, the development of exophthalmos appears 
to have been precipitated or accelerated by the 
administration of thyroid extract in individuals 
during the phase of postoperative hypothyroidism. 

Since thyroid extract is commonly administered 
either for the relief of myxedema or in the treatment 
of obesity, it is naturally in these cases that we should 
expect to find examples of exophthalmos appearing 
after the administration of thyroid extract. 
cases cannot afford statistical evidence that hypo- 
thyroidism plays a part in the production of the 
exophthalmos. Nevertheless, in view of the experi- 
mental and clinical facts just cited, it is probable 
that it does so. 


UNILATERAL EXOPHTHALMOS IN THYROTOXICOSIS 


The exophthalmos, in the patient reported in this 
paper, was strictly unilateral. It is a minor puzzle 
that an ocular symptom associated with a state of 
general intoxication should sometimes be unilateral. 
In two other reported cases of exophthalmos follow- 
ing the administration of thyroid extract—H. U. 


DR. RUSSELL BRAIN : EXOPHTHALMOS AND THYROID EXTRACT 


11. Marine, D., 
Such - 


19. NatYziger, H. ©. 
20. Naffziger and Jones, O. W.: Jour. Amer. Med. Assoc., 1932, 


21. Pulawski, A.: 
22. Sainton: 
23. Scowen, B.F., 


24. Stegmann, R. : 
25. Ulrich, ©.: 
26. von Notthaft, A. F. 

27. Zimmermann, L. M. 


[JaN. 25, 1936 


Møller’s and Moorhead’s cases—this symptom was 
unilateral. Unilateral exophthalmos sometimes occurs 
in spontaneous thyrotoxicosis. It was also rarely 
observed by Justin-Besancgon and his collaborators 
in their experiments with sympathomimetic drugs, 
and Friedgood states that in all his guinea-pigs in 
which exophthalmos was produced by the thyro- 
tropic hormone of the pituitary, the symptom was 
unilateral at some stage. 


CONCLUSIONS 
It is clear that the rôle of the thyroid in the patho-. 


genesis of exophthalmos is by no means simple. 


Certain conclusions, however, can be drawn from the 
experimental and clinical facts already described. 
(1) The administration of thyroid extract or thyroxine 
to normal animals and human beings is not, as a 
rule, followed by the development of exophthalmos. 
(2) Exophthalmos can be produced experimentally 
by the administration to animals of drugs which 
stimulate the sympathetic nervous system. (3) Thy- 
roxine appears to facilitate the action of such drugs 
in producing exophthalmos. (4) Exophthalmos can 
be produced by the thyrotropic hormone of the 
pituitary both in intact animals and in animals 
from which the thyroid has been removed, and there 
is some evidence that this hormone produces exoph- 
thalmos more readily in the presence of hypo- 
thyroidism. (5) Progressive exophthalmos may develop 
spontaneously following subtotal thyroidectomy in 
man even when the basal metabolic rate is subnormal, 
or may be precipitated in such individuals by the 
administration of thyroid extract. (6) Very rarely 
the administration of thyroid extract for the treat- 
ment of myxcedema, the relief of obesity, or some 
other purpose, is followed by the development of 
exophthalmos, and an example of this is reported. 
(7) It is probable, therefore, that when exophthalmos 
follows the administration of thyroid extract this is 
not a direct result of the action of the thyroid extract, 
but is due to some other. substance which in certain 
rare individuals is produced in response to thyroid 
extract. Experimental evidence suggests that this 
substance. may be the thyrotropic hormone of the 
pituitary. | 


REFERENCES 
. Béclére, M.: hae méd. de Paris, 1894, 9th ser., i., 499. 
. Burch, F. E. Minnesota Med., 1929, xii., 668. 
. Bre ee X e „and Serger, W. W., : Virginia Med. Monthly, 
D vi 


‘ Friedgood, H. B.: Bull. Johns Hopkins Hosp., 1934, liv., 48. 
» Holböll, S. A.: Ugeskr. f. laeger., 1927, xxxix., 916. Quoted 


by Mọller, E. 
. Hurxthal, L. Err. Surg. Clin. of N. Amer., 1931, xi., 441. 
Kohler, D., Schiff- Wertbeimer, and 


. Justin- Besancon, L., 
Soulié, P.: Bull. et mém. Soc. ’ méd. des hôp. do Paris, 
195. 


1931, xlvii. us 1883. 
í Kunde, M. M.: Amer. Jour. Physiol., 1927, Ixxxii., 
. Labbe, M., Villaret, M., Justin-Besançon, È; and Soulié. P. 

PU et mém. Soc. méd. des hôp. de Paris, 1931, xivii., 
97. 

10. Lawford, J. : THE LANCET, 1900, i., 310. 

TAA E. J., Spence, A. W., and Cipra, A.: 
Proc. Soc. Exp. Biol. and Med., 1931, XXİX., 822, 

12. Marine, Spence, and Cipra : Ibid., 1933, S 619. 

13. Marine, Rosen, S. H., and Cipra : ’ Ibid., . 901. 

14. Alar ing and Rosen : Amer. Jour, Med. Sci 1934, clXxxviii., 


15. Melor, E.: Acta Med. Scand., 1930, Ixxiii., 1. 

16. ‘3 : Deut. med. Woch., 1930, lvi., 1699. 

17. Méiler, H. U. : Dansk. Oftalin. Selsk. Forliande, 1928, xxviii., 
. 4. Quoted by u Moéller.?® 

18. Moorhead, T. G.: Brit. Med. Jour., 1931, i., 442. 

C ‘> Ann. of Surg., 1931, xciv., 582. 


SO Ome toe 


© oo 


xcix., 638. A 
Med. Klin., 1912, viii, <p 1235. 

Quoted by Labbé et al.’ 

and Spence, A, W.: Brit. Med. Jour., 1934, 


Wien. Klin. Woch., 1908 xix., 62. 

Therap. Monats. ., 1900, , 291. 

aA t. inn. Mod., 1898, xix. 
Amer. Jour. Med. 


ii., 805. 


e9 eee, 
Soi., 1929, 
clxxviii., 9 é 


THE LANOET| 


DR. ABDELSAMIE : EARLY AMPUTATION FOR SEVERE CRUSHES 


` 


{[JAN. 25, 1936 187 


EARLY AMPUTATION FOR SEVERE 
CRUSHING OF LIMBS 


A NOTE ON TWENTY CASES 


t 


By LOTFY ABDELSAMIE, M.B. Cairo 
LATE RESIDENT SURGEON, KASR-EL-AINI HOSPITAL 


(From the Surgical Unit, Kasr-el-Aini Hospital, Cairo) 


THIS paper is written with the object of encouraging 
very early amputation in cases where limbs have 
been severely crushed. The temptation to delay 
intervention is easily understood; the gravity of 
the injury dissuades the surgeon from advising 
the remedy of prompt amputation, even though the 
pulse be satisfactory and the patient’s condition 
‘fair. If on the contrary the general condition is less 
favourable, there is unfortunately a still more plausible 
pretext for waiting. I have twice been persuaded 
to adopt this policy of delay, and I have watched 
the state of two patients, neither of whom was 
exsanguinated, change in a couple of hours—in 
spite of saline infusion and warmth—from “‘fair”’ 
to ‘‘ moderate,” and from ‘‘ moderate ’’ to moribund. 
Their deaths and the knowledge that others were 
dying in like circumstance led me to consider the 
possibility of saving life by very early amputation. 

The theme is of course by no means new. Thirty- 
three years ago Harvey Cushing (Ann. of Surg., 1902, 
Xxxvi., 321) made a clear pronouncement regarding 
primary amputation that is still admirably modern, 
but this teaching is far too often forgotten. I venture 
to give it fresh emphasis by the following review of 
a rather intensive experience. 

In fourteen months (1933-34) I have collected 20 
cases with severely crushed limbs, all of which were 
treated at Kasr-el-Aini Hospital by early amputation. 
Of these, 19 were consecutive cases in the surgical 
unit, and were amputated by me; one was operated 
on by my colleague, Dr. Zacharia, and is included 
through the courtesy of Dr. Abdel Wahab Mooro, 
F.R.C.S. This last—a striking case of double 
amputation—will be specially referred to below. 

Of the 20 patients 2 died ; one of them suffered from 
other fractures and a severe head injury; the other, 
a woman aged 50, had her thigh amputated. In 
this woman and in all the surviving cases, the dominant 
lesion was crushing of the limb ; other injuries of small 
importance, except in one patient who had fracture 
of the contralateral femur. 

The method of treating these cases at present 
employed in the surgical unit at Kasr-el-Aini has 
been gradually developed under the guidance of its 
director, Prof. A. K. Henry, from the experience 
summarised in the following paragraphs. I shall 
therefore describe it last. 

DEFINITIONS 

It is essential in the first place to define what is 
meant by severe crushing of a limb. Imbert in 1911 
pointed out that many crushes carry in themselves 
little or no risk to life (Jour. de Chir., 1911, p. 365). 
Amongst these minor crushes he included those which 
affect the hand and the anterior half of the foot} 
Leriche in 1926 once more emphasised the fact that 
these injuries must not be called severe crushes— 
grands écrasements ; he reserves this term for more 
proximal injuries which present the following five 


- 


3 This distinction is essential. Prof. Henry, at a meeting of 
the Egyptian branch of the British Medical Association in 1930, 
showed five cases with tarso-metatarsal crushes—treated con- 
servatively by local resection of the crushed tissues—whicb had 
run aseptic courses, 


characteristics: (1) laceration and extensive stripping 
of the skin; (2) pulping of the muscles; (3) lesions 
of important vessels ; (4) lesions of important nerves ; 
(5) comminution of bone. Each of the 20 cases 
in my series conformed to.this description and I 
have grouped them as follows :—- 

Group I.—Severe crushes involving the entire foot 
requiring amputation in the leg (3 cases). 

Group II.—Severe crushes in the leg or forearm requiring 
amputation at a more proximal level in the leg or arm 


(7 cases—2 of arm ; 5 of leg). 


Group III.—Severe crushes in the leg or arm requiring 
amputation in the thigh or arm, or double amputation 


of the leg (10 cases—1 of arm; 1 (double) of legs; 8 of 


thighs). 

Oausation.—The crushing injuries in this series 
were due to the following causes: tram-cars, 8; 
motor-cars, 4; falls from a height, 4; machines, 2; 
fall of a stone, 1; train accident, 1. ` 

Age.—The average age of the twenty patients 
was 17} years; fourteen of ‘them were aged 13 or 
under. c o n 

Sex.—There was only one female in thé series; 
she was aged 50. | 


GENERAL CONDITION OF PATIENTS WITH CRUSHED 
LIMBS 
Pulse-rate on admission.—A striking feature is the 
number of cases that were admitted with relatively 
slow pulses, in spite of their severe crushes, and in 
spite too of their youth. Thus in 10 patients the 
pulse was under 100 on admission. (See Table.) 


Pulse-rate on admission. 


Group. 
Average. Maximum. Minimum. 
I. (3 cases) .. 98 109 92 
II. (7 »3 ) se 95 110 $ T4 
III. (10 ,, ) «. 96 120 70 


| 


Two time-intervals were recorded in each case: 
(a) the interval between the time of accident and the 
time of operation, and (b) the interval between the 
time of admission and the time of operation. 

The accident-operation interval (a) was 34 hours or under 
in all except three cases—two in Group I. with intervals 
of 5 and 4} hours respectively, both of which came to 
operation with fast pulses, and one anomalous case in 
Group III. with an interval of 74 hours. The average 
accident-operation interval in the entire series of 20 cases 
was just over 2} hours. 

The admission-operation interval (b) averaged just over 
1l hour, with a maximum of 2 hours and 10 minutes, and 
a minimum of 15 minutes. 


The pulse-rate during the admission-operation 
interval.—Observation showed that the pulse-rate 
during interval (b) increased in 10 cases, in spite of 
restorative treatment, remained unaltered in 3 
cases, and diminished in 6 cases. (In one early case 
the preoperative pulse was not noted.) In one 
case of the ten, where the pulse-rate increased, the 
pulse, which on admission was 100, became imper- 
ceptible before operation. The average rise in the 
other nine cases was 24 beats, with a maximal increase 
of 73, and a minimum of 2. The average fall in 
6 cases where the pulse-rate diminished was 9-8 
beats with a maximal fall of 16 and a minimum of 2. 


Note.—In two cases, though the pulse-rate observed 
immediately before operation was faster than it was on 
admission, there had been an intermediate fallin rate under 
the influence of restorative treatment. The best moment 
for intervention was therefore missed in these cases, 
though fortunately without fatal result. 


i 


188 THE LANCET] | 


DR. ABDELSAMIE : EARLY AMPUTATION FOR SEVERE CRUSHES 


(san. 25, 1936 


EFFECT OF DELAY IN AMPUTATION 


It is shown above that the average admission- 
operation interval (b) was short—just over one hour. 
In three cases, however, this interval was unavoid- 
ably extended, as the theatres were all occupied. 
The effect of this enforced postponement was striking. 
The pulses, which had been relatively slow and 
favourable at the times selected for operation, rose 
in each case to an alarming frequency during the 
comparatively short period of delay. The following 
paragraph gives details of one such case. 

Group III. (No. 22359).—Dr. Zacharia’s case of double 
amputation. Male, aged 12. Tram-car accident, Dec. 9th, 
1933. Crush of the middle and upper part of right leg ; 
continuity only maintained by skin. Left foot stripped 
of soft tissues, also left leg to level of lower third. Pulse 
on admission 100 (Temp. 36-8°C.). Accident-operation 
interval 1 hour 50 mins. Operation was fixed for half an 
hour after admission. Pulse at this time was still 100 and 
of fair tension. Operation had to be postponed for an 
hour. During this hour the pulse became imperceptible. 
Under ether, disarticulation at right knee; amputation 
at the middle of left leg. Duration of operation 30 minutes. 
Pulse again became countable at 140 about 20 hours after 
operation. Re-amputation, right thigh, on Feb. 2lst, 
1934. Discharged, healed, after 80 days. 


Two other “delayed,” but ultimately successful 
cases—one of the patients, besides a pulped right 
foot and lower third of leg, had fracture of the left 
femur—showed similar alarming accelerations. Thus 
in, three patients when amputation could not be 
performed at. the time fixed, the pulse-rate rose 
respectively in 2 hours from 96 to 140, in 1} hours 
from 102 to 175, and in 1 hour from 100 to 
‘“ imperceptible.” 

It will be seen therefore that these cases of post- 
poned amputation serve, though unintentionally, 
as control experiments. They suggest two conclusions 
regarding the early treatment of severely crushed 
limbs. (1) When the pulse is favourable the oppor- 
tunity of amputation should be seized at once. 
(2) Amputation will give patients with fast, or even 
imperceptible, pulses a chance—I think their only 
chance—of survival, provided always that these 
signs are due primarily to the crushing injury of the 
limbs themselves and not to manifest hæmorrhage 
or lesions in other parts.? 


IMMEDIATE EFFECT OF EARLY AMPUTATION 


The immediate effects of the operation seldom 
cause alarm. Asa rule there was only a small increase 
in the pulse-rate, and a slight fall in blood pressure. 
In the most serious cases, too, where amputation 
was performed whilst the pulse was already poor 
and fast, the condition was no worse after it. Thus 
the average increase of pulse-rate taken immediately 
after operation in eighteen cases was 16 beats with 
a maximum of 60 and a minimum of minus 20— 
the pulsc-rate falling 20 beats after operation. Other 
large rises of 60, 45, and 40 beats were recorded, 
the last in the fatal case with head injury, while the 
first two occurred in cases where the time of operation 
was prolonged to 40 minutes. In these two patients 
the pulse-rates had fallen during the admission- 
operation interval from 84 to 70, and from 88 to 75. 
A slow pulse therefore is no excuse for slow surgery 
in a case of crush. Operation, however, is some- 
times prolonged (1) by the presence of multiple 
injuries, and (2) by mistaking a crush for a mere 
compound fracture; time is then wasted over local 

* One anomalous case already referred to had a long accident- 
operation interval, 7} hours, During the hour between admission 
and operation the pulse-rate remained at 110. The case is 
mentioned to show that exceptions occur. Rare exceptions, 


however, are unpredictable and give no excuse for delaying 
amputation. 


treatment till the surgeon discovers that injured 
vessels and nerves call for amputation. 

The average blood pressures taken immediately 
before and after operation in fourteen cases were 
respectively 115/70 and 100/60, an average 
fall of 15/10. 

In view of these facts we can regard early, rapid, 
and simple amputation in cases of severe crush 
as relatively shock-free, 


Treatment of Severe Crushes 
To obtain this benign effect in amputation for 
crush it is necessary to insist on three things: (1) 
restorative treatment before and during operation ; 
(2) proper anesthesia; and (3) early and rapid 
intervention. 
VALUE AND LIMITATIONS OF RESTORATIVE TREATMENT 


Restorative treatment must never be omitted ; 
on the other hand, if the patient fails to show a 
quick and favourable response, it must not be allowed 
to delay amputation. In those cases, too, which 
are unfavourable, either because of the proximal 
level of the crush, or because they come too late to 
hospital, the patient should be taken at once to the 
operation room, which, we have learnt, need not 
be an orthodox theatre. Such patients often require 
treatment nearly as urgent as that for hemorrhage. 
The following example showsthat there is no place for 
any refinement that will cause delay. 

A man was brought into another service with both 
thighs crushed. The pulse-rate on admission was only 
75. The case was marked ‘for immediate operation,” 
but in the 30 minutes which elapsed while the theatre 
was prepared the pulse became uncountable, and amputa- 
tion failed to save him. 


After this event orders were given in the surgical 
unit that cases with severe crush must be taken to the 
first room available. There they are at once put 
under an electric cradle and given a large subfascial 
infusion of saline. Morphine gr.} to 4, or codeine 
gr. $ to ł is administered according to age. Simul- 
taneously—and this we think vital—local anesthesia 
with novocain is begun so that the limb shall be 
ready for the first incision 20 minutes from the 
moment the patient enters the hospital. During this 
time instruments can if necessary be flamed. 


ANESTHESIA 
We have come, in the surgical unit, gradually to 


rely on novocain infiltration in performing these 
amputations. Novocain alone was employed first 


in this series in a Group II. case on Feb. 9th, 1934. 
We use from 80 to 150 c¢.cm. of novocain in $ per 
cent. solution, with 7 drops of 1/1000 adrenaline 
per ounce, or 30c.cm. The infiltration must be 
given time to effect full analgesia, for no pain 
whatever must be caused by the operation. It is 
instructive to keep a finger on the pulse throughout 
one of these amputations in a “poor risk” and to 
note how any painful, unblocked, stimulus will 
tend to make it impereeptible. With full analgesia, 
on the other hand, the pulse often remains unaltered, 
and indeed will sometimes improve.* 

Technique.—A wide, encircling, weal is made in 
the skin; this requires from 20 to 40 c.cm. of novo- 

3 Since this was written improvement in pulse and blood 
pressure has been noted immediately after operation under 
novocain by my successor in the surgical unit, Dr. M. H. 
el Zoneiny, in a most unpromising case of double leg-amputation 
which recovered. Dr, Botros Salib, resident surgeon at Kasr- 
el-Aini Hospital, through the courtesy of Dr. Makar, 
I.R.C.S., in November, 1935, reports a remarkable case 
(1935, No. 20999) in a patient, aged 15, where an uncountable 
pulse becamo 150, and an unregistrable blood pressure, 90/50, 
after a double thigh-amputation which he performed under 


gas-oxygen anwsthesia, according to the “urgent”? technique 
described in this paper. The child recovered. 


THE LANCET] 


DR. C. BRAMWELL: GALLOP RHYTHM AND THE THIRD HEART SOUND [JAN. 25, 1936 189 


eee 


cain solution. The needle is then directed towards 
the principal nerves, and at least 10 c.cm. is injected 
into the neighbourhood of each. This quantity 
(80 c.cm.) is in general sufficient for full analgesia. 
An adult thigh, however, may require more novo- 
cain—up to 120 c.cm. , 

If the patient is nervous he may have gas-and- 
oxygen just before sawing the bone. This was given 
in this series first to a Group III. case on June 25th, 
1934. It is surprising how often the operation can 
be completed under novocain only without distressing 
the patient. 

Intraneural injections are made individually into 
the nerves before they are divided, and it is important 
to inject each nerve once more at a higher level, 
when it is drawn down from the face of the stump, 
before it is finally severed in the attempt to avoid 
terminal] neuroma. 

- Difficulties arise when other wounds require cleans- 
ing and excision. In such cases we prefer to 
administer gas-and-oxygen (or, as a second choice, 
ether) in addition to the novocain infiltration described 
above. 

. I have pointed out that the resistance of a patient 
with severe crush may be extremely frail though 
his pulse be slow and his blood. pressure normal ; 
it will soon break down if the operation lasts much 
beyond half an hour. For this reason when there 
are multiple injuries more than one operator should 
work at the same time. 


THE AMPUTATION 


The amputation in order to be rapid should be 
simple, and in some of the earlier cases guillotine 
amputations were performed. Little more time, 
however, is required for a circular amputation in the 
thigh, arm, or forearm, and for a flap amputation of 
the leg. 

It is essential, because of the hurried and therefore 
incomplete preparation of the skin, to use a separate 
knife -for dividing the deeper tissues. A couple of 
catgut sutures approximate muscles and fascia. 
The skin is closed with a few Michel clips to avoid 
bearing infection in from without by sutures. The 
wound is drained with half a split rubber tube. A 
good dressing for the stump is the sterile boric powder 
recommended by Sir Robert Jones, 


Conclusions 


l. Severe crushing injuries of the limbs can be 
clearly defined and are to be distinguished from 
minor crushes. Major crushes carry in themselves 
a grave risk of early death if amputation is not 
performed. 

2. These serious injuries are compatible for a brief 
period with slow pulses and good blood pressures. 

3. A slow pulse and good blood pressure indicate 
the moment of choice for intervention. This moment 
will soon pass. 

4. The lives of patients with fast or even imper- 
ceptible pulses can be saved by immediate amputation 
when these signs are due to the presence of crushed 
tissues in the limbs and not to grave injuries elsewhere, 
or to external hemorrhage. 

5. Amputation therefore should be performed at 
the very earliest opportunity in every case of severe 
uncom plicated crushing of the limbs. 

6. On admission to hospital the patient is brought 
at once to the first room available for performing 
amputation. 

7. Restorative treatment and novocain analgesia 
are to be administered simultaneously, and the patient’s 
limb or limbs should be analgesic and ready for 


amputation within: 20 minutes of his arrival in 
hospital. | 

8. Other injuries requiring general anesthesia 
(gas-oxygen ) for their treatment should, if possible, 
be dealt with during the amputation by another 
operator, and every effort must be made to limit the 
eae part of the treatment to less than half an 

our. 

9. Amputation under full novocain analgesia is 
a benign measure that does not shock the patient. 


GALLOP RHYTHM AND THE 
PHYSIOLOGICAL THIRD HEART SOUND* 


By CRIGHTON BRAMWELL, M.D. Camb., 
F. R.C.P. Lond. 


SENIOR ASSISTANT PHYSICIAN TO THE MANCHESTER 
ROYAL INFIRMARY 


DEFINITION 


UNDER certain conditions three instead of two 
sounds accompany each heart cycle. The familiar 
“lüb dupr” then becomes either “lib dipp dupp ” 
or “lub lub dupp.” From its resemblance to the 
sound made by a galloping horse, this triple rhythm 
has been called “gallop.” When the additional 
sound follows closely on thé second heart sound 


(Fig. 1B) the gallop: is termed ‘‘ protodiastolic,” 
but when it R p 
immediately _ p T p T 5 
precedes the ECG. AAA — NA 
first heart 
sound (Fig. 1c) 
it is termed i 2 1 2 
‘“presystolic.’? A — = \~ 
My object in | 
this communi- 
; ; 3 3 
cation is to Bg æ UY æ UU 


point out the 
importance of 
distinguishing 


between the © æ æ U æ æ U 
two types of FIG. 1.—Purely diagrammatic representa- 
triple rhythm tion of heart sounds, to illustrate time 
P ytam. relation of accentuated third beart sound 

They are fun- (3) and gallop sound (G) to first (1) and 
damentall y second (2) normal beart sounds. 

"Poar E.C.G. = Electrocardiogram. A=Normal 
different from heart sounds. B=Protodiastolic gallop. 
one another.  C=Presystolic gallop. 


The one is 

physiological ; the other pathological. Protodiastolic 
gallop is quite compatible with perfect health. 
Presystolic gallop, on the other hand, is a sign of grave 
prognostic significance. It has been called “the cry 
of the heart for help.” It warns us that the last 
reserves have been called up, and that the heart is 
struggling against desperate odds. 


PRESYSTOLIC GALLOP—CLINICAL FEATURES 


Let me give some actual figures in support of this 
statement. 

In a consecutive series of 1353 cardiac cases seen 
in private practice during the three-year period 
1930-32, I noted the presence of presystolic gallop 
in 63 patients. Of these, 1 has been lost sight of, 
55 are now dead, and only 7 are still alive. That, 
I think you will agree, is sufficient evidence of the 
gravity of this sign in prognosis. 

Only 15 of these 63 patients lived for more than 

* Based on a paper read at the section of medicine at the 


annual meeting of the British Medical Association at Melbourne, 
1935. 


190 THE LANCET] DR. C. BRAMWELL: GALLOP RHYTHM AND THE THIRD HEART SOUND 


[JaN. 25, 1936 


eighteen months after gallop was first noted. Table I. 
shows the duration of life in these patients. | 


TABLE I 
Less than 1 month eee >k aes 16 
l1- 6 months ; ee i ee oe ee 19 
6-1 8. >? oe se ee ee 12 
More than 18 months (now dead) s 8 
» » 48 o» (still living) eS 7 
62 


When one compares the 15 survivors with the 47 
who died during the same period (Table II.), one is 


TABLE II 
Lived for ' cane 
Died within 
Age. more aan 18 months. Total. 
. Under 47 — 16 16 
47-49 .. 2 ` 4 
50—59 6 13 19 
60-68 .. 7 9 16 
Over 68.. — 5 5 
— | 15 47 62 


struck by the fact that all the survivors were between 
the ages of 47 and 68. It is nut unexpected that the 
5 patients over that age should have died, but it 1s 
rather surprising that not 1 of the 16 patients under 
47 years of age should have survived. | 

The explanation of the very high mortality amongst 
the younger patients is that gallop rhythm may 
develop in association with several different types 
of heart disease (Table III.). Acute endocarditis 
and chronic Bright’s disease with high blood pressure 
accounted for 10 of the 16 deaths amongst the 
younger patients in my series ; whereas, amongst the 


TABLE III.—Died within eighteen months 


Age. Over 47. | Under 47. | Total. 
Essential hypertension .. 11 2 13 
Coronary arterio-sclerosis. 12 1 13 
Chronic nephritis.. ahs 1 { 4 5 
Acute infections .. a 0 6 6 
Miscellaneous ne aie 7 3 10 

— | 31 | 16 | 47 


older patients, essential hypertension and coronary 
arterio-sclerosis were the conditions most commonly 
found. These are more chronic diseases, and this 
appears to be the reason why the immediate prognosis 
in patients with gallop rhythm is rather less grave 
in the sixth and seventh decades than during the 
earlier period of life. 

Twenty-six patients in this series exhibited signs 
of heart failure with venous engorgement; 25 of 
these had regular heart action. This is a very 
significant clinical observation, for congestive heart 
failure is notoriously much more common in associa- 
tion with auricular fibrillation than with normal 
rhythm. The finding of normal rhythm in association 
with congestive heart failure, in these cases, suggests 
that contraction of the auricle is essential to the 
production of gallop, and that presystolic gallop is 
incompatible with auricular fibrillation. This hypo- 
thesis is corroborated by the fact that, if a patient 
with gallop rhythm develops auricular fibrillation, 
the gallop always disappears, but will recur if normal 
rhythm is restored. 


MECHANISM OF PRESYSTOLIC GALLOP 


Further corroborative evidence concerning the 
role of the auricles in the production of gallop is 
derived from experimental observations. All workers 


who have studied this problem by means of graphic 
records have found that the third sound in gallop 
is always synchronous with auricular systole. 


- Fig. 2, which is taken from one of many similar records 
made from my own cases, serves to illustrate this point. 
The upper tracing is an electrocardiogram and the lower 
a record of the heart sounds. The vibrations of the first heart 
sound (1) correspond in time to the R wave of the electro- 
cardiogram, those of the second sound (2) to the T wave, 
and those of the gallop sound (G) to the succeeding P wave. 


In order to explain the part played by auricular 
contraction in the production of gallop rhythm, 
I must briefly refer to certain events which take 


FIG. 2.—Electrocardiogram (unstandardised) and phonocardio- 
gram from a patient with gallop rhythm, to illustrate the time 
relations of the first (1), second (2), and gallop (G) sounds 
to the R, T, and P waves of the electrocardiogram. 


place during the cardiac cycle. For this purpose 
it is convenient to divide that portion of diastole 
which follows the opening of the mitral and tricuspid 
valves into three stages—early, middle, or late 
diastole. When the mitral valve first opens t the 
pressure in the auricle is much higher than that in the 
ventricle, and during early diastole blood is rushing, 
with considerable velocity, through the mitral orifice. 
During mid-diastole, the rate of blood-flow from 
auricle to ventricle is greatly reduced, and the pressure 
in both chambers rises very slowly as blood flows 
in from the great veins. The third and final stage 
of diastole is occupied by contraction of the auricle. 
When this occurs, there is a sudden rise in the auricular 
pressure, and the rate of blood-flow through the 
mitral orifice is again increased. It is important, 
however, to remember that by the time the auricle 
contracts the ventricle is generally so full that it is 
capable of accepting very little more blood. I 
would ask you to note especially, that the most 
rapid filling of the ventricle occurs during early 
diastole. | 

That is what happens when the heart is beating 
slowly. Let us now see how this is modified when 
the heart beats more rapidly. The three records 
in Fig. 3 were made on myself during the period of 
recovery from an inhalation of amyl nitrite. 


The upper tracing in each record is an electrocardiogram, 
the lower one a sphygmogram,. In the first record, the 
heart was beating at a rate of 130 per minute. In the 
second record, taken 30 seconds later, the heart-rate had 
slowed down to 110; and in the third record, taken four 
minutes later, it had returned to normal, and was beating 
at 73. In the corresponding diagrams, I have represented 
by black rectangles auricular and ventricular systole, 
as measured from the electrocardiograms. You will see 
that, when the heart-rate is 73, auricular and ventricular 


t The same applies to the right side of the heart. 


} 
THE LANCET] 


systole are separated by a time interval of more than 
three-tenths of a second, whereas, when the heart-rate 
is 110, the interval is reduced to about one-tenth of a 
second ; and, when the heart-rate is 130, there is no interval 
at all, auricular systole following immediately on ventricular 
systole. , 


In other words, in the first record, the entire 
diastolic portion of the ventricular cycle is occupied 
by auricular systole, and, even in the second record, 
auricular systole occurs very early in diastole. Now 
what is the significance of this? It means that 
when the heart is beating quickly, 
the rate of blood-flow from auricle 
to ventricle, which normally is 
most rapid during early diastole, 
is still further accelerated by con-'’ 
traction of the auricle. This I 
believe to be a factor of primary 
importance in the production of 
gallop rhythm. The abnormally 
rapid -rate of ventricular filling 
causes sudden distension of the 
ventricle. This sets its walls into 
vibration, and so produces a pre- 
systolic sound. It does more than 
that. It produces a palpable pre- 
systolic impulse, to which I shall 
refer again. l 

‘But that, is obviously not the 
whole story. If it were, every patient with tachy- 
cardia would exhibit gallop rhythm. A second factor 
is essential—namely, a lack of tone in the ventricular 
muscle. Whereas the healthy ventricle is able rapidly 
to accommodate itself to sudden changes in the volume 
of its contents, the muscle of the ventricle which is 
lacking in tone is unable to do so. If suddenly 
stretched, it will oscillate to and fro. 

This association of heart failure with tachycardia 
accounts for the grave clinical significance of gallop. 
The appearance of gallop means that the stroke 
volume of the failing ventricle is reduced to such an 
extent that the heart is no longer able to maintain 
an adequate output per minute, except by increasing 
its rate. 

To sum up, I believe that the additional impulse 


mitral stenosis. 


FIG. 3.—Electrocardiograms and optical carotid pulse tracings 
taken during recovery from an inbalation of amyl nitrite. to 
illustrate the curtailment of diastole during the tachycardia ; 
(a) $0 seconds after commencement of inhalation, (b) 110 
seconds after commencement of inhalation, (c) 360 seconds 
after commencement of inhalation. 


in presystolic gallop is produced by sudden distension 
of the hypotonic ventricle and the additional sound 
by vibrations of the ventricular wall, both these 
phenomena being the result of the abnormally rapid 
rate of filling of the ventricle, when contraction 
of the auricle occurs early in diastole. 

Other hypotheses.—It has been suggested that 
gallop rhythm may be due either to partial heart- 
block or to bundle branch block. My observations 
lend no support to this hypothesis. In my series, 


DR. C. BRAMWELL: GALLOP RHYTHM AND THE THIRD HEART SOUND [JAN. 25, 1936 191 


partial heart-block was present in only 1 of the 33 
cases in which an electrocardiogram was obtained. 
Bundle branch block, on the other hand, was relatively 
common. It was present in 7 of these 33 cases. 
This association, therefore, appeared 'to merit further 
inquiry. As a control, I examined all the electro- 
cardiograms taken in the 1353 patients amongst 
whom my 63 cases of gallop occurred, and I found 
that there were 9 cases of bundle branch block 
without gallop rhythm. Thus neither did the majority 
of patients with gallop rhythm exhibit bundle branch 


1 SM 2 3 


FIG. 4.—Electrocardiogram and phonocardiogram, from a patient with advanced 


DM 1 


(1) First heart sound (SM) systolic murmur, (2) second heart 


sound, (3) third heart sound, (DM) diastolic murmur. 


block, nor, did the majority of those with bundle 
branch block exhibit gallop rhythm. That bundle 
branch block and gallop rhythm should often occur 
together is not surprising, for both are signs of grave 
myocardial damage. There is, however, no evidence 
of a causal relationship between these two signs. 


ACCENTUATION OF PHYSIOLOGICAL THIRD HEART 
SOUND 

Let me now turn to the consideration of the “ proto- 
diastolic ” type of gallop—the type in which the 
additional sound follows closely on the second heart 
sound (lub, dupp, dupp). The term “ protodiastolic 
gallop ” is a bad one, because the epithet “ proto- 
diastolic °” is used by physiologists to describe that 
phase of the cardiac cycle which immediately pre- 
cedes the closure of the semilunar valves, whereas 
the additional sound in protodiastolic gallop occurs 
not before, but about one-tenth second after, the 
closure of these valves. There is a second objection 
to the term protodiastolic as applied to gallop. 
When the heart-rate is rapid, contraction of the 
auricle takes place early in diastole (see Fig. 3). 
Presystolic gallop then becomes ‘ protodiastolic ” 
in time. Actually the additional sound in proto- 
diastolic gallop is nothing more nor less than an 
accentuated physiological third heart sound. Much 
confusion would be avoided if it were so called, and 
if the term ‘‘ gallop ” were reserved for the presystolic 
variety. 

Now what is this ‘physiological third heart 
sound’? In many perfectly healthy young people, 
three instead of two heart sounds can be heard. 
The third heart sound is rather faint, and occurs 
about 1/10th sec. after the second heart sound. It 
can be brought out by any procedure which increases 
the rate of venous return to the heart, such for 
example as exercise or elevation of the limbs. 

Thayer į of Baltimore studied this problem both 
clinically in man and experimentally in animals, 
In a series of 231 healthy young persons whoni he 
examined, Thayer found that a third heart sound 


+ Thayer, W.S.: Trans. Assoc. Amer. Phys., 1908, xxiii., 326; 
19)9, xxiv., 71. 


> 


192 THE LANCET] 


was present in 65 per cent. He also demonstrated 
the presence of a similar sound in dogs. This sound 
corresponded in time to the sudden distension of 
the ventricles which occurs early in diastole. He 
suggested that it was produced by vibration of the 
valve cusps, set up by the first rush of blood from 
auricle to ventricle. 

This type of triple rhythm is always best heard 
in the vicinity of the cardiac apex. It can therefore 
easily be distinguished from that due to a “split” 
second sound produced by asynchronous closure of 
the aortic and pulmonary valves, which is audible 
only over the base of the heart. The third heart 
sound is a perfectly normal phenomenon. It has no 
pathological significance. l l 

To sum up, I believe that the physiological third 
heart sound is produced by vibration of the A.V. 
valves, whereas the gallop sound is due to the vibra- 
tion of the wall of the atonic ventricle. Further, the 
physiological third heart sound results from an 
acceleration of the blood-flow from auricle to ven- 
tricle, when the rate of venous return to the heart 
is increased, whereas the gallop sound is due to 
sudden distension of the ventricle, when the auricle 
contracts early in diastole. 

Now how can we distinguish clinically between 
presystolic gallop rhythm and an accentuated third 
heart sound? In the first place, the gallop sound is 
generally accompanied by a palpable diastolic impulse, 
whereas the third heart sound is not. The normal 
cardiac impulse is a single thrust. The gallop impulse 
is a double wave. This gives to the hand the impres- 
sion of a damped oscillation of the chest wall. Secondly 
the sounds in gallop (lab, lub, dupp) are almost 
evenly spaced ; whereas the accentuated third heart 
sound (lüb, duipp, dipp) is obviously more closely 
related to the preceding second than to the succeeding 
' first heart sound. Lastly, the accentuated third 
heart sound is frequently present in patients with 
auricular fibrillation, whereas fibrillation and gallop 
never occur together. . 

Mitral stenosis —Fig. 4 is taken from a patient 
with mitral stenosis. It shows the accentuated first 
heart sound and the duplicated second sound charac- 
teristic of that condition. It will be observed that 
the first component of the second sound is syn- 
chronous with the end of ventricular systole as 
indicated by the T wave in the electrocardiogram, 
and that the second component occurs about 1/10th 
second later. This second component is merely an 
accentuated third heart sound; it bears no relation 
to the P wave in the electrocardiogram, as was the 
case with the gallop sound. On the other hand, it 
does bear a constant relation to the preceding second 
heart sound, since it is synchronous with the opening 
of the mitral valve which follows the closure of the 
semilunar valves by about 1/10th second. 

Although mitral stenosis is the condition par 
excellence in which to listen for an accentuated third 
heart sound (or, as it is commonly called, a “ redupli- 
cated second sound ”), I have never met with pre- 
systolic gallop in a patient with this lesion. The 
explanation of this incompatibility is twofold. In 
the first place, gallop rhythm occurs only when heart 
failure is present or imminent. Now heart failure, 
in patients with mitral stenosis, is almost always the 
result of auricular fibrillation. This complication, 
as we have seen, excludes the possibility of gallop. 
Even in those very rare cases of mitral stenosis with 
heart failure and normal rhythm, the conditions 
present are such as to prevent the development of 
gallop. As I have pointed out, rapid filling of the 
ventricle is essential to the production of gallop, 


DR. J. J. LAWS: SONNE DYSENTERY IN A MENTAL HOSPITAL 


[JAN. 25, 1936 


but rapid filling of the ventricle cannot occur when 
the mitral orifice is stenosed. 
CONCLUSION 

In conclusion let me once again emphasise the 
grave significance of presystolic gallop, and the import- 
ance of distinguishing it from that type of triple 
rhythm which is due to accentuation of the physio- 
logical third heart sound. 


SONNE DYSENTERY IN A MENTAL 
HOSPITAL 


By J. J. Laws, M.R.C.S. Eng., D.P.M. 


ASSISTANT MEDICAL OFFICER, HORTON MENTAL HOSPITAL, 
EPSOM, SURREY — 


OUTBREAKS of dysentery due to infection with 
Bacillus dysenterie Sonne have been described 
with increasing frequency in many parts of the world 
since Sonne in 1915 demonstrated that this organism 
is a cause of the disease. Many of these outbreaks 
have mainly affected children,! 2 but one of them,’ 
in a hospital staff, was confined to adults and clinically 
showed considerable similarity to the outbreak 
at Horton Mental Hospital. A prominent feature 
of the Horton epidemic was its high infectivity among 
the patients, although no member of the staff was 
taken ill. The first cases occurred in three adjacent 
wards on the male side, but almost at once further 
cases of the same type manifested themselves in widely 
separated parts of the hospital, and efforts to control 
the spread of infection were unavailing. Strict isola- 
tion of cases was practised from the beginning and 
possible causes of propagation—such as contaminated 
food or water-supply and inadequate treatment of 
foul linen—were investigated with negative results. 
The origin of the infection could not be discovered. 
It may have been previously present in a mild or 
symptomless form, as in some of the cases in the 
outbreak described by Felsen and Osofsky.4 The 
epidemic lasted some six weeks—from the latter 
end of March, 1935, until the middle of May—and 
was followed by a further slight outbreak at the end 
of June and the beginning of July. In all 113 cases 
were recorded during the main epidemic, and 
bacteriological investigations were made on 75 of these. 

It is probable that in an outbreak of such propor- 
tions, occurring among the insane, a number of mild 
or possibly symptomless cases were missed, and this 
may explain the wide spread of the infection. 
Reference to carriers among patients in mental 
hospitals is made by Gardner ë who, in discussing 
so-called “asylum dysentery ” quotes the opinion 
expressed by H. S. Gettings “that carriers are the main 
source of infection.” A questionnaire on carriers 
cirewated by a research subcommittee of the Royal 
Medico-Psychologiecal Association € showed that ten 
hospitals recorded carriers of both typhoid and 
dysentery—three of dysentery only—in all 28 cases. 
Although the infection appears to have been of the 
Flexner type, the same may well be true of Sonne 
dysentery. 

Clinically the disease, though acute at the onset, 
was relatively benign and there were no deaths from 
the dysentery itself, although it appeared to hasten 
the death of a number of previously debilitated 
patients. The principal points in the clinical picture 
were a sudden onset, mostly with a sharp rise of 
temperature, varying from 99° F. to 104° F. (60 per 
cent. of the cases) ; vomiting (23 per cent.) often with 
considerable prostration ; and abdominal pain and 


THE LANCET] 


discomfort (20 per cent.). About 90° per cent. of the 
patients had diarrhoa commencing at the onset ; 
the motions were numerous and small, containing 
mucus, and in 23 per cent. of cases traces of blood. 
As a rule the temperature dropped in 24-48 hours, 
and the acute symptoms subsided in 1-7 days. The 
acute stage was often followed by obstinate constipa- 
tion as noted by Fraser and Smith! at Aberdeen. 
In a few cases the illness was somewhat longer, 
but in these it was not necessarily more severe ; 
indeed, many of those of short duration had a sharper 
reaction. . Recovery was usually rapid and complete. 
This description of the clinical findings is essentially 
similar to that given by other authors. In their 
“severe adult type” Felsen and Osofsky t describe 
a sudden.onset, high temperature, vomiting, prostra- 
tion, and bloody diarrhea. In their general descrip- 
tion of clinical manifestations Fraser and Smith? 
note a temperature of 99°-103° F. (53 per cent. of 
cases) for 24-48 hours, vomiting (94 per cent.), 
diarrhea (91 per cent.), blood in stools (13-5 per cent.), 
and abdominal pain (32-1 per cent.) Cann and 
Navasquez ® describe giddiness and malaise, abdominal 
discomfort and diarrhea, and pyrexia (never over 
101° F.) with return to normal in 48 hours—a slightly 
milder type of the disease. 


BACTERIOLOGICAL INVESTIGATION 


Specimens of fæces were obtained from each patient 
and inoculations were made on plates of McConkey’s 
medium. Most of the plates grew Bacillus colt in abundance, 
but certain of them showed small pale colonies of a non- 
lactose-fermenting type. These were picked off, sub- 
cultured into broth, and also used for inoculating sugars. 
Specimens from 16 cases were thus examined, and of these 
7 gave positive fermentation and agglutination reactions. 
In the fermentation tests lactose did not show the typical 
reaction (acid without gas) until the seventh day, and 
saccharose not until the tenth totwelfth day. Agglutination 
was also somewhat delayed, and it was found necessary 
to subculture in broth several times before a positive 
result could be obtained, with titres varying from 1 in 500 
to l in 1250. . 

In view of the fact that fermentation was a lengthy 
procedure and that one was apparently dealing with an 
outbreak of Sonne dysentery, further investigations were 
limited to plating on McConkey’s medium, and agglutina- 
tions of broth cultures, as advocated by Gardner. 5 

In all some 75 cases (66 per cent. of total) were 
investigated by cultural methods, of these 22 (30 per 
cent.) ‘showed the Sonne organism, The positive 
results might have been higher. if it had been possible 
to make more than one culture in each case. About 
seven weeks after the commencement of the outbreak 
the decline in the number-of fresh cases made it 
possible to undertake a second investigation, and a 
single specimen was again examined from 70 of the 
original cases. Only 3 of these ¢ gave a positive result— 
four weeks, three weeks, and one week after the onsets. 

It is generally agreed that as a rule the organisms 
disappear rapidly from the stools. Cann and 
Navasquez ? say “a few days” ; Fraser and Smith ? 
state that of 53 cases 41 were negative in a week. 
Of the remainder, 4 were negative by the second week, 
another 4 by the third week, and -3 more by the 
fourth. Only 1 was positive for seven months. 

In the early stages of the investigation serum 
agglutination tests were made on a few cases. Ten 
sera were thus tested within a fortnight of the onset, 
and nine of these gave a positive reaction with titres 
varying from 1 in 25 to 1 in 600. A more complete 
investigation was made later, at the same time as the 
second examination of freces—seven weeks after the 
commencement of the outbreak. Of the original 
113 cases 83 were examined, and of these 51 (60 per 


DR. J. J. LAWS: SONNE DYSENTERY IN A MENTAL HOSPITAL 


[yan.°25, 1936 193 


cent.) were positive, 41 of them at a titre of 1 in 125 
(the highest dilution used). In all agglutination 
tests standard suspensions and sera only were used. 


THE SECOND OUTBREAK 


As previously mentioned the second outbreak 
was small, being confined to a single ward. Cases 
had occurred there previously, but had always been 
transferred to isolation, and there had been no fresh 
cases, either in this ward or elsewhere, for about six 
weeks, Ten patients were affected during a period 
of three weeks. They all showed the usual clinical 
symptoms and were at once removed to isolation. 
Sonne’s bacillus was isolated in only two cases, but 
clinically there was no doubt of the diagnosis in all 
the ten patients. The stools of the 48 patients remain- 
ing in the ward were also investigated—a single 
culture only being made in each case, with the interest- 
ing result that three hitherto unsuspected cases were 
found to be harbouring Sonne’s bacillus. 

Although these patients never showed clinical 
symptoms, precautionary measures were taken and 
the stools of each of them were examined again on 
eight separate occasions during the following six 
weeks. Two were found to be still positive at the 
end of a month; thereafter all three were negative. 
In view of this evidence of infection in patients 
showing no clinical symptoms, it was decided to 
carry out serum agelutinations on as many as possible 
of the 48 cases in the ward, all of whom might presum- 
ably have been exposed to the risk of infection, A 
total of 34 sera were tested and 25 of these (including 
the three culturally positive cases) proved positive 
in dilutions varying from 1 in 25 to 1 in 1250. As, 
however, a small dose (125 million or ganisms) of a 
prophylactic vaccine had previously been given to 
13 of these 25 cases (again including the three with 
positive cultures) the value of these results is some- 
what doubtful. It is of more significance that of the 
21 cases not vaccinated a positive result was obtained 
in 12—nearly 60 per cent. | 


CONCLUSIONS 


Sonne dysentery is a disease of high infectivity, 
usually acute in onset and of moderately benign 
course. Most cases soon become free from infection, 
but a small number continue to harbour the bacilli, 
while others pass organisms in the stools without 
having shown any clinical symptoms. Both these 
forms of carrier may play a large part in spreading the 
disease. 

Agglutination of standard suspensions of Sonne’s 
bacillus by patients’ sera can be obtained in a large 
proportion of cases showing clinical symptoms, even 
if culture has proved negative, and also in some cases 
in which there is no clinical evidence of the disease. 
In the former type agglutination is valuable in confirm- 
ing a diagnosis, while in the latter it is possibly useful 
in “detecting carriers or latent cases. 


I wish to thank Dr. W. D. Nicol, medical superintendent 
of Horton Mental Hospital, for his kind encouragement and 
for permission to publish these cases, and also Dr. S. A. 
Mann, of the L.C.C. Central Pathological Laboratory, 
Maudsley Hospital, for his help and advice. 


REFERENCES 
Quart. Jour. Med., 


. Fraser, A. M., and Smith, J. 1930, 
XXiii., 245. 

. Soule, M. H., and Heyman, A. M.: Jour. Trop. Med., 1933, 
XXXVi., 281. 

. Cann, L. W. ., and de Navasquez, S.: Jour. of Hyg., 1931, 
XXXi., 361. 


. Felsen, J., and Osofsky, A. G.: 
1934, ciii., 966. 

5 Gardner, A. D.: System of Bacteriology ted: Research 
Council’s), London, 1929, vol. iv., p. 244 

. Jour. Ment. Sci., 1930, Ixxvi. . 808, 


Jour. Amer. Med. Aasoc., 


QO GW ke GW N m 


194 THE LANCET] 


SARCOMA OF THE DUODENUM 
By GERALD Sor, M.D., M.R.C.P. Lond., D.P.H. 


SENIOR PHYSICIAN, ROYAL WATERLOO HOSPITAL, LONDON, AND 
ROYAL HOSPITAL, RICHMOND PHYSICIAN IN CHARGE, 
RHEUMATISM SUPERVISORY CENTRE, LONDON COUNTY 
COUNCIL; AND 


M. H. FRmJgonun, M.B. Dub., B.Sc. 


CLINICAL ASSISTANT, ROYAL HOSPITAL, RICHMOND 


SARCOMA of the duodenum is rare, and compara- 
tively few cases have been reported. As Rolleston ! 
has pointed out, sarcomata involve the duodenal 
tract more extensively than carcinomata; and in 
sarcoma dilatation due to softening by the growth 
occurs, whereas in carcinoma obstruction is commoner. 
Very few cases of primary sarcoma have been 
described and therefore it is difficult to form 
conclusions. We have discovered the following 
recent records :— 

Strauss et al.? describe a lymphosarcoma of the 
duodenum located distally to the ampulla of Vater. The 
patient survived two years after a gastro-enterostomy 
and a course of deep X ray therapy. 

In the radiographic diagnosis of duodenal tumours 
Brdiczka ° points out that of 84 cases of intestinal myoma, 


only 6 were found in the duodenum. He quotes a case of- 


mvosarcoma of the duodenum in a female of 60, who died 
suddenly from lung embolism a week after operation. 
The tumour was situated in the right epigastrium, was 
attached to the bulb of the duodenum, and was the size 
of a foetalhead. There were no metastases, and the gall- 
bladder was not involved. 

Pfundt ‘ reported a case of spindle-cell sarcoma of the 
duodenum occurring in a female aged 41. She had had 
pain in the right epigastrium for a few weeks, and the 
pain was almost continuous. She had lost 20 lb. in weight 
—there was no vomiting or nausea. Her gencral nutrition 
was good and there was no distension of the abdomen. 
A tumour the size of an orange was found in the right 
epigastrium and appeared to be attached to the liver. 
A blood.count showed 10,800 leucocytes. At operation 
the tumour was found to be a large thick-walled tumour, 
filled with cysts, attached to both the gall-bladder and the 
pars superior duodeni. Processes of the tumour, 2-3 cm. long, 
were found infiltrating the lumen of the duodenum. The 
duodenal mucous membrane was normal, and after closing 
of the abdomen the patient made an uneventful recovery. 

LaRoque and Lee Shiflett ê reported the case of a female, 
aged 48, who complained of a mass in the upper thigh. 
Various small nodules had been removed during the 
previous thirteen years. There was a history of previous 
gastric trouble consisting of gastric fullness, vomiting and 
pain, but no hematemesis. The patient was found to be 
emaciated and anemic. The liver was large, and there 
was a palpable mass in the right upper quadrant. Radio- 
graphy showed that the duodenal bulb was much dilated, 
and an abdominal operation revealed a hard tumour the 
size of a hen’s egg inside the lumen of the duodenum, The 
pyloric portion of the stomach and the first three inches 
of the duodenum were removed. After temporary rallving 
the patient died suddenly from dilatation of the stomach. 
The tumour proved to be a spindle-cell sarcoma. 

Libman ® has collected 54 cases of lymphosarcoma of the 
bowel—15 of which were in the duodenum. None of the 
patients were below ten years of age, and 9 between ten 
and twenty years. He states that sarcoma is very rare, 
and has not recorded any recoveries. Possibly its course 
may be delayed by X ray and radium therapy. 

Andersen and Door 7 recorded a case of a malo, aged 37, 
who had had tarry stools for the previous seven weeks. 
This was associated with loss of weight, @dema of the 
lungs and feet, and a lump in the right side of the abdomen. 
No abdominal pains or fever. There was a tender swelling 
in the right upper abdomen which projected two inches 
below the margin of the liver; it was hard and irregular. 
This patient was not operated upon, and died six days 
after admission from shock following extensive hemor- 
rhage into the gastro-intestinal tract. At the autopsy 


DRS. SLOT & FRIDJOHN : SARCOMA OF THE DUODENUM 


[yan. 25, 1936 


the tumour was found to involve the posterior aspect of 
the second portion of the duodenum and the posterior 
and inferior aspects of the third portion of the duodenum. 
The anterior surface of the duodenum was free. Histo- 
logically it was found to be a primary leimyosarcoma ; 
it had caused compression of the inferior vena cava and 
thrombosis of the iliac veins. The authors of this paper 
state that the only other case of leimyosarcoma was 
reported by Salis in 1920.8 This case was that of a man, 
aged 40, who was found post mortem to have a large 
tumour attached to the duodenum above the duodeno- 
jejunal juncture. He had previously had an operation 
for gastric symptoms from which he recovered, leavmg 
@ tumour and fistula, and it was four months after the 
second operation for the removal of this tumour and 
fistula that he died. 

Berstein records ® a case of myoma of the duodenal 
bulb, while Gehrig !° gives an account of polyposis of the 
duodenal bulb. 


Our patient was a male, apea 38, and was first seer 
by one of us (M. H. F.) on Feb. 27th, 1934. He 
said that while dressing he had been seized with 
severe abdominal pain and had collapsed. There 
was no vomiting, but within a couple of hours he 
passed some large tarry stools. He had no previous 
history of ill-health and had never before suffered 
from any abdominal discomfort. 


On examination he showed extreme shock ; he was very 
pale and his pulse was hardly perceptible. Nothing 
definite was found on examination of his abdomen; there 
was no tenderness and no rigidity. On palpation per 
rectum nothing could be found, but proctoscopic examina- 
tion revealed melena. The heart sounds were normal 
and the blood pressure 100/70. He was first of all treated 
for shock with atropine and camphor, and heat was 
applied externally. Heart stimulants were given by 
mouth, and during the next three days his condition 
improved somewhat and the melæna diminished. 

On March 2nd he was sent to the West London Hospital 
with a diagnosis of “ bleeding duodenal ulcer.” On 
admission he was given a blood transfusion—(14 oz., 
group 4). The next day he had much melxna. He was 


treated by rectal salines, followed by Lenhartz's diet. 
During convalescence the patient complained of blurred 
Mr. H. P. Gibb reported : 


vision in the right eye. “ both 


FIG. 1.—The duodenum opened to shaw the tumour in its 
posterior wall, adherent to the pancreas. 


discs have blurred margins—there is a large oval hemor- 
rhage over the right macula, and a smaller hemorrhage 
on the nasal side of the right dise. In both fundi there 
are spots of choroidal disturbances, which may be the 
result of hemorrhages which have cleared up.’ A barium 
meal showed a hypertonic stomach. The duodenal cap 
would not fill, and there appeared to be a small crater 
where the duodenal cap is usually situated. The evidence 
was suggestive of duodenal ulcer. 

Blood counts.—In March a blood count 
red cells, 1,400,000 ; hæmoglobin, 23 per cent.; colour- 
index, 0-82; white cells, 8000; marked polychromasia, 
with poikilocytosis and anisocytosis ; nucleated red cells 
rare, The patient was given ferri et ammon. cit., grs. 40 
t.d.s., and a blood count on May 4th showed: red cells, 


showed : 


THE LANCET 


4,000,000; hemoglobin, 
0-95 ; white cells, 8000. . | 

‘Course of tlness.—Discharged in July, 1934, he was 
seen again later that month when his teeth were removed 
as a possible focus of infection. Between July and 
October he had no trouble whatever ; he gained about $ st. 
in weight, and stated that he had never felt better in his 
life. But on Oct. 23rd, and until the end of the year, 
he complained of vague abdominal pain, which he described 
as “indigestion.” This pain was relieved by alkalis. 
From the findings at the previous X ray examination the 


76 per cent.; colour-index, 


FIG. 2.—Microscopical sections of tumour: low power and 
high power. 


possibility of a small duodenal ulcer was still kept in mind, 
and early in November he was given Larostidin injections, 
5c.cm. daily, for three weeks. Between January and 
March, 1935, his symptoms gradually abated. On 
March 8th he was seen again in a state of collapse, and his 
condition exactly resembled his first attack. He was 
again removed to the West London Hospital. On this 
occasion his hemoglobin was 24 per cent., but it rose to 
42 per cent. with a month’s intensive iron treatment. 
A barium meal showed irregularity and irritability of the 
duodenal cap. The patient remained in hospital ‘until 
May, when he was discharged owing to his developing a 
mild attack of scarlet fever. On discharge he was advised 
to return later for laparotomy. From May until August 
he was free of symptoms, but on August 14th he collapsed 
_ while walking in the street and was brought home. His 
condition was again similar to his previous one, and he 
was admitted to the Royal Hospital, Richmond. Here 
he was found to be extremely collapsed and suffering from 
shock and internal hemorrhage. Nothing could be found 
on palpation of the abdomen. A blood transfusion was 
advised, and while preparations were. being made the 
patient died. 

Post-mortem examination revealed the body of a fairly 
well-nourished man. The heart and lungs were normal. 
The liver contained no secondary deposits. As will 
be seen from Fig. l, there was a tumour the size of a 
small hen’s egg at the junction of the first and second 
parts of the duodenum, adherent to the pancreas. The 
tumour was in the posterior wall of the duodenum and 
had ulcerated through the lumen. The mucosa was 
congested and red, and the bowel full of blood. No 
metastases or glands could be found. Microscopically, 
Dr. David Murray reported the tumour to be a spindle- 
celled sarcoma (Fig. 2). 

This case is interesting in view of the temporary 
recoveries and the excellent condition of the patient 
between the attacks. Clinically the outstanding 
feature was hemorrhage, and there was no vomiting 
or evidence of obstruction. No positive evidence of 
a duodenal lesion was obtained and the patient was 
well nourished at the time of decease. 

We are indebted to Dr. Geoffrey Konstam for the notes 
of the case while at the West London Hospital. 

(References at foot of next column) 


MR. R. C. TATHAM : SPONTANEOUS FRACTURE IN OSTEOMYELITIS [JAN. 25, 1936 195 


SPONTANEOUS FRACTURE IN ACUTE 
AND SUBACUTE OSTEOMYELITIS. 
REPORT OF TWO CASES 


By R. C. TaTsam, F.R.C.S. Eng. 


LATE SURGICAL REGISTRAR, MIDDLESEX HOSPITAL, LONDON 


FRACTURE is a recognised though uncommon 
complication of chronic osteomyelitis, usually due 
to excessive removal of bone for cure of a chronic 
abscess or in sequestrectomy. But fracture in 
acute or subacute cases is exceedingly rare. Thus 
Capener and Pierce’ in a series of 1086 cases of 
osteomyelitis found it in 18 (1-7 per cent.) and of these 
only 2 cases were classified as subacute and 1 as 
acute. The following cases therefore seem worthy 
of record. 


CasE 1.—A boy, aged 14, was admitted to the Middlesex 
Hospital under the care of Mr. Pearce Gould on Oct. 30th, 
1931, with a history of having eight weeks previously 
developed a painful swelling of the lower end of the left 
thigh and knee, thought at first to be tuberculous. After 
a few days a popliteal abscess had been opened and drained, 
and the pus from it showed staphylococci. There was no 
definite history of injury. On admission there was a 
wound on the inner side of the left thigh just above the 
knee discharging much pus; the knee was slightly flexed 
and there was varus deformity with great pain on attempted 
movement. The general condition was good and the 
temperature and pulse normal. Radiography (Fig. 1) 
showed a fracture through the metaphyseal region with 
impaction and angulation, and a general patchy rarefaction 
of the whole of the lower end of the shaft. Some periosteal 
new bone was visible proximal to the line of fracture. The 
deformity was corrected under general anesthesia and the 
limb put in plaster with a window. The patient was 
returned to his local hospital on Nov. 26th, 1931. A 
letter from his doctor dated Oct. 3rd, 1935, stated that 
he was at work in a garage; no operation had been 
performed since leaving Middlesex Hospital, but a sinus 
was still present though repeated X ray examinations 
failed to show any sequestrum. 

Case 2.—A boy, aged 9, was admitted to Dudley-road 
Hospital, Birmingham, on June 6th, 1935, under the 
care of Mr. Parsons, with an acute painful swelling of the 
lower end of the left thigh of four days’ duration. There 
was a history of mild injury while at school the day before 
the onset, but it was not sufficiently severe to prevent him 
running about at play afterwards. On admission (five days 
later) the pulse-rate was 106 and temperature 102-2° F. 
A popliteal abscess was opened and drained and the 
limb put up on a back splint with foot-piece and side splints. 
The lower half of the thigh remained extremely tender for 
the first week, but the local and general condition gradually 
improved, the temperature becoming normal on the 
eighteenth day after admission. X ray examination 
(Fig. 2) on the eleventh day showed a fracture with slight 
displacement through the metaphysis of the lower end 
of the femur, general patchy rarefaction of this region, and 


some periosteal new bone, most conspicuous on the inner 
1 Capener, N., and Pierce, K. C.: Jour. Bone and Joint 
Surg., 1932, xiv., 501. 


(Continued from previous column) 


REFERENCES 


1. Rolleston, H.: THE LANCET, 1901, j., 1121. 

2. Strauss, Block, Friedman, and Hamburger: 
N. Amer., 1925, v., 977. 

. Brdiczka, I. G.: Röntgenpraxie, 1931, iii., 625. 

. Pfundt, W.: Archiv f. klin. Chir., 1930-31, clxiii., 488. 

. LaRoque, G. P., and Shitlett, E. L.: Ann. of Surg., 1933, 
xeviii., 178. 

. Libman (quoted by Kellogg, E. L., and Kellogg, W. A.): 
Amer. Jour. Surg., 1933, xix., 267. 

. Andersen, D. H., and Door, E. F.: Arch. of Path., 1933, 


xvi., 795. 
. Salis, H. W.: Deut. Zeits. f. Chir., 1920, clx., 180. 
. Bernstein, A.: Beitr. z. klin. Chir., 1929, exlv., 532, 


. Gehrig, R.: Deut. Zeits. f. Chir., 1927, cevii., 286. 


© 


Surg. Clin. 


COCO u QO Oeu 


ba 


196 THE LANCET] 


and popliteal surfaces. The wound continued to discharge, 
and on Sept. 27th a further radiogram (Fig. 3) showed a 
sequestrum, which on removal proved to be a portion of 
the cortex, the lower end being just above the line of 
fracture which was no longer visible. There was a massive 
involucrum. 


In neither of these cases was there a history 
suggesting that fracture preceded the infection. 
In the first case fracture was noted eight weeks 


FIG. 1 (Case 1).—Radiograin of lower end 
of femur showing fracture through a 
diffusely rarefied area in the region of 
the metaphysis. Periosteal reaction 


region, 
slight and not related to fracture. 


after the onset of the disease and in the second case 
on the fifteenth day of the illness—i.e., earlier than 
in any other recorded case. In both cases back splints 
had been applied after the initial drainage, which 
did not involve’ the removal of any bone. The 
exciting trauma must therefore have occurred while 
the limb was on the splint or after the splint had 
been removed for a dressing. There was no note 
of any knock or sudden bend, so that it must have 
been very trivial. In Capener and Pierce’s earliest 
case fracture occurred at the junction of the middle 
and lower thirds of the femur eight weeks after 
drainage, and was due to a blow on the uncovered 
but supported thigh ; the medulla had been drained. 
In the cases here recorded no bone had been removed 
for drainage. 

' When osteomyelitis follows its usual course there is 
simultaneous weakening of bone from vascular and 
osteoclytic absorption, and strengthening of it from 
periosteal new bone-formation ; so that by the time 
the original bone has been absorbed sulliciently to 
allow of fracture enough new bone has been formed to 
prevent such an accident. If the rate of absorption 
outstrips that of new bone-formation, and if the 
absorption proceeds throughout the thickness of the 
shaft, then fracture becomes possible. The conditions 
necessary for rapid absorption are a high proportion 
of vascular tissue to bone and patent vessels, Such 
conditions are found in the metaphysis and in the 
more subacute type of case. Should all the vessels 
become thrombosed by the acuteness of the process, 


DR. J. S. COLEMAN : TWIN-LOCKING 


FIG. 2 (Case 2).—Radiogram of lower end 
of femur showing fracture with very 
little displacement through metaphyseal 

Slight but definite rarefaction. 

Some periosteal new bone posteriorly. 


[Jan. 25, 1936 


then absorption is, of necessity, osteoclytic and slow, 
the bone being a dead structure. Further reference 
to the above cases will show that they were both 
of the less acute type, the first being at first regarded 
as tuberculous, and that the fracture occurred through 
a widespread area of rarefaction in the metaphyseal 
region. There is also ə. noticeable lack of new bone: 
formation in the region of the fractures (Figs. 1 and 2). 
Furthermore the after-histories show that sequestrum- 


1wa- me . 


formation was minimal and in Case 2 not immediately 
related to the fracture. Thus the clinical and X ray 
findings and after-histories support the explanation 
of causation which has been given. 


My thanks are due to Mr. Pearce Gould, surgeon to 
Middlesex Hospital, and to Dr. F. W. Ellis, medical super- 
intendent, and Mr, K. O. Parsons, surgeon to Dudley- 
road Hospital, for permission to publish the cases. 


TWO CASES OF TWIN-LOCKING 


By J. STANLEY COLEMAN, M.B. Lond. 


LATE DEPUTY MEDICAL SUPERINTENDENT, FOREST GATE HOSPITAL, 
LONDON, E. 


APART from certain features of interest, the rarity 
of this obstetric complication would be suflicient 
reason for placing these cases on record. According 
to von Braun? the condition occurred only once in 
90,000 deliveries in Vienna. 

Case 1.—Mrs. A., aged 29, a 2-gravida, was admitted 
to the Forest Gate Hospital at 6.30 a.m. on Nov. 21st, 
1934. Labour had commenced about an hour earlier 
with a sharp vaginal hemorrhage, on account of which 
sho was sent into hospital. Tho last menstrual period 
began on March Ist, so that the pregnancy had advanced 
to about the thirtv-cighth week. 

Vaginal examination revealed an os that admitted two 
fingers, the cervical canal had not been taken up, and no 
placenta could be palpated around the margin of the os. 
A presenting vertex lightly engaged at the brim could 


—_— 


1 Eden and Holland’s Manual of Midwifery, Loudon, 1925, p.358. 


FIG. 3 (Case 2).—Radiogram of lower end 
of femur showing sequestrum (indicated 
by white lines) lying in a massive in- 
volucrum. Line of fracture not visible. 


THE LANCET] 


DR. J. S. COLEMAN : TWIN-LOCKING 


[JAN. 25, 1936 197 


be palpated with the fingers through the unruptured 
membranes. The pelvis was judged to be roomy, and on 
inquiry the patient told me her first infant weighed 12 lb. 
at birth, and the labour was quite normal. Abdominal 
examination was difficult owing to frequent strong contrac- 
tions; over-distension of the uterus was noted but 
hydramnios was not present. Only one foetal heart could 
be heard all over the lower abdomen and only one breech 
palpated with certainty at the fundus. Between pains, 
however, I thought I could palpate a second head slightly 
to the left of the midline at the lower pole of the uterus. 
A tentative diagnosis of twins was made, both foetuses 
presenting by the vertex. A catheter specimen of urine 
showed a cloud of albumin. 

Labour was allowed to proceed and twelve hours later 
vaginal examination revealed the os three-quarters 
dilated, the cervix thick all round with some cedema of 
the anterior lip. A foetal head was half engaged at the 
brim, extended, and lying in the left occipito-posterior 
position. Morphia and later chloral were administered 
and the patient obtained a little respite from the pains 
that continued strong and frequent. Fifteen hours later 
examination revealed no further advance and the woman 
was becoming exhausted. The abdomen was now very 
tender and any movement or palpation distressed the 
patient considerably. 

At 9.30 a.m. on Nov. 22nd, 28} hours after the onset of 
labour, chloroform was administered and a careful pelvic 
examination made. I found two heads firmly impacted 
at the brim. The foremost head was lying face to pubes 
in the extended position and a loop of cord was felt around 
the neck. The second heed was firmly wedged under the 
chin, against the neck and upper part of the thorax of 
the first foetus. The back of the second fœtus was in the 
midline anteriorly. 

The cervix was first gently dilated to its maximum, the 
second head pushed up out of the brim, and the first head 
completely rotated and flexed as much as possible. I 
always use my left hand for the manœuvre of manual 
rotation, so that I was able to apply the forceps without 
removing my hand from the uterus. The first head was 
gently drawn down to the vulva and delivered after 
removing the forceps, and it was soon found to be quite 
impossible to deliver the trunk, owing to the extreme 
tension on the cord and the loop drawn tightly around 
the neck which could not be slipped over the head. The 
cord was divided between forceps and the first fœtus, a 
live female weighing 5lb. 120z., rapidly delivered. 
Sharp intrapartum hemorrhage now occurred so I applied 
the forceps to the second head and delivered another live 
female weighing 5 lb. 13} oz. ten minutes later. There 
was some post-partum hemorrhage which was checked by 
rapidly expressing both placentz from the uterus. 

The case was one of binovular twins with two separate 
placentz (one of the battledore variety) and no 
membranous fusion. The puerperium was uneventful 
and the patient left hospital with the vigorous twins 
twelve days later. 

I would draw attention to the following points: 
(1) The difficulty of establishing firmly the diagnosis 
of twins without X ray examination. In my 
experience the diagnosis is often missed. (2) The 
frequency with which loops of cord around the fetal 
neck cause primary extension of the head leading to 
complications such as persistent occipito-posterior 
positions, ‘‘ face ” and “ brow ” labours and prolapse 
of an arm. In this case extension of the leading 
head allowed the second head to become impacted 
under the chin. (3) Intrapartum hemorrhage after 
delivery of the first twin should be an indication for 
immediate delivery of the second foetus. 

CasE 2.—Mrs. B., aged 27, a primipara, was admitted 
to the hospital on Nov. 16th, 1934, as a case of albuminuria 
of pregnancy. There was cedema of the legs and vulva 
and some puffiness of the face. The blood pressure was 
raised to 160/100 mm. of mercury, and the urine loaded 
with albumin. Some degree of hydramnios was noted and 
apart from the discomfort of the distended abdomen there 
were no symptoms. A diagnosis of twins had already been 
made and verified by X ray examination. The last 


menstrual period began on March 3rd, so that on admission 
the pregnancy had advanced to about 37 weeks and the 
expected day of confinement calculated in the first half 
of December. The pelvis was judged to be roomy; 
external pelvimetry revealed normal measurements, and 
on vaginal examination nothing abnormal was noted. 

With rest in bed, special diet, and mild eliminative treat- 
ment on classical lines, the general condition improved, 
the cedema completely disappeared, and the albuminuria 
diminished. The membranes ruptured suddenly on 
Dec. 5th at 10.30 P.m. and the patient went into labour. 
She was examined at 11.30 P.M., the os admitted two 
fingers, the cervix was not taken up, and a head was lightly 
engaged at the brim. The second vertex could easily be 
palpated per abdomen in the midline anteriorly. By 
6 a.M. the first head was well engaged, the dilatation 
very slow (three fingers), and it was noted the. vertex 
was extended and lying almost face to pubes. At 1.30 P.m. 
on Dec. 6th, 15 hours later, the os was fully dilated, the 
extended head was found impacted low in mid-cavity, 
lying face to pubes with marked moulding, the parietals 
overlapping the displaced frontal bones, and a large caput 
over the anterior portion of the left frontal bone. The 
pains were strong and frequent and. with the thought that 
the foetus was probably not very big the patient was 
left for spontaneous delivery to occur. 

By 4 P.M. it was manifest that the obstruction was more 
serious. The anus and vulva were cdematous, the 
patient much distressed, and the lower abdomen tender on 
palpation. There had been no advance at all and 
interference was obviously indicated. A general anzs- 
thetic was administered and a careful pelvic exploration 
revealed the extension of the leading head to be due to a 
hand being doubled under the chin. The second fetal 
head was found entering the pelvic brim along with the 
lower part of the neck and upper part of the thorax of 
the first foetus. The back of the second foetus was in the 
midline anteriorly. 

The second foetal head was pushed up and to one side, 
the leading head completely rotated and flexed as much as 
possible after dislodging the hand from under the chin. 
The whole manceuvre was carried out with the left hand, 
so that the forceps could be applied without removing 
my hand from the uterus. The leading vertex was 
drawn down to the vulva and owing to the distorted 
(somewhat quadrilateral) shape of the head, bursting of 
the cedematous perineum seemed inevitable. Right 
lateral episiotomy was at once performed and the head 
quickly delivered. The birth of the first infant, a living 
male, weight 5 lb. 8} oz., was followed by a sharp intra- 
partum hemorrhage. The second bag of membranes 
was ruptured digitally and the forceps applied to the 
second head, which was gently drawn down to the vulva, 
and the delivery of the second living male infant, weight 
6 lb. 144 oz., effected. There was a fair amount of post- 
partum hemorrhage, which ceased when the massive 
placente were expelled from the uterus eight minutes 
later. The episiotomy incision was accurately sutured 
with silkworm gut. 

The placentz exhibited partial fusion along their margin 
of contact for a distance of 4in. by strong bands of 
connective tissue and placental substance. No large 
vessel passed over the foetal aspect of the line of fusion, 
all the main vessels terminating in each placenta some 
distance from the fused margins. There were two complete 
chorionic and amniotic sacs, but along the area of contact 
the two chorionic membranes had become loosely applied 
to each other, but could be separated easily by gentle 


traction. One of the placentze was of the battledore 
variety. I regard the case therefore as one of binovular 
twins. 


(1) In this second case the primary extension of 
the head appeared to be due to a hand and arm being 
impacted under the chin. This I have found to be a 
frequent complication in difficult deliveries due to 
extension and malrotation of the foctal head. (2) In 


‘both these cases the anesthesia and manipulations 


were carried out with the patient in the left lateral 

position. By using the left hand to carry out the 

manœuvre of rotation of the head the application 
D3 


198 THE LANCET] 


ROYAL SOCIETY OF MEDICINE 


: NEUROLOGY [JaAN. 25, 1936 


of the forceps is greatly facilitated and intra-uterine 
Manipulation reduced to a minimum. (3) When 
the condition of twin-locking is suspected it is infinitely 
preferable to interfere early rather than to wait for 
the impaction to become very severe, when a 
destructive operation on the leading head would 
become necessary. 


THE INHALATION OF COMMON PINS 


By J. McFaRLanp, M.D. Liverp., F.R.C.S. Edin., 
D.L.O. 


ASSISTANT THROAT SURGEON TO THE ROYAL LIVERPOOL CHILDREN’S 
HOSPITAL AND ALDER HEY HOSPITAL, LIVERPOOL 


TuE following case may interest bronchoscopists, 
especially as it raises debatable questions. 


On Oct. 7th, 1934, a boy aged 
13 inhaled a common pin, and 
a radiogram showed it lying 
head-downwards in a posterior 
bronchiole of the right lower 
lobe. The same day a broncho- 
scopy failed to discover the pin, 
nor could I sce in the bronchial 
epithelium any evidence of the 
transit of a foreign body. No 
physical signs developed in the 
chest, and the only symptom 
was pain in the right hypo- 
chondrium, probably reflex in 
origin and due to irritation of 
the diaphragm. Several attempts 
were made to remove the pin 
under the fluoroscope, but without 
success, and after seven months 
there was no change except that 
the pin had moved downwards 
and outwards. The boy was 
quite well and but for a cough 
showed no physical signs. Apparently neither the pin 
nor the manceuvres had affected him. 

On May 8th, 1935, he coughed the pin into his mouth 
and brought it to hospital. It proved to be an ordinary 
common brass pin, tin-coated and about I4in. long. A 
small amount of mucopus adhered to it and there was a 


little erosion of the tin coating. 
since. 

In two other comparable cases the pin has remained 
in the lung for six and twelve months respectively, 
without causing any apparent pathological changes. 

One is led to inquire about the state of the lung 
epithelium in contact with the foreign body during 
these seven months, and whether a pin could be 
coughed up without there being any infection present. 
It has been stated that sooner or later infection will 
supervene and that therefore every effort must be 
made to retrieve the foreign body. My own feeling, 
based on these three cases, is that where a foreign 
body of small cross-section passes to the utmost 
depths of the lung, it does not at first set up any 
dangerous processes. Unless the foreign body can 
be seen through the bronchoscope it is well to wait 
until low-grade infection has dilated the minute 


He has been quite well 


Lateral and antero-posterior radiograms showing position of the pin. 


passages, rather than risk injuring the tissues by 
seeking for it under the direction of an external 
observer. 


I am indebted to my senior, Mr. P. Leathart, for 
permission to publish this case. 


MEDICAL SOCIETIES 


ROYAL SOCIETY OF MEDICINE 


SECTION OF NEUROLOGY 


AT a meeting of this section held on Jan. 16th 
the chair was taken by Prof. F. L. GOLLA, the president, 
and a paper on 


The Spleen, the Liver, and the Brain 


was read by Prof. B. BROUWER (Amsterdam), The 
relationship between these three organs, he said, 
could be viewed in a wider aspect since the introduction 
of the study of the so-called lipoidoses. Since 
Kinnier Wilson had first described hepatocerebral 
degeneration, knowledge of the clinical syndrome had 
been extended, and it had been shown that the patho- 
logical. changes might be widespread in the central 
nervous system. Various writers had reported 
families suffering from hepatocerebral degenerations 
in which some members had no lesions in the brain, 
and had suggested that the primary lesion should 
be sought in a damaged liver which produced or 
passed toxins having a special effect on the central 
nervous system. There were, however, still differences 
of opinion. Prof. Brouwer had, he said, bad the 


opportunity of studying three brothers suffering 
from this disease, with a classical clinical picture: 
extrapyramidal motor disturbances, brownish-yellow 
granular pigmentation of the cornea, the so-called 
ring of Kaiser-Fleischer, and mental symptoms. 
In two of them autopsy had shown hepatic cirrhosis, 
splenic enlargement, and symmetrical lesions of the 
corpus striatum. The neuroglia cells of Alzheimer 
had been seen. These lesions seémed typical of 
Wilson’s disease, but there had also been a bilateral 
pathological change in the forebrain cortex: small 
cavities, increase of glia, and newly formed hlood- 
vessels. The changes were chiefly in the frontal area, 
gradually diminishing towards the occiput, and 
strongly suggested a congenital inferiority. 

The idea that the toxin in hepatocerebral degenera- 
tion was formed in the liver had been influenced by 
analogy with Kernikterus (icterus gravis neonatorum). 
In this condition there was usually erythroblastwmia 
in the blood and liver and spleen. This was, however, 
secondary and not always present. It represented 
“regeneration after destruction, the destruction having 
caused the icterus. The brain changes varied from 
case to case, but the globus pallidus and corpus 
subthalamicum were chiefly affected. Maternal 


THE LANCET] 


toxemia had been proved to be the cause of this 
condition. In typical cases of Kernikterus the 
yellow coloration was not due to liver disease 
but to hemolysis. The analogy with hepatocerebral 
degeneration was not, therefore, a sound one. 


A case of hemochromatosis had been studied by 
Prof. Brouwer’s Institute. This rare condition was 
characterised by melanodermia, liver cirrhosis, and 
diabetes, and was almost confined to males. This 
patient, however, had also had disease of the brain: 
character changes, followed by confusion, restlessness, 
incontinence, and somnolence. After an attack 
the use of the hands and legs and speech had been 
impaired. He had also shown dysarthria, dysphagia, 
emotionalism, tremor in both arms, stiffness in the 
facial muscles, and hypotonia in limb muscles. There 
had been no pyramidal signs. At autopsy there 
had been the usual signs of hemochromatosis, a 
typical Laennec cirrhosis, fibrosis of the spleen and 
pancreas, and the cerebral lesions of Wilson’s disease. 
Two kinds of pigment were found in this condition : 
hemosiderin and a brown melanin pigment derived 
from protein. At one time the diabetes and later the 
cirrhosis had been regarded as the primary factor, 
but Prof. Brouwer thought there was a disturbance 
of iron and protein metabolism, of unknown endo- 
genous origin. The pathological changes were all 
coordinated with one another. Hemochromatosis 
associated with pseudosclerosis was not Wilson’s 
` disease, but the two conditions could not be very 
different. Hepatocerebral degenerations probably 
helonged to that class of metabolic disturbances 
which were characterised by lesions in organs with 
congenitally poor resistance. The etiological factor 
was unknown. | | 

The question arose whether such disturbances 
could be limited to special organs. Relevant argu- 
ments were found in the “‘lipoidoses,? the three 
principal ones being Schiiller-Christian’s disease, 
Gaucher’s splenohepatomegaly, and Niemann-Pick’s 
splenohepatomegaly. The first showed defects in the 
bones, especially of the skull and pelvis, and the 
cell deposit was cholesterin. In Gaucher’s disease 
it was kerasin and in Niemann-Pick’s disease it 
was partly lecithin and partly phosphatide. Niemann- 
Pick’s disease was associated with amaurotic idiocy 
and was characterised by the accumulation of an 
enormous quantity of large, pale cells filled with fine 
drops of lipoid, the so-called foam cells, in liver, 
spleen, and other organs. There was a general 
disturbance of lipoid metabolism. M. Bielschowsky 
had regarded amaurotic idiocy as a result of this 
disturbance. Prof. Brouwer described a case of 
typical amaurotic idiocy and the post-mortem 
findings, which supported Bielschowsky’s view. The 
patient was a girl, aged 18 months, with classical 
symptoms: idiocy, commencing hypertonia of the 
extremities, and increase of the deep reflexes. In 
the macula the typical white area with central red 
spot was found on both sides. The child had had 
several epileptiform convulsions, developed con- 
tractures in the limbs, and died at the age of 23. 
Autopsy revealed the typical findings; the nerve- 
cells of the cortex, basal ganglia, midbrain, pons, 
medulla, and spinal cord were all swollen and distended 
by lipoid deposits. Myelinisation was retarded in 
all four lobes, in the cord, and in the thalamus, but 
almost normal in the hypothalamus, corpus striatum, 
and midbrain. Changes were very marked in the 
cerebellum; in many places the granule cell layer 
was considerably atrophied and there was increase 
of glia everywhere. It was obvious that normal 


TUBERCULOSIS 


ASSOCIATION [yan. 25, 1936 199 
fibres might proceed from cells filled with lipoid. 
The pathological changes were limited to the ecto- 
derm, thus supporting Schaffer’s theory that the 
fundamental process in amaurotic idiocy was a 
primary affection of the nerve-cells, but in the spleen 
of this case typical foam cells had been found, though 
without splenomegaly. During the last months 
of life the quantity of lecithin in the:blood had 
increased in proportion to the cholesterin. | : 

In conclusion, he said that all the diseases he had 
mentioned, except Kernikterus, were disturbances 
of metabolism, and such disturbances need not be 
general but might show a localisation in certain 
organs. It depended on the inborn factor which 
organ would suffer. Chemistry must take the lead 
in further researches on these subjects. 


DISCUSSION 


Dr. J. G. GREENFIELD asked where the poisons 

arose, and welcomed Prof. Brouwer’s attention to the 
neglected corpus ‘subthalamicum.—Prof. BROUWER 
replied that he thought the poison might be intestinal, 
but admitted as a research worker that he had seen 
several cases where the liver had been practically 
normal, and he did not really know. 
Prof. A. MAYER thought that Prof. Brouwer’s 
Kernikterus material might throw some light on the 
lesion of the globus pallidus appearing at or soon 
after birth described by Hallevorden and Spatz, 
and its identity with the status demyelinatus of 
C. and O. Vogt. He asked if there had been any 
evidence of birth trauma.—Prof. BROUWER replied 
that he was sure there was no birth trauma. 
. Dr. E. PARKES WEBER cited some cases of family 
cirrhosis where all the usual etiological factors were 
absent; he thought such cases were a form of con- 
genital developmental disease: inborn disease which 
either appeared at birth or was potential at birth and 
appeared later. Three diseases of this kind were 
associated with cirrhosis of the liver: Wilson’s 
disease, hemochromatosis, and generalised congenital 
developmental telangiectasia (Osler’s disease). The 
most likely explanation of the cirrhosis in Wilson’s 
disease was that it was a congenital developmental 
dysbiotrophy. Hzemochromatosis belonged to the 
same group as hematoporphyrinuria and alcapto- 
nuria. Why Osler’s disease showed cirrhosis was a 
puzzle, but it certainly did.— Prof. BROUWER observed 
that there were many cases of lipodystrophy without 
mental symptoms. He had no experience of Osler’s 
disease. 

Dr. GorDON HoLMES, proposing a vote of thanks, 
commented on the curious systematised susceptibility 
of parts of the nervous system and mentioned 
manganese and other poisonings. The primary 
agents must, he thought, be multiple. 


TUBERCULOSIS ASSOCIATION 


AT a meeting of this association held at Manson 
House on Jan. 17th a discussion was opened by 
Dr. NoEt D. BARDSWELL on 


After-care of the Tuberculous in London 


The organisation of after-care in London differed, 
he said, from that elsewhere by reason of the enormous 
size of London and the unavoidable division of 
responsibility. Each of the London boroughs made 
its own arrangements, and in consequence consider- 
able variation existed as to the character and scope 
of this provision. Although in the main London 


200 THE LANCET] 


was faithful to the voluntary principle, the care 
committees were tending more and more to become 
official bodies, with, e.g., a hitherto voluntary 
secretary replaced by a secretary employed and paid 
for by the borough. The Metropolitan Boroughs 
Standing Joint Committee had recently expressed the 
view that care committees should consist. of eight 
borough councillors and seven other members 
representing voluntary charitable agencies operating 
in the borough. He doubted whether a care committee 
of this composition would prove as useful as one chiefly 
composed of individuals prepared to render personal 
service to particular patients. On the question 
whether a single officer or a committee was the better, 
he thought that when both were first-class there was 
probably little to choose, but he leaned to a com- 
mittee with a good secretary, a committee having 
the advantage that it tapped more sources, spread 
responsibility, and had greater opportunity of raising 
funds in various ways. Care work, in the broadest 
sense of the term, was the determining factor in the 
future of most patients, but to be effective it must 
be continuous. There was often a hiatus of a year 
or more during a patient’s stay in an institution. 
Much might happen in a home during this time. 
The services of a visiting almoner might prove a 
valuable link between the patient, his home, and those 
interested in his after-care. On the vexed question 
of funds for care committees the L.C.C., 
Dr. Bardswell said, had always taken the view that a 
financially aided care committee would merely be 
an additional relief agency, but although in principle 
he thought this was a sound view, assistance to be 
effective must sometimes be immediate, and a care 
committee should have command of a small fund— 
preferably raised by themselves—for this emergency 
work. 


PULMONARY CASES 


Not the least important extension of after-care 
facilities had been the establishment of the industrial 
settlements at Papworth and Preston Hall, but such 
settlements though valuable were of course no solution 
of the after-care problem, since only some 4 per cent. 
of the patients admitted proved suitable colonists. 
Work centres run on commercial lines had obvious 
limitations, but were useful within these limits; 
while the handicraft classes now to be found in 
15 boroughs were one of the most pleasing features 
of after-care work in London. Woolwich and 
Deptford had gone further, and had instituted 
cookery classes for women patients and the mothers 
and wives of patients. Another growing and effective 
factor in after-care was the L.C.C.’s policy of rehousing 
overcrowded households which contained a case of 
active tuberculosis. During last year 33°5 per cent. 
of the households recommended for removal by the 
public health department at County Hall secured 
new accommodation. The principle of letting houses 
on a new estate to a tuberculous family was not 
universally approved. Recently he had addressed 
a conference on this subject at Oxford and was 
surprised at the amount of opposition aroused by the 
proposal, experienced public health workers in the 
county expressing horror at the suggestion that 
their nice new municipal cottages should be 
contaminated by the tuberculous. 

Dr. Bardswell concluded with a brief review of 
the L.C.C.’s scheme for the boarding-out of children 
from an infected home, or to allow of a mother going 
away for treatment. On the average 150 children 
were away at any one time, 25 per cent. to remove 
them from risk of infection and 75 per cent. to allow 


TUBERCULOSIS ASSOCIATION 


[JaN. 25, 1936 


of a patient going to an institution. Other directions 
in which public authorities had in late years eased the 
burdens of care committees were by the provision 
of extra nourishment, of dentures, of beds and 
bedding, and clothes. Finally, he suggested that 
A.P. refills, even if no longer clinically effective, were 
an aid in after-care, inasmuch as they kept a patient 
in constant touch with skilled knowledge of tuber- 
culosis—a most valuable thing. 


SURGICAL TUBERCULOSIS 


Dr. J. G. JOHNSTONE (Princess Mary’s Hospital for 
Children, Margate), who followed, confined himself 
mainly to after-care in children who had suffered 
from tuberculous disease of bones and joints. It was 
generally agreed that at the present day a well- 
organised follow-up system in connexion with surgical 
tuberculosis was essential for several reasons: (1) 
Tuberculosis was a generalised infection which 
manifested itself in active processes at one or more 
sites, and, having been quiescent, might light up 
again at any time in the old lesion or elsewhere. 
(2) Recrudescence in the early stages generally arose 
insidiously, unknown to the patient, requiring a 
practised clinician to recognise its occurrence. (3) 
Arrest of the disease in the case of tuberculous bones 
and joints did not mean the final end-result. With 
the arrest of the disease, few cases retained full range 
of function in the affected part. Partial immobilisa- 
tion and “ posturisation’’ had to be maintained 
over a long period to prevent a recurrence of activity 
and to maintain the optimum position of the area 
relative to the rest of the body. Between 66 and 75 
per cent. of cases of tuberculous arthritis resulted in 
osseo-fibrous ankylosis which, in the case of children, 
took several years to become organised and con- 
solidated after quiescence. (4) To maintain the 
optimum position with relative immobilisation and 
relief from pressure or friction, some firm mechanical 
apparatus had to be worn, and this necessitated 
supervision, repair, and often renewal—depending 
on the site of disease, age of patient, and other factors 
—the appliances being eventually gradually discarded 
at the appropriate time. (5) Tuberculous disease of 
spine and hip might result in permanent disability 
from deformity or shortening, necessitating the 
constant provision of a spinal support or surgical 
boots. Such conditions left untreated resulted in 
chronic spinal arthritis in middle life from mere 
anatomical malalignment. (6) It was frequently 
necessary to contemplate surgical interference at 
some future date, and the choice of the proper time 
should be left entirely in the hands of the surgeon 
who had had charge of the patient during the active 
stages of the disease. 

It was of vital importance, he said, that effective 
surgical after-care should be carried out by the 
surgeon undertaking the in-patient treatment, to 
ensure continuity in the programme of treatment 
extended over a period of years. Moreover, his 
experience at several hospitals working along different 
lines had taught him that effective supervision in the 
after-care resulted in cases being admitted at an 
earlier stage in reactivation, with minor deformities. 
It was noticeable that cases which came from areas 
with effective after-care organisation were in better 
condition that those from areas where arrangements 
were of an indifferent character. A very compre- 
hensive system of after-care had been developed 
by the L.C.C. in connexion with cases of surgical 
tuberculosis—no small achievement in a city like 
London. Consideration of the after-care began 


THE LANCET] 


almost as soon as the patient reached hospital, when 
an environmental report was received. Notice was 
taken of the home conditions, and allowance was made 
in the ambulant period at the hospital before the 
case was recommended for discharge. The speaker 
described in detail the procedure followed in three 
groups of cases: (a) those discharged to their own 
homes within the administrative area of the L.C.C. ; 
(b) those discharged to convalescent homes or other 
institutions; (c) those discharged to other areas 
outside the administrative area of the L.C.C. Ninety- 
five per cent. of the cases of tuberculous disease of 
bones and joints discharged to London from Princess 
Mary’s Hospital, Margate, were supervised in their 
after-care from the central hospital. This after-care 
clinic was held at the County Hall every Monday. 
In spite of the steady increase in the attendance 
roll, there had been no increase in the incidence of 
reactivation, and there had been a reduction in the 
development of gross deformities requiring correction. 
The position was remarkable when compared with 
the state of affairs only a decade ago, when the 
percentage of readmissions was high and the disease 
and deformity well established. Though the after- 
care clinic entailed considerable time, trouble, and 
labour, it had proved well worth while. Any ortho- 
pedic hospital failing to have a well organised and 


conducted follow-up scheme was, in his opinion, 


accomplishing only half its function to the community 
which it served. 

Vocational training, Dr. Johnstone added, was a 
sound economic and preventive proposition, and 
he would like to see it extended to a greater number of 
cases. This country had not yet reached the American 
standard in the rehabilitation of the cripple into 
industry, but there were great possibilities. 


LIVERPOOL MEDICAL INSTITUTION 


AT a meeting of this institution, held on Jan. 9th, 
with Dr. C. O. STALLYBRASS, the president, in the 
chair, a paper entitled 


Some Aspects of Bronchial Carcinoma 


was read by Dr. E. T. BAKER-BaTeEs. After pointing 
out that this disease is recognised more often than 
it was 25 years ago, he gave reasons for doubting 
whether there has been a comparable increase in its 
incidence. The first symptoms, he said, might be 
hemoptysis, paroxysmal dyspnea, or those of pleural 
effusion or localised pulmonary infection, and in the 
early case there might be no physical signs. In 
diagnosis the position of the heart and trachea were 
of greatest significance. With collapse of the lung, 
which followed stenosis of a main bronchus, they 
were displaced towards the affected side—a most 
suggestive finding. Later, dullness on percussion, 
diminished breath sounds, and reduction in the hemi- 
diaphragmatic movements were the commonest signs. 
Radiography might show nothing if the growth was 
confined to the lumen of the bronchus or if it was 
retrocardiac. Again the shadows cast by collapse 
of the lung and the suppuration following bronchial 
obstruction might obscure the picture. Lipiodol was 
useful in the early diagnosis and in pleural effusion 
after air-replacement. It indicated the upper margin 
of the growth and showed the extent of the intra- 
bronchial growth (rat-tailed bronchus). The outline 
of the growth was nearly always convex; fusiform 
narrowing was probably due to chronic inflammatory 
changes. Dr. Baker-Bates had never seen any dele- 


LIVERPOOL MEDICAL INSTITUTION 


[yan. 25, 1936 201 
terious effects due to the lipiodol. “The value of 


‘bronchoscopy in the early diagnosis and treatment 


could not, he thought, be over-estimated. The 
technique had now been mastered sufficiently to 
permit of its being performed with ease and without 
discomfort to the patient under local anesthesia, 
and it added a certainty to the diagnosis which could 
not be obtained in any other way, by giving informa- 
tion as to the site and extent of the lesion, and 
enabling tissue to be removed for section. If any 
successful treatment could be evolved, its success 
depended on early diagnosis; one should therefore 
be prepared to investigate with the bronchoscope 
all patients presenting any of the recognised mani- 
festations of the disease. Patients with advanced 
bronchial carcinoma suffered from the mechanical 
effects of a blocked bronchus, and the introduction 
of radon seeds which would keep the lumen patent 
made their lives far more bearable by allowing 
bronchoscopic drainage and preventing suppurative 
complications. The duration of the disease depended 
upon whether the patient had a patent bronchus or 
not. If the bronchus was occluded the course was 
rapid, death occurring from inflammatory changes 
in the “drowned lung °” which formed a suitable 
nidus for pneumonic consolidation and abscess forma- 
tion. When the growth remained extrapulmonary 
the progress was slow, and the patient might live in 
comparative comfort for a couple of years. Deep 
X ray therapy often gave relief, especially where 
there were large mediastinal glands producing medias- 
tinal obstruction, but it did not seem to influence 
the primary growth in the bronchus. 


Dr. A. ADAMS said that since the foundation of 
the tuberculosis service, patients suffering from 
pulmonary diseases had been coming more and more 
to the tuberculosis officer for diagnosis, and the 
voluntary hospital now rarely saw them. This was 
well illustrated in the figures published by the depart- 
ment in Manchester, where in 1932 there were 138 
deaths from cancer of the respiratory system and a 
record of 89 cases of pulmonary carcinoma given, 
almost all of bronchial origin. The Manchester area 
appeared to be the most fertile source of this disease 
in the kingdom, thus approximating to the mining 
districts of Czechoslovakia and Saxony. Severe 
hemorrhage was a rare complication, but staining 
of the sputum occurred in about 40 per cent. of cases 
at some period. The symptoms and physical signs 
found in the chest were usually caused by occlusion 
of a bronchus or by pressure. Metastases in the 
central nervous system were commoner than the 
published reports suggested. The type of disease 
described by continental physicians as lymphangitis 
carcinomatosa had been missed by many clinicians, 
the X ray appearance being misread as miliary 
tuberculosis. The recent work of Dudgeon and 
Wrigley, showing how groups of malignant cells in 
the sputum could be rapidly recognised, was a 
valuable addition to the clinical examination. Lipio- 
dol for demonstrating the presence of a growth should 
be used with great care as it might prevent a patient 
later being submitted to deep therapy treatment, 
and was usually not necessary for diagnosis. 


Prof. HENRY CONEN emphasised that nearly a 
quarter of all cases had an acute pneumonic or pleu- 
ritic onset. Rarely the radiological features of miliary 
tuberculosis were so closely simulated by carcinoma 
that only by post-mortem examination could a 
diagnosis be established. Nearly 10 per cent. of all 
cases had a positive Wassermann reaction, though 
pathological examination proved the lesion to be 


202 


THE LANCET] 


malignant; and the association of tuberculosis with 
malignancy was by no means infrequent. ‘* Unre- 
solved pneumonia ” was a seductive though dangerous 
term, and whilst the radiologist might be justified 
in using it, the physician should recognise the possi- 
bility of an underlying carcinoma in all such cases. 
A special technique might reveal the presence of 
malignant cells in the sputum, though a negative 
finding was of no value. Three of the cases of proved 
bronchial carcinoma under Prof. Cohen’s care had 
had as their presenting symptom intense lumbar 
pain, although there was no radiological evidence of 
metastasis ; later the pain radiated up the spine to 
the neck. The possibility of metastases giving no 
radiological signs of their presence was offered as 
an explanation, though no opportunity for con- 
firmation by the post-mortem examination lad been 
afforded in these cases. The superior pulmonary 
sulcus tumour, described by Pancoast, was usually 
a bronchogenic carcinoma at the pulmonary apex. 
He had seen many cases of generalised metastases 
from a primary carcinoma of the bronchus so small 
that there was neither clinical nor radiological evidence 
of its presence during life. All the patients he had 
referred to surgeons had died within twelve months 
of operation—with one exception, that of a man 
with a pedunculated carcinoma removed from the 
right main bronchus, who was alive and well two 
years later. Both X ray treatment and radium had 
given very disappointing results. 

Mr. H. V. Forster recalled Yankauer’s suggestion 
that in all cases of hemoptysis in which no tubercle 
bacilli could be found bronchoscopy should be carried 
out, and that the endoscopist should encourage the 
physician to look upon this useful direct method as 
one not carrying a great risk. As Dr. Baker-Bates 
had pointed out, the endoscopist could help to relieve 
pulmonary collapse due to bronchial narrowing, and 
he himself had been able once to remove to a con- 
siderable extent with punch forceps a growth involving 
the left main bronchus with restoration of ventilation. 
The question whether deep X ray therapy could be 
helpful seemed to have been answered favourably 
by ‘many observers in America. Some patients had 
experienced relief for as long as five years. 

Dr. P. H. WHITAKER emphasised the importance 
of screen examination in cases of early bronchial 
carcinoma. It was often possible to detect deficient 
air-entry before it became clinically apparent by 
noting limitation of diaphragmatic movement on 
the affected side. The obstacles to eflicient irradia- 
tion were difficulty of access and the fact that a 
large enough dose could not be at present directed 
on to the tumour. This accounted for the poor 
results. 

Dr. IlowrLL Hugues said that from a surgical 
point of view there were four main types of bronchial 
carcinoma ; being classified according to radiograph- 
ical and bronchoscopic findings. (1) Intrabronchial 
carcinoma, in which the early radiographical appear- 
ance was a slight increase in the shadow of one hilum, 
and later, with bronchial obstruction, a dense wedge- 
shaped shadow spreading from hilum to periphery. 
(2) Mediastinal, which spread from a large bronchus 
into the mediastinum, but not peripherally, giving 
increase of the mediastinal shadow. (3) Peripheral, 
which spread outwards, and might invade the chest 
wall, while mediastinal glands were not involved. 
Radiographically an almost rounded shadow was seen 
in the lung, making contact with the hilum. Pan- 
coast’s tumour described by Dr. Baker-Bates was 
probably of this type, and merely because of its 
position and size caused the complications described, 


NEW INVENTIONS 


[san. 25, 1936 


and so did not justify a separate group. (4) Paren- 
chymal, which radiographically showed a rounded 
shadow in the lung distinct from the hilum, with late 
glandular involvement. In types 3 and 4 lobectomy 
or pneumonectomy might bring about cure, but 
in type 1 the most that could be done was to relieve 
obstruction by means of radon seeds. 


Mr. CosBIE Ross read a paper on Lipiodol in 
Surgery of the Biliary Passages. 


NEW INVENTIONS 


APPARATUS FOR CONTINUOUS 
ADMINISTRATION OF SALINE SOLUTION 


THE accompanying drawing shows an apparatus 
I have designed for giving continuous drip intra- 
venous saline, for use with Crookes’s bottles of gum 
or glucose saline, 


It consists of two corks to fit the bottles, each provided 
with a long and ashort tube. When the bottle is inverted, 
saline runs out of the | 
short tube, while the 
long tube allows air 
to flow in, thus pre- 
venting a vacuum 
forming. The short 
tubes are connected to 
a Y-piece, below which 
is an adjustable clamp 
and a glass visible- 
drip connexion. From 
here the saline runs 
down through a metal 
U-tube in a thermos 
flask, where itis heated 
to the required tem- 
perature before it 
reaches the vein. The 
whole apparatus is on 
a stand which places it 
at the right height 
above the bed. 

The tubes and corks 
can be removed en 
bloc from the stand, 
boiled in a steriliser, 
and fitted to the 
bottles. Boiling water 
is put in the thermos, 
and the apparatus is 
ready for use. The two 
bottles are emptied 
alternately, the omptv 
one being clamped ott 
and changed for a full one; thus the administration of 
saline may be kept up for as long as is required. 

The apparatus has proved very satisfactory in 
use, its advantages being that it is easy to sterilise 
(the contents of the bottles being already sterile), 
that it never runs out, and that the saline is 
administered hot. If necessary it can be used to 
administer saline rapidly instead of by the drip 
method, simply by unscrewing the adjustable clamp 
above the visible drip connexion. 

It has been made for me by Jack Storey, Station- 
road, Ashford, Middlesex. 

C. E. Watson, M.R.CS., 


House Surgeon, King Edward VIIth 
Hospital, Windsor. 


Thermos Flask 


ROYAL SANITARY INSTITUTE.—Mr. John Wilson, 
chief architect to the department of health for Scotland, will 
open a discussion on the sanitation and planning of flats ata 
meeting to be held at the institute (90, Buckingham Palace- 
road, London, S.W.) on Tuosday, Feb. llth, at 5.30 r.m. 


mie Se ee o i e 


THD LANCET] 


[Jan. 25, 1936 203 


REVIEWS AND NOTICES OF BOOKS 


A Text-book of Fractures and Dislocations 
Third edition. By KELLOGG SPEED, S.B., M.D., 
<- F.A.C.S., Professor of Clinical Surgery, Rush 
Medical College of the University of Chicago. 
London: Henry Kimpton. 1935. Pp. 1000. 50s. 


TuIs book presents an exhaustive account of the 
subject of fractures and dislocations; for example, 
three and a half pages are devoted to fractures of the 
laryngeal cartilages. The pathology and mechanism 
of each fracture is dealt with at some length, and 
as the unusual types of fracture receive considerable 
attention, the importance of the work to the practising 
surgeon is obvious. Different methods of treatment 
of each fracture are considered and compared—e.g., 
every type of suture material and every incision 
used in repair of fracture of the patella is described. 
The author mentions in the preface that he has been 
at pains to avoid fads; but from the point of view of 
the surgeon faced with the immediate treatment of 
a case, a definite description of the method employed 
by the author, and evolved by his own experience, 
would have been helpful. The references in the text 
and at the end of each chapter to the work and writings 
of various surgeons should be of great use to the 
research student. 

An individual feature of the book is the method of 
illustration by line drawings which are tracings from 
original radiograms. These are well drawn and are 
most convincing. It is interesting to find that in 
applying suspension traction for fractures of the 
femur, the author uses the body-weight of the patient 
as the extending force, and does not apply weights 
to the limb. This method, an excellent one in 
practice, seems to be too little used. Its great 
advantage is that it allows considerable mobility of the 
patient, and of the limb as a whole, without upsetting 
the line of traction or the finely adjusted suspension 
of the splint. 
hang at the head of the bed, well out of the way. 
The section on operative treatment contains an 
excellent account of the methods of application of 
skeletal traction, with instructions for avoiding its 
two main dangers—infection and over-extension. 
There seems to be some ambiguity in the description 
of the angle of flexion advised in the treatment of 
supracondylar fracture of the humerus. An angle 
“ never more than 60,” and flexion “ as far as possible” 
are mentioned in the same paragraph (p. 374). Full 
supination is recommended for this fracture, a posi- 
tion which Böhler and others have condemned on 
very definite grounds. 

We can congratulate author and publishers on a 
work which is well-produced, clear and precise, and 
pleasant to read. 


Die Differentialdiagnose 

Erkrankungen 

By W. BRAEUCKER, Hamburg; H. F. O. HABER- 

LAND, Köln; H. KLrose, Danzig; and M. ZUR 

VERTH, Hamburg. Edited by H. F. O. Haberland. 

Berlin: Walter de Gruyter and Co. 1935. Pp. 1180. 

R.M.52. 

Tus large book on surgical diagnosis is intended, 
the authors affirm, for students and practitioners. 
It may well prove to be too large a work to appeal 
to undergraduates, but on the other hand many 
surgeons will wish to possess it as a work of reference. 
It is well and simply written and easy to read, and 
deals systematically with the diagnosis of surgical 


chirursischer 


All weights suspending the splint _ 


diseases of all parts of the body. The illustrations, 
over 450 in number and of high quality, include not 
only photographs of surgical affections but radio- 
grams of diagnostic interest and very useful diagrams 
of methods of examination. The section dealing 
with the nervous system is particularly valuable 
in this connexion. An attractive and rather unusual 
feature of the book is the short epitome of treatment 
which follows the account of each disease. 

The work is a creditable compilation of present- 
day surgical diagnosis. 


Practical Zoology 

By H. R. HEWER, A.R.C.8., D.I.C., M.Sc. Lond., 

F.L.S., Lecturer in Zoology, Imperial College of 

Science and Technology. London: Hutchinson’s 

Scientific and Technical Publications. 1935. 

Pp. 118. 5s. 

Tus book contains a set of detailed instructions 
for observation and dissection of the usual type- 
specimens used in an elementary course of zoology, 
together with an account of methods of fixation, 
preservation, section cutting, and mounting of 
specimens. There is nothing particularly original in 
the subject matter nor in the manner in which it is, 
presented. Those, however, who are about to teach 
elementary zoology in universities or schools will do 
well to refresh their memories by a study of its pages 
and may find that it fits their ideas closely enough 
to enable them to base their course on it. To 
students working on their own this book should 
prove extremely useful. 


1. Elementary Morphology and Physiology 
for Medical Students 
Second edition. By J. H. Woopcer, D.Sc., 
Reader in Biology in the University of London. 
London: Humphrey Milford, Oxford University 
Press. 1935. Pp. 498. 12s. 6d. 

2. Practical Biology for Medical Students 
By C. J. WALLIS, M.A., Master-in-charge of Biology, 
University College School, Hampstead. London: 
William Heinemann (Medical Books) Ltd. 1936. 
Pp. 247. 12s. 6d. 

1. Thelarge number of bookson elementary zoology 
which have appeared during the past twenty years 
may roughly be divided into two classes : those which 
describe the structure of a series of animals in entire 
isolation from one another (the majority), and those 
which deal with general principles but do not give 
sufficient facts to make those principles intelligible 
to the beginner. As an introduction to comparative 
morphology Dr. Woodger’s book is one of the best 
we have seen. The structure of the types and the 
embryology of the vertebrates are well described with 
good illustrations, and the facts are coérdinated and 
are given a real significance in relation to general 
principles such as adaptation and evolution. It is 
in fact a book which can be read with interest during 
a course of dissection. The emphasis is laid on 
morphology. This for beginners is probably advis- 
able, and the author has not given as much life to 
his chapters on physiology as he has done to those 
dealing with structure. It is to be regretted that 
in the last theoretical chapter, which has been 
rewritten in the second edition, the evidences for 
the theory of evolution are not discussed in the light 
of the relevant facts which are all supplied in various 
places but not co6drdinated. 


904 THE LANCET] 


REVIEWS AND NOTICES OF BOOKS’ 


(JAN. 25, 1936 


2. This is an improvement on other elementary 
practical books in that an attempt is made to 
illustrate the principles of biochemistry and physio- 
logy from animals as well as from plants. The 
experiments suggested are such as can be performed 
without complicated apparatus. It is to be regretted 
that simple experiments in animal physiology such 
as the action of cilia, muscles and nerves, fertilisation, 
growth, and regeneration are not included. The 
directions for dissection, preparation of slides, and 
observation of embryological material are good, but 
not better than those to be found in many other 
text-books. 


Traité de physiologie, normale et patho- 
logique 
Tome X. (deux fascicules). Edited by G. H. 
RoGER, Hon. Professor of Physiology, and L. BINET, 
Professor of Physiology in the Faculty of Medicine, 
Paris. Paris: Masson et Cie. 1935. Pp..1580 
(2 vols.). Fr.220. 


ALTHOUGI this work consists of 11 volumes, that 
now issued, Vol. X., completes it, for the eleventh 
volume has already run into two editions. Vol. X. 
is the longest of all, and is divided into two separately 
bound parts, the second of which deals mainly with 
the special senses. Multiple authorship makes 
inappropriate any general criticisms; some of the 
articles would make books in themselves. It would 
almost be easier to review the Bible, which is at least 
divided into the Old and New Testaments. The 
subjects now treated are as follows : psychophysiology, 
cerebellum, pons and medulla, spinal cord, cerebro- 
spinal fluid, cranial nerves, autonomic nervous 
system, physiology of skin, touch, speech, hearing, 
vision, taste, smell. The style and approach of the 
numerous authors are as various as their subjects, 
but the articles on the cerebellum and the autonomic 
system may be picked out as most in keeping with 
the modern physiological viewpoint. The former is 


based on phylogenetic as well as on experimental © 


studies, and is as sound an account of cerebellar 
function as could be written in the present state of 
the subject. The latter provides an excellent historical 
résumé of the numerous generalisations which have 
been attempted from time to time on the function 
of the vegetative nervous system, besides giving a 
good account of its physiology. The bibliography of 
the article on the cerebellum is good, and the list of 
references to literature on the sympathetic and para- 
sympathetic appears to us to be exhaustive. 

The other articles, with the exception of that on 
speech which treats the subject historically and is 
extremely interesting, are dominated by the old 
“anatomical ” tradition ; they are encyclopzxdic but 
lack vitality. One must hasten to add that reflex 
action is dealt with in Vol. IX. of the series, and in 
a comprehensive work of this sort a place must be 
found for the bread and butter as well as for the 
cakes and ale. Although some of the sections make 
dull reading, this is often inevitable and does not 
detract from their value for purposes of reference. 
The well-illustrated and full account of the cranial 
nerves and their lesions is excellent, and is perhaps 
the most conscientiously written part of the book. 
The article on the cerebro-spinal fluid also contains 
much useful information, clinical and pathological as 
well as physiological. The remainder of the articles 
are no more, and sometimes rather less, than one 
would expect. The physiology of the skin is treated 
thoroughly and unimaginatively, but is misplaced, 
having nothing to do with the nervous system ; 


there is a separate section on the physiology of touch. 
If the skin article had been omitted and that on 
vision correspondingly enlarged (and treated as 
methodically), the balance of the book would have 
been improved. 

Speaking generally, we can definitely recommend 
this volume as useful, particularly to those wishing to 
restore contact with the often neglected French 
literature. In places it is outstanding, and those who 
contemplate adding it to their library will be well 
advised to consult its pages on the subjects in which 
they are especially interested and be guided by their 
impressions after such a survey. Most of them will 
proceed to business. 


Diseases of the Nose and Throat 


For Practitioners and Students. By CHARLES J. 
IMPERATORI, M.D., F.A.C.S., Professor of Clinical 

' Otolaryngology, New York Post-Graduate Medical 
School ; and HERMAN J. Burman, M.D., Instructor 
of Clinical Otolaryngology to the Medical School. 
London and Philadelphia: J. B. Lippincott 
Company. 1935. Pp. 723. 35s. 


Tus book is, as stated in the preface, written to 
supply answers to the questions with which the 
practitioner and senior student are constantly 
confronted, ‘‘ what is the diagnosis of this condition 
and how shall I treat it?” The arrangement is 
unusual, in that symptoms, diagnosis, and treatment 
are placed first, and the pathology and causation 
of the diseases are considered at the end of each 
discussion; this has the advantage of enabling 
the busy reader to find the treatment recommended 
quickly, but it often makes it difficult to visualise 
the precise condition under discussion. For instance, 
the symptoms, diagnosis, and treatment of ulceration 
of the nasal septum are described, and at the end of 


‘the section we find, under the heading ætiology, 


that it may be caused by such general diseases as 
tuberculosis and syphilis which, however, have not 
been mentioned in the paragraph on treatment. 
The book is arranged throughout in tabular form, 
which does not make for easy reading ; indeed, it is 
obviously intended rather for quick and ready 
reference than to give the student a comprehensive 
knowledge of disease. This method is unsuited to 
teaching the characteristics and behaviour of such 
a protean affection as tuberculous laryngitis, or to 
giving real help in the diagnosis of cancer of a vocal 


cord. The arrangement of the work naturally makes 


for dogmatism and for errors of statement. Of 
malignant disease of the tonsil it is said that 
extirpation by surgery or electrosurgery is impera- 
tive; treatment by radiotherapy, not mentioned 
here, is discussed in a separate section of the 
book. Killian’s operation on the frontal sinus is 
recommended as the external operation almost 
universally employed; in this country it has been 
largely replaced by a limited opening through the 
floor of the sinus with removal of .the fronto- 
ethmoidal cells. In the treatment of chronic 
laryngitis, potassium iodide in doses of 15 drops 
is advised. 

These criticisms are called for. But the important 
thing remains that the work is exhaustive in scope, 
covering concisely almost every disease and lesion 
of the throat and nose; the technique of methods 
of examination and treatment is well described and 
illustrated, and there is a good index. While it is 
hardly to be recommended to the student desiring 
to gain his first general knowledge of the specialty, 
it will be useful to him, and to the practitioner. 


THE LANCET] 


THE LANCET 


LONDON: SATURDAY, JANUARY 25, 1936 


KING GEORGE V 


. ALTHOUGH the final illness of His Majesty 
King GEORGE V. was brief the country had been 
acquainted by regular bulletins of the ominous 
nature of his symptoms. All must have known 
from the very onset, medical men and public alike, 
that the issue might be the gravest, taken in 
connexion with his serious illness of seven years 
ago. We then had Jaid before us, in regular and 
candid statements, the story of a brave man’s 
struggle, now advancing, now decliping back, now 
reaching a point when victory might reasonably 
be expected, and now falling to the level when 
nothing but defeat could be anticipated. The 
story, then unfolded to us with pathetic clearness, 
none can have forgotten, and the wonder has been 
that the survivor of such an ordeal should have 
been able to face the responsibilities of a real 
and active monarch, one who lived up to his own 
ideal as father of his people. Great worker and great 
sportsman as the KiNG was he met with anxious 
conscientiousness his multifarious engagements 
despite his physical delicacy. He lived and he 
has died a great King, and not only is this the 
knowledge of his sorrowing subjects to-day, but it 
will be the certain verdict of posterity when the 
vast events of his reign are seen in their proper 
perspective. It is a fine and consoling reflection 
that the occasion of his jubilee offered a unique 
opportunity for a demonstration of genuine affection 
and admiration from all classes, and his last broad- 
cast, put the seal upon those feelings of love which 
were felt for him asa man. The Kine spoke, with 
obvious emotion, of the personal link existing 
between himself and his people. “I am thinking,” 
he said, ‘‘ not so much of the Empire itself as of 
the individual men, women, and children who live 
Within it, whether they are dwelling here at home 
or in some distant outpost of the Empire.” His 
closing words were: “I send to you all, and not 
the least to the children who may be listening to 
me, my truest Christmas wishes, and those of my 
dear wife, my children, and grandchildren who are 
with me to-day.” The message was heard through- 
out the world, and drew for the millions who 


heard it a picture of the great ruler as one who 


cared for his subjects as a father. 
Kryc GEORGE V. was born on June 3rd, 1865, 
at Marlborough House, and succeeded to the 


throne on May 6th, 1910, being crowned at West- 


_ KING GEORGE V. 


minster Abbey in June of the following year. He 
was the only surviving son of his father, an elder 
brother, the Duke of Clarence, having predeceased 
that father. For a brief period he made use of 
the ancient royal title of Duke of Cornwall, until, 
after a fitting interval, he became Prince of Wales. 
Before he was heir to the throne he remained a 
working officer in the Royal Navy ; his record in 
the Senior Service was that of a capable and 
strenuous officer, and he never lost his deep love 
of the sea. There is no doubt that the devotion 
to duty and the bonne camaraderie which dis- 
tinguishes the personnel of the Navy counted for 
much in the manner in which the Kinc met his 
responsibilities and filled his post as the National 
Chief, for rectitude, . simplicity, and sympathy 
formed his daily expression of conduct. Assuredly 
in the dealings of his kingdom with other countries 
these plain characteristics of our ruler played an 


effective part. He may not have had the intimate ] 


knowledge of the Royal circles of Europe which 


made his father so conspicuous a figure in con- $ 


tinental politics, but he was as free from party 


bias as Kina EDWARD, and as firm in the times | 


of political unrest prevalent at his accession to the 
throne as his father had been before him, as 
respectful to the constitution and to the authority 
of Parliament, and as sound in his knowledge of 
affairs. 


with the world issues in which the war involved 
the Empire, Kina GEORGE, in public and private 
capacity alike, proved himself a veritable leader 
and example. He was throughout unsparing in his 
efforts, loyal to his advisers, and a sharer prac- 


~ ePi. 
nre Ny a 


RE te a 


When all political dissensions became of | 
secondary importance to the nation by comparison § 


[vax. 25, 1936 205 


a 


as 


oy co ei 
g -A "6 ae 


tically in the anxieties and privations of his p 


subjects. 


he reaped a splendid harvest of personal affection $ 
from his subjects who year by year and even $ 


day by day grew to have a better understanding 
of their Kina. We all knew that he was a good 


Thus in the third period of his reign es 


man, and it must surely add poignancy to our Š 
grief to recall that this patriot in the largest sense $ 


had so intimate a love for England. The KINęg’s 


love of England, English scenes, English sports, $ 


and his English domestic life endeared him to his 
subjects in a very particular sense. It has been 
well known to his medical advisers for some years 
past that he could have enjoyed more certain 


health and probably prolonged his days by spending 


the winter months at warmer and more sheltered 
places than his London or his Sandringham homes, 
but the Kine remained in England not only from 
that sense of duty which made him the most 
serviceable of monarchs, but because the Norman 
castle, which gives to the Royal House its present 
name, and the heaths and marshes of Norfolk 
made an appeal to him more urgent than the 
balmier prospects of the continental health resorts 
could offer. He did not avail himself of climatic 
advantages which are only open to a small 


mat N 


x 


206 THE LANCET] 


THE CAUSES OF VARIATIONS | 


[yan. 25, 1936 


proportion of his fellow Englishmen, and in their 
memory of him this will count. ` 

To the profession of medicine Kinc GEorcE V. 
was always a sterling friend, and although his 
name is not associated, as is that of his father, 
with any medical movement of a significance com- 
parable to the foundation of King Edward’s 
Hospital Fund, it has been abundantly apparent 
that in deed as in will he realised the importance, 
in all the social history of to-day, which underlies 
medical service. And his deep interest in the 
voluntary hospitals of the country was manifested 
in the xgis which he extended to the voluntary 
hospital movement, where he carried on his father’s 
work, and in the fact that during his reign it 
became an established tradition that members of 
the Royal Family should be heads of hospitals, 
and that the Royal Family should take part in a 
practical manner in all developments of medical 
charity. 


THE CAUSES OF VARIATIONS 


THE discovery and use of cabbages which would 
stand the winter in northern climates was an event 
of a sanatory importance comparable to that of 
the invention of vaccination against small]-pox. 
When there were no winter greens available for 
man and no turnips or swedes to provide fresh 
meat, the population must have come to the early 
spring in poor trim, for scurvy and near scurvy 
-= must have been the common lot and dovecots were 
only for the few. The first flush of edible green 
in the countryside is still often welcomed by 
nibbling the hawthorn buds on the roadside 
though perhaps those who do it know the reason 
for their ritual as little as the cook knows why 
there should be greens of some sort every day. 
With his unerring instinct for what is good, man 
seized on the cabbage and has grown it in one 
form or another as universally as he has the 
potato, partly for himself and partly for his 
animals. And many varieties there are—spring 
cabbage, curly kale, cauliflower, brussels sprouts, 
kohl-rabi, and the rest. All of them breed true 
to seed and with ordinary luck we can have kale 
or broccoli at will, which means that all this varia- 
tion is due to germinal changes and not to environ- 
ment or special methods of cultivation. They are 
all in fact sports, or as we say nowadays mutations, 
of the plain wild Brassica oleracea which lives here 
and there on our southern coasts and behaves in 
winter like any natural biennial plant. 


And in the eighteenth century, along with the 
introduction of cabbages and turnips and the 
depopulation of dovecots, began the revolution of 
thought which led men to suspect that they lived 
in a moving world and not as they had supposed 
in fixed and settled surroundings which had 
nothing more to expect than the crack of doom. 
They began to see change and infer it and to be 
curious about its nature and causes. Their thoughts 
crystallised once about the origin of species and have 
crystallised again in this century from MENDEL’s 
discovery of unit characters and alternative 
‘inheritance. At the moment there is a pretty 


general consensus of opinion that many of the 
features of animals and plants are primarily deter- 
mined by specific particles in the chromosomes, 
and there is abundant evidence that the sudden 
heritable changes, which are always found if large 
populations of live organisms are closely examined, 
are due to changes in these g2nes. Mutation is a 
plain fact of nature, and there is no visible end 
to the possibilities which would be to hand if its 
occurrence could be brought under control. It 
would indeed be strange if people were not acutely 
interested in trying to discover the causes of 
germinal changes, in the hope of promoting good 
things such as brussels sprouts and of preventing 
evil things such as idiots. Our readers will there- 
fore perhaps be interested in a paper which Mr. 
HamsHaw Tuomas, F.R.S., of the Cambridge botany 
school, gave to the Linnean Society, printed in 
the last two numbers of Nature. The particular 
point which he discusses is the possible influence 
of the penetrating radiations known as cosmic rays 
which pour on to the earth out of space and take 
origin very possibly in the annihilation of matter. 
That this kind of influence can cause mutational 
change was established when MULLER obtained 
heritable variations by the action of X rays. 
But whether short wave-length radiations have 
any special action apart from their ability to 
penetrate cells and, by virtue of their small size, 
to injure only a limited part of a cell, is uncertain ; 
it is perhaps generally true that if many cells 
are knocked about by any harmful agent a propor- 
tion of them will suffer only that particular local 
damage required to produce a mutation. Be that 
as it may, and admitting the probability that 
HARRISON brought about germinal changes by 
feeding caterpillars with poisonous salts, the influence 
of radiation is an attractive suggestion. Experi- 
ments in which animals have been more or less 
shielded from cosmic rays by being kept as far as 
may be in the bowels of the earth have so far 
given no clear answer ; negative results of observa- 
tions which are in the evolutionary sense of 
momentary duration are of no great weight. 
Cosmic rays are few and far between; many of 
any chromosomal injuries which they may inflict 
would be incompatible with life and in any case 
only a minute proportion of germ cells give rise 
to individuals sufficiently adult to show their 
characteristic features. Dr. Hamsaaw THOMAS 
appeals to evidence of another kind. It being 
known that the intensity of cosmic radiation 


` increases greatly with altitude so that there is 


about ten times as much at 20,000 feet as at 
sea-level, he points out that there are many more 
kinds of plants on mountains than on plains, 
they they are more variable and include a larger 
number of peculiar local species. Thus Costa Rica, 
largely mountainous and only half the size of 
Florida, contains as many species of plants as the 
whole of the south-eastern United States: there 
are 60 varieties of wheat in Afghanistan and only 
12 in Italy, and many more mountain than low- 
land species of primula, while several naturalists 
have remarked on the abundance of endemic 
species on mountains. | 


THE LANCET] 


Of these facts there are obviously other possible 
explanations, but Dr. THomas’s suggestion that an 
abundance of cosmic rays is responsible for an 
excess of variation needs further examination and, 
if possible, experiments on a large scale. If there 
is much in it, it would probably be apparent in a 
thorough study of the high Andes where there is a 
considerable human population, partly native, 
partly immigrant, which badly needs examination 
against the background of Western medicine. The 
question is one of great theoretical and practical 
importance, and it is perhaps not too much to 
hope for a more or less permanent commission to 
be established there to see what can be ascertained 
about the variability of men, animals, and plants, 
and to make a thorough study of the medical 
position there. It is true that cosmic radiation is 
not as abundant in Peru as it is further north, 
but the presence of a considerable indigenous 
population well outweighs this disadvantage. 


Man is far better known than any other animal, 


and careful observation should be able to determine 
whether he is more liable to mutations in the 
Andes, possibly also in Tibet, than elsewhere. 
And where man lives experiments can be made, 
though in this connexion where great numbers and 
long times are involved observation may be more 
likely to find an answer. 


A NEW PUBLIC HEALTH CODE 


THE statute book: is, in CROMWELL’s phrase, 
an ungodly jumble. More than any other depart- 
ment the Ministry of Health labours to remove 
the reproach. Not long ago the departmental 
committee, which it had appointed under the 
chairmanship of the late Lord CHELMSFORD, 
produced the admirable code which became the 
Local Government Act of 1933, re-writing in 
modern language and compendious form a mass of 
confused and overlapping enactments. And now 
the same committee, under the experienced 
guidance of Lord ADDINGTON, has produced another 
big Bill (Cmd. 5060; 3s. 6d.) which forms a draft 
code of the existing laws of public health. Over- 
haul of our health legislation was indeed overdue. 
The principal act of 1875, parent of a scattered 
progeny, was itself descended from acts of 1848 
and onwards which it all too faithfully reproduced. 
Much has happened in Whitehall and in the 
countryside since those early years when panic 
over an.epidemic of cholera was one of the chief 
motives of legislation. Prevention, and not merely 
cure, of disease is now the accepted policy. The 
individual’s health is recognised as the com- 
munity’s concern. Slum clearance, water-supply 
and sewerage, maternity and child welfare, and 
school medical services are related parts of a 
national effort. Comparison of ancient and modern 
statistics of cholera, plague, and _ small-pox, 
typhoid, diphtheria, and tuberculosis, is a sufficient 
reminder of progress. In the statutory structure 
of public health over the same period the central 
and local authorities have been transformed. 
The Ministry of Health has replaced the Local 
Government Board of 1871. Boards of guardians 


A NEW PUBLIC HEALTH CODE 


[san. 25, 1936 207 


are gone. Popularly elected county councils, 
created in 1888, now form, with county boroughs, 
fewer and bigger units; with ampler resources, 
a wider outlook and a rational re-allotment of 
institutional facilities, they administer public 
health in the spirit of social service rather than 
of poor relief. A principal act of 1875 was hardly 
fit to govern such developments. 

The departmental committee was directed not 
only to frame consolidating legislation, but also 
to consider what amendments would facilitate 
their work and would secure simplicity, uniformity, 
and conciseness. Fifty-year-old clauses will not 
stand literal reproduction to-day. The 1875 Act, 
for instance, contained no fewer than four differently 
expressed provisions as to power of entry. Pure 
consolidation would dictate the separate re-state- 
ment of each in the new code, but common sense 
will substitute one uniform provision for four. 
Elsewhere a handful of random examples will 
show the opportunity for unobtrusive modernisa- 
tion. Section 134 of the 1875 Act enabled regula- 
tions to be made for speedy interment of the dead 
and house-to-house visitation in times of formidable 
epidemic. No such regulations have been made 
for many years, and the section can clearly be 
dropped. Nor is it necessary to reproduce 
Section 138 whereby poor-law medical officers 
and other doctors who attend patients on board 
ship (under regulations prescribed by Section 130) 
can recover charges from ship-owners ; the pro- 
vision is a dead letter. An enactment of 1907 
forbade the connexion of drainage with a rain- 
water pipe; modern sanitary practice is against 
connecting a rain-water pipe with a sink; the 
new clause incorporates a restriction to this effect. 
The 1875 Act, as already noted, was itself framed 
out of a group of earlier statutes. Perhaps this 
is why it uses, without definition, sets of alternative 
phrases abhorrent to the modern draftsman. 
It speaks of “infectious disease,” ‘‘ fever or other 
infectious disease,” “infectious disorder,” 
“ dangerous infectious disorder,” and “ dangerous 
infectious disease.” The Customs Act of 1876 
uses the phrase “highly infectious distemper.” 
The Infectious Disease (Notification) Act of 1889 
contains a catalogue, it is true, of specific 
‘‘ infectious diseases’; but the vocabulary of the 
acts is needlessly confusing. The new code uses 
simply the two phrases “infectious disease ” 
and “‘ notifiable disease.” Incidentally, in re-stat- 
ing the list of “notifiable diseases °?” from the 
1889 Act, it omits to specify the fevers therein 
described as “continued or puerperal”; the 
“continued fever” was an old term, covering 
undiagnosed pyrexias, which is nowadays of 
little significance, and “ puerperal fever ” is left, 
for administrative simplicity as well as on medical 
grounds, to be governed by regulations such as 
those whereby in 1926 the Minister made puerperal 
pyrexia notifiable. On the whole the committee, 
composed of members with legal and administrative 
rather than medical qualifications, has‘ refrained 
from stiffening the law in directions where medical 
Opinion might have recommended it. The com- 
mittee found its hands full enough without pursuing 


208 THE LANCET] 


medical questions. It leaves the general improve- 
ment of the Jaw to future parliamentary effort. 

The new code consists at present of 334 clauses. 
Had it dealt with every aspect of what might 
popularly be regarded as public health, a thousand 
might have been required and an unwieldy 
document would have resulted, with multiplied 
vulnerabilities. The project excludes housing, 
mental treatment, midwives, burial and cremation, 
building lines and open spaces, and those unrelated 
Home Office topics which have been grouped in 
public health acts of the past. It confines itself 
to strictly public health provisions in relation to the 
prevention and treatment. of disease—i.e., as 
regards environment, the arrangements for drains 
and sewers, water-supply, buildings and the 
abatement of nuisances, and, as regards personal 
hygiene, arrangements for hospitals, maternity 
centres, and the like. The draft bill covers the 
Canal Boats Acts, the Baths and Washhouses Acts, 
the Maternity and Child Welfare Act, 1918, the 
Nursing Homes Registration Act, 1927, and the 
infant life production provisions which are the 
sole surviving part of the Children Act, 1908. 
Its plan and its limitations, and the details of its 
proposed changes, are set out with well-reasoned 
justifications in the blue-book (Cmd. 5059; 2s.) 
which accompanies the bill. One final word of 


‘ STAMMERING 


[Jan. 25, 1936 


warning we respectfully add. Under technical 
parliamentary rules a bill which is purely consolida- 
tion cannot be amended. The process of consolida- 
tion with amendment is usually performed by 
framing one bill for consolidation and another 
for amendment, the latter being passed first and 
then swallowed up by incorporation in the former. 
This process was not adopted with the new Public 
Health Bill if for no other reason than that the 
separate amending bill would have been distracting 
in its complexity and unintelligible in its terms. 
As the new bill includes a modicum of amendment 
along with pure consolidation, it is open to any 
member of Parliament to propose further amend- 
ments. If such a right is exercised on a large 
scale, the bill is doomed, and all the disinterested 
labours of its expert authors will be lost. The same 
situation arose over the parallel Local Government 
Bill in 1933, but private members nobly refrained 
from sabotage and the code was successfully passed 
into law. Those who are not satisfied with the 
new public health code should hold their hands 
and effect their amendments by separate bills in 
the future. Amendment indeed will be far more 
easy once this clear code receives the Royal 
Assent. To choke it to death now by excessive 
alteration would be a crime against public health 
administration. 


ANNOTATIONS 


STAMMERING 


ANY defect of speech is a serious handicap to a 
school leaver in search of employment. Stammering 
is far the commonest of speech defects; about 
one child in a hundred stammers, four times as many 
boys as girls. The stammer differs from other 
speech defects in two respects: under certain condi- 
tions no stammer is apparent, and it does not respond 
to the usual speech-training methods—suggesting 
that a stammer must be more than a mere defect of 
speech. Regarded as a speech defect it is essentially 
an interference with the codrdination of the muscular 
articulatory mechanism, associated with some 
disturbance of respiration, particularly, according 
to Seth and Guthrie, of the synchronisation of thoracic 
and abdominal breathing. Its more obvious mani- 
festations take usually oneoftwo forms: the “ clonic,” 
popularly known as the stutter, in which the sound 
to be produced is repeated several times; and the 
“tonic” in which a silent period, long or short, 
precedes utterance of such sounds as give difficulty. 
The ‘‘ tonic’? form may be accompanied by spasmodic 
contractions of the muscles of face, lips, larynx, or 
even limbs, which appear to take the place of the 
articulatory contractions of the stutter. 

Many theories of causation have been advanced, 
but there is a growing convergence of opinion to-day 
towards the view that stammering is in essence a 
neuropathie condition and as such therefore may 
be attributable to many causes. It cannot have 
escaped the observation of any students of the 
condition that stammerers are usually nervous 
children. A special inquiry? among Manchester 
school-children, initiated by Dr. H. Ilerd, revealed 
the frequency of neuropathic symptoms such as 


1 Quoted in ‘‘ The Health of the School Child ” (report of 
the C.M.O. of the Board of Education for the year 1934), p. 101. 


excitability, irritability, abnormal fears, enuresis, 
night-terrors, nail-biting; 41 of 53 stammerers 
were of a very excitable type. These symptoms are 
‘not the result of the stammer, but are parts of the 
stammering syndrome. Stammering, then, is not 
merely a disorder of speech, but a disorder of 
personality, an emotional disturbance. Stammerers 
are, in fact, one type of ‘‘difficult child.” As is 
shown in a Rochdale inquiry,? it is the child 
who lives in an ‘‘atmosphere of over-solicitude ”’ 
whether through his place in the family, through 
illness, or other cause who, when some crisis (to him) 
occurs in his life—the arrival of a baby sister or brother, 
change of school or teacher, fright, loss of a parent, 
family disharmony—fails to adjust normally and 
may develop a stammer, just as he may develop 
asthma.? Thero may, in addition, be some inherited 
neuropathic tendency, difficult often, however, to 
separate from the environmental influence of a 
neuropathic parent. 

Realisation of this wider aspect of stammering 
involves some enlargement of the scope of treatment 
beyond the mastery of vowels, of consonants, and 
their combinations, The methods of a child guidance 
clinic may have to be employed in order to deal with 
possible maladjustments and to elucidate the subtle 
psychological factors, if such there be. In the 
solution of these matters the parent and the teacher 
may have a large part to play. So far as the 
individual child is concerned, the first essential is the 
production of self- confidence ; ; its lack is character- 
istic of the stammerer and the inferiority complex 
is most manifest in the presence of strangers. This 
defect must be steadily overeome by the suggestion 
of the teacher. Next in importance to suggestion 
is ‘relaxation, the significance of which is apparent 


3 THE LANCET, Jan. 11th, 1936, p. 96, 


THE LANCET] 


from the tenseness of effort displayed by the 
stammerer in his struggles to speak. Natural speech 
should proceed in an easy flow. The act of speech 
should be more.or less unconscious; there should be 
no sense of strain, no tensely contracted. muscles. 
The habit of general muscular relaxation can be 
fostered by exercises alternating with short periods 
of complete rest. The older method of speech 
therapy involved a too intense concentration of 
effort on the production of sounds and contradicted 
the principle of relaxation. For this reason some 
authorities have dispensed with any specific speech 
training and have concentrated, if the use of the 
word is allowable, on relaxation. This treatment 
has been advocated and practised by the London 
education authority with considerable success under 
the control of Dr. E. J. Boome. The careless habits 
of speech, however, that many stammerers develop 
do justify some practice at least in correct speech 
in the form of reading along with others, or reciting 
in dramatic form, conditions under which a stammer 
naturally tends to disappear. Parents and teachers 
must coéperate if a satisfactory result is to be reached 
and retained ; education authorities should modernise 
their methods of treatment in accordance with 
recent knowledge, invoking the help (see p. 225) 
which the Central Association. for Mental Welfare 
offers. 


SUPPLY OF BLOOD-GROUPING SERA 


For an efficient and safe transfusion service it is 
necessary to determine quickly and accurately the 
blood group of prospective donors. In practice this 
requires stock sera against which the grouping can 
be tested, but so far the blood-grouping sera on the 
market have for the most part been unstandardised 
as regards potency, and the expense has militated 
against their general use. For these reasons it has 
been the custom of various independent laboratories 
to make their own stock blood-grouping sera from 
Group 2 (A) and Group 3 (B) individuals, any member 
of the staff, whose blood was of either group, being 
considered a convenient source of. supply. The 
amount of isoagglutinins, the responsible factors 
in such sera, has not, with rare exceptions, been esti- 
mated. Dr. H. F. Brewer, medical officer to the 
British Red Cross Blood Transfusion Service, work- 
ing on the blood donors of this organisation, has 
found a normal variation ranging from 1 in 23 up 
to 1 in 800 in the titre of the « and @ isoagglutinins 
in the sera of Group 3 (B) and 2 (A) donors respec- 
tively. Repetition at intervals of the titre estima- 
tions on batches of donors proved that the titre of 
isoagglutinin content for the serum of a particular 
donor is practically constant. A point of interest is 
that the average titre of the œ isoagglutinin in 
Group 3 (B) serum is higher than that of the 6 iso- 
agglutinin in Group 2 (A); this has also been pointed 
out by K. Kettel, and applies to the œ and 6 iso- 
agglutinins present together in the serum of Group 4 
(o) individuals. The isoagglutinin titre of grouping 
serum gradually deteriorates with storage, and 
obviously the higher the initial titre the longer will 
be the period during which it can be used ; a serum 
with an isoagglutinin titre of 1 in 200 will maintain 
a satisfactory potency as regards agglutination for 
a period of six months, even at room temperature. 
If the initial titre should be less than 1 in 25, it may 
deteriorate within this time to such an extent that 
it fails to clump red cells containing the homologous 
isoagglutinogen, and an error in blood grouping will 
result. 

In an attempt to make a supply of grouping sera 


SUPPLY OF BLOOD-GROUPING SERA 


[sam. 25, 19386 209 


of high titre and of cheap price generally available 
throughout the country, the Red Cross Transfusion 
Service has arranged to provide free to Messrs. 
Burroughs Wellcome and Co. serum in bulk from 
Group 2 and Group 3 donors specially selected on 
account of their high isoagglutinin titre (1 in 200 or 
above); such serum will be put up in capillary tubes 
each containing about 0-1 ¢.cm. and packed by the firm 
mentioned at a cost just sufficient to cover.expenses, 
and will be distributed from the Blood Transfusion 
Service, 5, Colyton-road, East Dulwich, London, 
S.E.22 (Tel.: Forest Hill 2264), to whom application 
can now be made. The price is 6s. per dozen pairs 
of capillary tubes if supplied to hospitals, medical 
practitioners, and provincial services affiliated to 
the London service; 12s. per dozen pairs to non- 
affiliated hospitals and others. Instructions about 
blood-grouping technique will be enclosed. The 
scheme should facilitate blood transfusion generally 
by rendering blood grouping more readily available 
and more accurate. At the present price it may be 
practicable for every medical practitioner and medical 
institution to keep a supply and replenish it when 
there is any risk of staleness. Undue calls on Group 
4 (0) (“ universal”) donors should now diminish. 


THE SURGERY OF THE SYMPATHETIC 


A ‘BRIEF report of the Tenth Congress of the 
International Society of Surgery appeared from 
a correspondent in THE LANCET of Jan. lith.? In 
this report mention was made of the plea put forward 
by Prof. Archibald Young, of Glasgow, for the 


consideration of peri-arterial sympathectomy in 


properly selected cases, Prof. Young contending that 
though the discussion before the Congress was nomin- 
ally restricted to the surgery of the lumbar sympathetic 
it would have been more profitable if it had been 
extended to include the results obtained by numbers 
of surgeons from peri-arterial operations in the 
limbs and on the inferior mesenteric artery, and also 
to review their experience of presacral neurectomy. 
He repeated the claims which he has formulated else- 
where for peri-arterial neurectomy which in his 
opinion had suffered undeserved neglect, stating 
that in his hands the operation had yielded satisfactory 
results in 65 per cent. of cases. Turning to lumbar 
ganglionectomy he stated that in his experience the 
operation had given excellent results in Raynaud’s 
disease, and that more was to be expected of it in 
arteriosclerosis than in thrombo-angiitis obliterans. 
He had experienced striking success in a few cases 
of chronic arthritis and this encouraged him to 
advocate lumbar ganglionectomy though the patient 
may be bedridden. He also referred to the treatment 
of Hirschsprung’s disease and of painful conditions 
of the bladder by operations closely allied to lumbar 
sympathectomy. 


AVERTIN ANAESTHESIA IN CHILDHOOD 


EVIDENCE of the interest taken in Sweden in 
Avertin anesthesia will be found in four papers 
published in Nordisk Medicinsk Tidskrift for Dec. 21st. 
It was in August, 1932, that avertin was first adopted 
by the large children’s hospital, Kronprinsessan 
Lovisas Vardanstalt, and between this date and the 
end of October, 1935, it has been used in 1250 cases 
without mishap and with excellent results. Its 
administration in an enema saves the cluld from 
the struggling and the psychic disturbances which 


1\WWe take this opportunity of mentioning tbat the official 
representative of the Royal College of Surgeons of England at 
the congress was Mr. C. H. Fagge. 


210 THE LANCET] 


sometimes follow the application of an ether mask 
to the face, and the profuse bronchial secretion 
evoked by ordinary ether anesthesia is also avoided. 
Ether is not, however, totally dispensed with in this 
hospital, and a little is usually given (from 10 to 
30 c.cm.) after consciousness has been lost under 
avertin. Dr. Einar Perman, who provides this 
information, states that avertin was first used only 
in exceptional cases and when lesions of the respira- 
tory tract contraindicated ordinary inhalation anes- 
thesia. Its advantages, however, soon became so 
evident that it has now been adopted as the standard 
anesthetic for children, who do not react to it with 
the psychic upsets occasionally seen in adults. Avertin 
is now used for all circumcisions and operations for 
hernia and mastoid disease. In many cases of 
empyema difficult to locate, the exploratory punctures 
as well as the operation itself are performed under 
avertin, which has also proved valuable for cysto- 
scopic examinations. In another paper, Dr. Georg 
Bremer reports from the same hospital his observa- 
tions on avertin. anesthesia in dentistry. He has 
found avertin the solution to the problem of the 
child under school age requiring unavoidably painful 
dental treatment. His experiences in this field since 
the beginning of 1934 concern two-score children 
and a couple of young adults whose mental condition 
would have been a contraindication to any dental 
operation carried out with only a local anesthetic. 
The remaining two papers describe the treatment of 
tetanus with avertin—a method familiar in this 
country through the writings of L. B. Cole '—and 
the temperature of the skin during avertin anesthesia. 


THE PHYSIOLOGY OF FERTILITY 


RECENT analyses of population trends suggest that | 


reproduction, not only in England and the rest of 
North-West Europe but also in other regions inhabited 
by Europeans, is proceeding at a dangerously slow 
rate, and that unless a pronounced increase in the 
number of births occurs before long, the relevant 
populations will be considerably diminished and 
their age constitutions greatly altered. In an address 
delivered to the Eugenics Society on Tuesday last, 
Dr. S. Zuckerman suggested that this fact puts a 
completely different complexion on the usual view 
that is taken of man’s fertility. Even allowing for 
full working capacity, the human reproductive 
machine does not compare favourably with that of 
most other vertebrates, for even apart from specially 
designed contraceptive measures, many normal and 
pathological factors militate against a higher fertility. 
For example, the childbearing period in woman 
forms a relatively short part of her total life compared 
with that of most other mammals. 

The normal limiting factors to the process of 
conception itself, said Dr. Zuckerman, are not 
conducive to a very high fertility. Ovulation both 
in man and in old-world primates, it is now believed, 
occurs at some time during the middle period of each 
menstrual cycle. Occasionally, too, and for reasons 
not yet understood, ovulation may fail to occur in 
otherwise normal menstrual cycles. There are no 
data regarding the viability of the ovum of any 
primate, but if investigations on lower mammals are 
any guide, the human ovum does not live more than 
a matter of some hours. Sperms are also short-lived, 
and unless the male and female gametes meet within 
a fairly brief critical period conception during any 
given cycle is impossible. Man and most of his 


1 THE LANCET, 1935, ii., 246 and 256; Quart. Jour. Med., 


1935, iv., 295. 


THE PHYSIOLOGY OF FERTILITY 


(yan. 25, 1936 


fellow old-world primates do not experience, as do 
most other mammals, a sharply demarcated cstrus 
which would ensure that insemination occurred at 
the most favourable time for conception, and it 
would almost seem that an increased frequency of 
coitus is the primate mechanism which replaces 
from this point of view the cestrus of the lower 
mammal. Discussion still continues on the question 
of the occurrence of a ‘‘ safe period ” in the menstrual 
cycle; the balance of clinical evidence seems to be 
in its favour. Dr. Zuckerman pointed out that in 
the absence of any available sign of ovulation in 
man, the further analysis of the ‘‘ safe period ” into 
its two components, the period of viability of the 
sperm and the period of viability of the ovum, is 
clearly impossible. Such an analysis is at present 
being conducted on monkeys which in their sexual 
skin cycles provide a clear external index of the 
occurrence of ovulation. The data so far collected 
do not provide any information on these two par- 
ticular points,s but clearly support the idea of 
only a limited period of fertility in each menstrual 
cycle, l 
DILATATION OF THE URETERS 


A LEADING article in our last issue described some 
recent investigations into the cause of dilatation of the 
ureters during pregnancy. It appears that Traut 
and McLane ! have also been studying the tone of the 
ureters during pregnancy using, like Baird, a modifica- 
tion of the hydrophorograph originally introduced 
by Trattner.? Their conclusions agree with those of 
most other workers. They found a definite atony 
of the ureters, beginning in the third month of 
pregnancy and reaching its peak in the seventh and 
eighth months. During the last month there seemed 
to be a definite return of muscular irritability as 
expressed by peristalsis and response to stimulation. . 
They ascribe the dilatation of the ureters partly to 
the pressure of the gravid uterus and partly to this 
atony, which they believe to be due to some hormonic 
factor. 


VITAL STATISTICS FOR 1935 


Tue Registrar-General has issued a provisional 
statement of the figures for birth-rate, death-rate, 
and infant mortality for the year 1935. 


Birth Death- Infant 
— rate. rate. mortality-rate. 

England and Wales .. | 14:7 11:7 57 
121 county boroughs | 

and great towns, in- 

cluding London 14:8 11-8 62 
140 smaller towns | 15:1 11:4 55 
London (administrative 

county) is oa 13:1 11:3 58 


The smaller towns are those with estimated resident 
population of 25,000-50,000 at the 1931 census. The 
birth- and death-rates for England and Wales as a whole 
are calculated on the estimated mid-1935 population, but 
those for the towns aggregates and for London are 
calculated on the estimated mid-1934 populations. The 
birth-rate is based on live births, the death-rate on crude 
deaths. 

The birth-rate for 1935 is 0°1 per thousand below 
that of 1934 and is 0°3 above that of 1933, the lowest 
recorded. The crude death-rate is also 0°1 below that 
of 1934, the only years with a lower or similar record 


1 Traut H. F.. and McLane, C. M.: Surg., Gyn., and Obst., 


January, 1936, p. 65. 
i rrattuer, Hi. R.: Jour. of Urol., 1932, xxviii., 1. 


THE LANCET] | 


being 1923 (11°6), 1926 (11°6), 1928 (11°7), and 1930 
(11°4). The infant mortality-rate is the lowest 
recorded, the previous record years being 1934 (59) 
and 1930 (60). The rates are provisional and are 
issued for the information of medical officers of 
health, but they are not likely to require substantial 
modification. 


TUBERCULOSIS IN HOSPITAL EMPLOYEES 


THE investigations of Scheel and Heimbeck at the 
Ullevaal Hospital in Oslo have stimulated statistical 
investigation in other hospitals whose employees 
have shown a disquieting tendency to develop tuber- 
culosis. The latest report! on this subject comes 
from the tuberculosis hospital of Söderby, Stockholm. 
Its medical superintendent, Dr. A. Gullbring, has 
found that between 1918 and the middle of 1935 
there have been 45 cases of tuberculosis developing 
in a staff of 2016—an incidence of 2-2 per cent. 
While this rate was 2:6 per cent. (40 out of 1525 
persons) among the staff in direct contact with 
patients, it was only 1 per cent. (5 out of 491 persons) 
among the administrative staff. Since 1928 new 
members of the hospital staff have. been tested with 
tuberculin (Mantoux’s test), and 20 per cent. of the 
484 persons thus examined have been found to be 


tuberculin-negative. All the negative reactors tested 


at a later date showed a positive reaction. Of the 
tuberculin-tested employees, 19, or 3-9 per cent., 
have since developed tuberculosis, including only 
one belonging to the administrative staff. A com- 
parison of the originally tuberculin-negative employees 
with the originally tuberculin-ptsitive employees 
showed that the subsequent tuberculosis-incidence 
was 8-4 per cent. among the former and 2:8 per cent. 
among the latter—an observation confirmatory of 
the Scheel and Heimbeck teaching that the tuberculin- 
negative probationer is much more likely to develop 
tuberculosis. It may be noted in passing that in 
another Swedish hospital, the Serafimer Lasaret, the 
practice has now been adopted of inoculating with 
BCG those of the hospital staff who are found 
to be tuberculin-negative. Valuable data should, 
therefore, soon be available wherewith to control 
the claims made on behalf of BCG inoculation of 
tuberculin-negative nurses by the authors of the 
Ullevaal experiment. 


RUDYARD KIPLING 
RUDYARD KIPLING was in every sense of the word 


a patriot; all classes of society from the highest | 


to the lowest recognised his deep devotion to our 
country and admired his heartfelt expressions 
thereof. That some could not go the whole way 
with him proves the difficulty that will arise always 
when the claims of fervent nationalism clash with the 
international spirit; but pause to any criticism is 
given here in Kipling’s case by the tributes to his 
genius and to his fiery love of humanity paid by 
the press of the civilised world. Where Kipling 
will stand in the estimates of an extended future 
no one can say exactly, but he must long remain 
a great figure. And this position has been definitely 
allotted to him by the decision that he should be 
buried in the Poets’ Corner of Westminster Abbey. 
Kipling was passionately poetical while replete with 
exact knowledge of many material things; he was 
deeply moving and quite slangy ; he was a master 
of the English language and original, even unprincipled, 
in his use of it; he was a brilliant story-teller, the 


1 Nordisk Medicinsk Tidskrift, Jan. ith, 1936, p. 14. 


RUDYARD KIPLING 


[yan. 25, 1936 211 


most widely read poet of his day, and unsurpassed 
as a journalist. 

It is fitting to record from his own lips his attitude 
towards medicine. In an address delivered to the 
students of Middlesex Hospital the following passage 
occurs: ‘“‘ Every sane human being is agreed that 
this long-drawn fight for time which we call Life is 
one of the most important things in the world. It 
follows therefore, that you, who control and oversee 
this fight and you who will reinforce it, must be 
amongst the most important people in the world... . 
In all times of flood, fire, famine, plague, pestilence, 
battle, murder, or sudden death, it will be required 
of you that you report for duty at once, go on duty 
at once, and remain on duty until your strength 
fails you or your conscience relieves you, whichever 
may be the longer period. This is your position. 
These are some of your obligations. I do not think 
they will grow any lighter.” On another occasion, 
addressing the guests at a Hunterian banquet at the 


‘Royal College of Surgeons of England, he said: 


“Your dread art demands the instant, impersonal 
vision which in one breath, one beat of the pulse, 
can automatically dismiss every preconceived idea 
and impression, and as automatically recognise, 
accept and overcome whatever of new and unsus- 
pected menace may have slid into the light beneath 
your steadfast hand. But such virtue is not reached 
or maintained except by a life’s labour, a life’s single- 
minded devotion.” It was thoroughly characteristic 
of Kipling that the main thing which impressed him 
in the life of those who follow the calling of medicine 
was the claim made at all times and all places for 
the discharge of duty, for over and over again in 
prose and verse Kipling delighted to draw and extol 
the virtues of selflessness and resolution. 


It is fitting for members of the medical profession, 
who know from experience the keen anxiety attached 
to the care of a patient whose cardiac reserve is 
slight and whose duties are onerous, to voice the 
gratitude of the Empire to Lord Dawson of Penn, 
on whom for eight years a heavy burden has fallen. 
It must have been due in no small part to his 
constant unobtrusive watchfulness as well as to his 
clinical wisdom that these years were for King 
George years of joyous fulfilment. 


TuE official proclamation of King Edward VIII. 
was made on Wednesday morning in pursuance with 
the Order in Council and in accordance with precedent. 
The proclamation was first read by Garter Principal 
King of Arms at the balcony in Friary Court, 
St. James’s Palace, when a procession was formed 
and, flanked by the Royal Horse Guards, moved by 
way of the Mall and the Admiralty Arch to Charing 
Cross where the proclamation was again read by 
Lancaster Herald. On the site of Temple Bar a 
barrier marked the boundary of the City of London 
and at the corner of Chancery-lane the proclamation 
was read for the third time after formal admission 
to the City with the Lord Mayor in attendance. 
The procession then proceeded to the Royal Exchange 
where the proclamation was read for the fourth and 
last time. 


KENT COUNTY OPHTHALMIC AND AURAL HOSPITAL. 
The extensions to this hospital, which was founded at 
Maidstone in 1847, are being opened to-day, Jan. 24th. 
A debt of £10,000 on the new aural wing which was opened 
in 1930 has still not been cleared and the hospital now 
carries a total debt of £15,000. 


212 THE LANCET] © 


THE KING’S LAST ILLNESS 


¥ 2 , eo et i - o 
~ oat 
. 


_ THE KING’S LAST ILLNESS 


The following statement is based on authority :— 


“ THoUuGH it is understood that for some 


weeks His Majesty Kın Gerorce’s health 


had not been altogether satisfactory the Kine 
was able to go out and in fact rode on his pony 
for a short time on Wednesday, January 15th. 
On Thursday, the 16th, the Kina showed 
signs of a mild catarrh which soon began to 


abate. The ‘disquiet’ expressed in the- 
‘bulletins of Friday and Saturday arose from 


evidences of cardiac insufficiency. The margin 
of cardiac reserve has in recent days been 
narrowing. This illness therefore arose from 


within and was in the nature of a culmination. 


It was thus not comparable to the invading 


streptococcal septicemia localising at the base 


of the right lung from which KING GEORGE 


| suffered eight years ago. It is true that that 
_ - illness: placed heavy burdens on the heart 


which may have had a causal relationship to 
this last illness. It is a remarkable achieve- 
ment that Kina GEORGE recovered from 


_ septicemia and reigned over his Empire seven 


years through times which have been eventful 
and sometimes anxious. 

“ This last illness showed that the body 
carried through its work till its powers were 


ended and then came to rest after an illness 
short, and peaceful in its close.” 


— [yan..25,:1936 


THE LANCET, Jan. 25, 1936 : "tt 


a. a 
SAS 


HIS MAJESTY KING GEORGE V. BEING RECEIVED BY SIR AUSTEN CHAMBERLAIN, 
CHAIRMAN OF TIIE GOVERNING BODY, ON THE OCCASION OF THE OPENING OF 
THE BRITISIL POSTGRADUATE MEDICAL SCHOOL ON MAY 13TH, 1935. 


214 THE LANCET] 


[san. 25, 19386 . 


PROGNOSIS 


A Series of Signed Articles contributed by invitation 


LXXXV.—THE PROGNOSIS IN DEAFNESS 


II 
(Concluded from p. 160) 


Otosclerosis 


THERE remains for consideration among the varieties 
of deafness attributable to lesions in the middle ear 
the important group of cases classed as otosclerosis ; 
this is more common in females, is frequently here- 
ditary, and is characterised by formation of new bone 
on the inner tympanic wall occluding the fenestra, 
and, clinically, by the signs of middle-ear deafness 
with, at first, a strongly negative Rinné, good 
or increased bone-conduction, and marked loss 
of low tones, with a normal drum and Eustachian 
tube. Later there is often degeneration of the 
internal ear, but these patients, like other suf- 
ferers from middle-ear disease, rarely become 
completely deaf. Here, too, progress is not down- 
wards along an even slope, but there are long stationary 
periods, often with a step down as the result of an 
illness, and sometimes an improvement with better- 
ment of the general health. It happens not infre- 
quently that otosclerosis is associated with some 
degree of chronic catarrhal otitis; in these cases 
attention to the hygiene of the nose, throat, and 
Eustachian tubes may be expected to give some 
improvement of hearing. Pregnancy has a pecu- 
liarly bad effect; although the hearing tends to 
improve again after delivery, it usually remains at a 
lower level than before, and it is sometimes advisable 
to induce abortion. Many forms of treatment have 
been tried and abandoned. <A few otologists recom- 
mend a method of treatment by sonorous vibrations, 
introduced by Ziind-Burguet, in this affection as well 
as in chronic catarrhal otiris, but the results appear 
to be evanescent, and it has not been generally 
adopted. The late Dr. Albert Gray has employed 
weekly injections of thyroxine through the mein brane 
into the tympanum with some encouraging results. 
Of surgical? measures one, which holds out 
a faint hope for the future treatment of oto- 
sclerosis and of severe fibrotic occlusion of the 
fenestrie, consists in opening the bony labyrinth 
at the external semicircular canal, or in the region of 
the fenestrie, and covering the fenestration so made 
with a thin graft. In this way the hearing has 
certainly been improved, but there has been much 
tendency to relapse, due probably to the difficulty 
of keeping the opening patent and the graft from 
becoming rigid. Perhaps more lasting results may 
be obtainable by modification of the technique, but it 
must at present be acknowledged that no treatment 
has as yet any proved and lasting effect on the progress 
of this disease. 

Nerve-deafness 

This includes deafness caused by lesions of the 
labyrinth, the auditory nerve, or the nerve-paths to 
the brain, and is irremediable in a large proportion 
of cases, though not in all. Certain drugs cause 
deafness of this type ; of these quinine and salicylates 
are the most important, and cause tinnitus at the 
same time. The hearing recovers when the drugs are 
withdrawn, but permanent impairment may follow 
continued large doses of quinine. Lead, mercury, 
and carbon disulphide may all produce deafness, 
while excessive use of alcohol and tobacco have a 
deleterious effect. Many instances of severe deafness 
following the administration of the salvarsan group 


-especially in males. 


of drugs have been recorded ; when syphilitic nerve- 
deafness is present salvarsan should be withheld 
until it has responded to mercurials. Syphilis causes 
nerve-deafness by affecting the cochlea and auditory 
nerve, and by producing basal meningitis; it may 
appear as early as the secondary lesions or as late 
as the development of tabetic symptoms. Improve- 
ment may follow early and thorough treatment, 
but often the disease progresses rapidly, and some- 
times to complete loss of hearing ; congenital syphilis 
is one of the commoner causes of deaf-mutism. 
Epidemic cerebro-spinal meningitis is accompanied 
by nerve-deafness with a frequency which varies in 
different epidemics from 4 to 30 per cent. and is a 
common cause of deaf-mutism; it is usually per- 
manent but occasionally the patient recovers. Toric 
deafness is common in enteric fever, but disappears 
during convalescence. Nerve-deafness is a rare 
complication of mumps ; it is complete and incurable 
but, fortunately, usually unilateral. Measles, also, 
beside causing the common middle-ear infections, 
is an occasional cause of incurable bilateral nerve- 
deafness, probably of meningitic origin. Myxoedema 
has a bad effect on the hearing ; any form of deafness 
in patients with hypothyroidism may be improved 
by thyroid extract. The patient with deafness 
resulting from traumatic concussion frequently 
recovers Within a few days or weeks, but any impair- 
ment remaining after that time is likely to continue. 
The deafness due to fracture of the base of the skull 
is, of course, permanent. 

Occupational deafness from prolonged exposure to 
noise is common in certain callings, such as riveting 
or machine-gunning ; when established, it tends 
slowly to advance in spite of removal from the 
cause, and is only curable by change of occupation 
at an early stage. The single loud sound of an 
exploding shell was a frequent cause of deafness 
during the late war; improvement usually occurred 
during the first few weeks but some degree of deaf- 
ness often remained. Allied to this is the condition 
called “‘ shell-shock” deafness, the. victim having 
been in action or buried by an explosion and becoming 
and remaining totally deaf. Probably he will have 
been deafened by labyrinthine concussion which 
recovered, but a psychic deafness persists. In such 
cases the hearing can be restored by appropriate 
psychiatrie treatment, but it is difficult to distin- 
guish sullerers from psychic deafness from those 
who have received organic damave of the cochlea. 
It is usually held that there is a probability of 
a physical lesion if the vestibular reactions are 
greatly diminished, but that the deafness is func- 
tional when these are approximately normal, True 
hysterical deafness is uncommon ; it may be suspected 
when responses to testing are anomalous and, though 
it is curable, it may prove very obstinate. Senile 
deafness is a degeneration of the internal ear, charac- 
terised by relatively greater loss of the high notes, 
and of sharp sounds, such as the tick of a watch, 
compared with the continuous tone of a tuning-fork ; 
it may begin prematurely at any age over fifty, 
All deafness in old people is 
not, however, necessarily due to their age; they 
may suffer, hke others, from cerumen or Eustachian 
catarrh, amenable to treatment. 

Hearing Aids 


Hearing aids have a bearing on prognosis in that 
they make conversation possible for many sufferers 


THE LANCET] 


from advanced deafness. Those with middle-ear 
deafness can always be helped by such means s0 
long as secondary degeneration of the cochlea’ is 
not serious; hearing aids are therefore most useful 
to patients with middle-ear deafness, especially 
otosclerosis, who have good bone-conduction, and 
for them the more recently introduced electric aids 
with bone-conduction receivers are particularly 
suitable. It is generally possible to tell these patients 
that they will remain able to hear conversation by 


MR. A. F. MACCALLAN : TRACHOMATOUS CONJUNCTIVITIS 


suited to patients with 


[san. 25,1936 215 


means of a suitable apparatus. On the other hand, 
severe tinnitus is apt to be made worse by the 
use of electric aids, and these are in general less 
senile deafness than is 
some form of trumpet or, for the severest forms, 
the old-fashioned conversation-tube. 


HAROLD BaRWELL, M.B., F.R.C.S., 


Consulting Surgeon for Diseases of the Throat 
and Ear to St. George’s Hospital. 


SPECIAL ARTICLES 


TRACHOMATOUS CONJUNCTIVITIS 
ITS SURGERY AND PATHOLOGY * 


By A. F. MacCarran, C.B.E., M.D. Camb., 
F.R.C.S. Eng. 
PRESIDENT .OF THE INTERNATIONAL ORGANIZATION AGAINST 


TRAOHOMA ; OPHTHALMIO SURGEON IN CHARGE OF 
OUT-PATIENTS, WESTMINSTER HOSPITAL 


DURING the last thirty years trachoma has become 
a comparatively rare disease in London. Ophthal- 
mologists can realise with difficulty that the stigmata 
of the disease are borne by as many as half the inhabi- 
tants of the globe. For it is practically universal 
among the Mongolian and Semitic races, and among 
the Red Indian tribes; it is also widely spread 
among the Caucasians of India, and among the 
Malayans. Nevertheless, our knowledge of the 
etiology of trachoma is incomplete; the clinical 
diagnosis may be impossible in the absence of bulky 
and expensive apparatus, and no aids are to be 
obtained by means of chemical or microscopical 
tests; while the treatment has not improved during 
the last thirty years. 


Pathological Anatomy 


The response to attack by the virus of trachoma 
is a generalised flooding of the subepithelial tissue 
of the conjunctiva with lymphocytic cells. Typically, 
there are in addition special aggregations of these 
cells, which have been called follicles; however, in 
some cases no such follicles are to be differentiated 
from the general exudate of lymphocytes (Mikhail). 
The follicles, when present, differ in no way from 
similar aggregations of cells which appear in the 
condition known as follicular conjunctivitis. The 
conjunctival epithelium first proliferates, and then 
becomes villous ; or it ulcerates and becomes replaced 
by scar-tissue epithelium. | 

The numerous underlying sebaceous or meibomian 
glands are at first affected by simple blockage of 
ducts and dilatation, the result of pressure by the 
cellular infiltration. Later the ducts become strangu- 
lated by the developing connective tissue, which 
begins to take the place of the lymphocytic exudate. 
The result is the appearance on the surface of the 
conjunctiva of numerous bleb-like excrescences, 
which burst on pressure, giving vent to gelatinous 
matter, the retained secretion of the sebaceous 
glands, with numerous cells. These bleb-like excres- 
cences by all trachomatologists up to the present 
time have been looked upon as the follicles, described 
above, which have become dilated. ‘There is no 
evidence that such dilatation occurs, nor has anyone 
ever observed such a phenomenon to develop. It 


e Abstract of a Hunterian lecture delivered at the Royal 
College of Surgeons of England on Jan. 17th, 1936. 


would be impossible for such a metamorphosis of the 
follicles to occur. Mikhail also has observed the 
dilatations of the ducts of the meibomian glands, 
but has not connected them with the bleb-like 
excrescences of the second stage of trachoma. 


The whole process, for the description of which I 
am indebted to Pulvertaft, is a chronic progressive 
inflammatory change, almost certainly due to a 
secondary infection of the subepithelial tissues, 
following a primary epithelial lesion. The difference 
between other forms of conjunctivitis and trachoma 
is that the effect of the virus is much more lasting 
in trachoma, leading to this enormous subepithelial 
exudate, which penetrates to the tarsus, and via the 
fornical conjunctiva to the upper corneal limbus. 
The natural end of this severe exudate is its trans- 
formation into cicatricial tissue, thereby differen- 
tiating trachoma from other forms of conjunctivitis. 
The involvement of the tarsus in the cellular exudate, 
and the subsequent cicatrisation which occurs, leads 
to thickening of this boat-shaped structure, and so 
to entropion. The trichiasis which accompanies the 
entropion is due to the development of supernumerary 
lashes by offshoots from existing hair follicles. This 
new development is caused by the hyperemic con- 


dition of the lid margin which always occurs in 


serious cases of trachoma. 


The hypertrophy of the superficial conjunctival 
epithelium leads to the appearance of numerous 
polygonal areas, which form a papillary hypertrophy. 
This is the result of irritation and is present in all 
forms of long-continued inflammation of the con- 
junctiva, 


PANNUS 


The term pannus was originally applied to the 
cloth-like opacity which the cornea of an inveterate 
case of trachoma exhibited. Completely ignorant 
of the pathology of the disease the surgeons of a 
former day used to attempt its removal. We now 
understand the term pannus to apply to an infiltra- 
tion of the clear cornea by a cellular exudate, which 
is accompanied by the vascularisation of a previously 
avascular tissue. This may be observable only by 
optical magnification, or may be obvious to the naked 
eye. Following the primary epithelial lesion of the 
conjunctiva by the trachoma virus, whatever its 
nature may be, there is an infection of the sub- 
epithelial tissues to which response is made by a 
widespread inflammatory exudation. This spreads 
from the site of origin, near the retrotarsal fold, to 
the fornix, travelling beneath the epithelium, and 
from the fornix proceeds to the upper part of the 
limbus of the cornea. In this area pannus appears, 
which in early trachoma is the only pathognomonic 
sign of the disease. 

Mikhail has made it quite clear that the changes 
at the upper corneal limbus occur in this way, and 


218 THE LANCET] 


cannot therefore be exercised in endeavouring to 
achieve this end. 


General Principles of Bacteriological Grading 


Since the taking of representative samples is diffi- 
cult, since the results of any one sample are affected 
largely by the time-temperature conditions under 
which it is taken and held, and since atmospheric 
temperature plays a very important part in deter- 
mining the number of bacteria present, it is con- 
cluded that the cleanliness of the milk of any given 
producer should be judged, not on the basis of one 
or two samples taken at some particular season, but 
on samples taken frequently and regularly through- 
out the year. Whatever test is used, separate stan- 
dards should be laid down for summer and winter, 
and penalisation should not be practised so long as 
a given proportion of samples, such as 75 per cent., 
conform to these standards. What is required, 
therefore, for the routine bacteriological grading of 
milk is a simple inexpensive test, With a small experi- 
mental error, which can be used on a large scale by 
relatively unskilled workers. 

Bearing these general principles in mind, it is 
concluded that, though undoubtedly of use for 
certain special purposes, neither the sediment test, 
the leucocyte count, the titratable acidity, the Il-ion 
concentration, the increase in acidity, the brom- 
thymol blue test, the keeping quality test, nor the 
laboratory pasteurisation test can be regarded as 
suitable for the routine grading of milk. 


THE COLIFORM TEST 


None of the three premises on which the use of this test 
for the control of water-supplies is based holds good for 
milk. With the possible exception of its employment 
on empirical grounds for Certified milk, there seems, 
therefore, to be no justification for the use of either the 
coliform test or the coli-acrogenes ratio test in the grading 
of raw milk. 

For pasteurised milk, on the other hand, the coliform 
test may be of same value. It may serve as an index of 
the efficiency of the processing, if performed on freshly 
pasteurised milk, or as an index of the subsequent con- 
tamination or exposure to unsuitable temporatures, if 
performed on the bottled milk at the time of delivery to 
the consumer. The experimental error of the test is, 
however, very large, and on this account the results 
should preforably be reported, not in absolute numbors, 
but as above or below an arbitrary standard. 


THE BREED SMEAR METHOD 


This method has not received in this country the atten- 
tion it deserves. It is in the rapid grading of milk that 
the method finds its greatest value. There is no other 
test that enables a differentiation between clean and 
dirty milks to be made so rapidly—within a few minutes— 
and the test is, therefore, of inestimable servico at collect- 
ing stations where milk from individual farms is bulked 
preparatory to dispatch to the large towns in rail or road 
tanks. The test is of considerable assistance to farm 
inspectors and agricultural advisers, because it so fre- 
quently enables a distinction to be drawn between the 
various faults of production to which any given milk is 
subject. It can bo used as a control to the plate count, 
or as a substitute for it. As a general test, however, for 
the routine examination of large numbers of milks, the 
Breed smear method is, we believe, less suitable than the 
modified methylene-blue reduction test that we have 
described. 

THK PLATE COUNT TEST 


Ostensibly this test measures the numbers of bacteria 
in milk, but in fact it does not. On account of the 
difference between various species of bacteria in their nutri- 
tional, rospiratory, and temperature requirements, on 
account of the fact that many organisms may be dead, 
and most important of all on account of tho gross irre- 


BACTERIOLOGICAL GRADING OF MILK 


(san. 25, 1936 


gularity in the distribution and clumping of the organisms 
in the milk, the plate count merely registers the number 
of bacterial units capable of multiplying under the parti- 
cular conditions selected. Since the average number of 
bacteria per clump is variable from one milk to another, 
and from time to time in the same milk, and since these 
clumps may disintegrate to a quite uncontrollable extent 
during the process of dilution, it follows that the figures 
yielded by the plate count are arbitrary, not strictly 
comparable from milk to milk, merely approximate, and 
have no real significance. 


The technique is complex, is difficult to standardise, 
and requires highly skilled workers. Even under favour- 
able conditions, with the method standardised as far as 
possible, the experimental error is very large, and on any 
one count an allowance of + 90 per cent. may have to 
be made. Even this margin of error will not include all 
results. Besides demanding costly apparatus and a delay 
of at least two days in the result, the plate count seems 
to afford no better index of the sanitary conditions of 
production or of the keeping quality of the milk than the 
Breed test or the modified methylene-blue test. It is 
therefore recommended that the plate count test should 
be discontinued as a method of grading ordinary raw 
milk. Even for Certified milk it seems to have no advan- 
tage over the modified methvlene-blue reduction test. 

The quantitative expression of the results in figures 
extending over a wide range affords a fictitious appearance 
of accuracy which leads, not onlv in laymen, but even in 
public heath officials. to a wholly unjustifiable feeling of 
confidence in their value. If the plate count is to be used, 
it should be permitted only on one condition—namely, 
that the results are reported not in quantitative terms, 
which are often grossly misleading, but as above or below 
an arbitrary standard. 


For pasteurised milk, with the possible exception of 
Grade A pasteurised, the plate count is not recommended. 
The actual count on pasteurised milk is determined by so 
many factors independent of the efficiency of the pro- 
cessing that the results bear little relation to any important 
quality of the milk. 


THE MODIFIED METIILYLENE-BLUE REDUCTION TEST 


This test seems to fulfil most of the requirements 
demanded of a test for the routine gracing of raw milk. 
It is a simple inexpensive test, with a very small experi- 
mental error, which can be carried out by relatively 
unskilled workers on large numbers of samples, which 
demands a minimum of equipment, which can classify 
milk on the basis of cleanliness into the maximum number 
of grades clesirable, and which affords on the whole a 
very good index of the keeping quality of the milk. Besides 
these advantages, it gives more information about the 
milk than does the plate count. The result does not 
appear to be seriously atiected by the degree of aggrega- 
tion of the organisms in the milk, and the test is a very 
much more sensitive index than the plate count of bac- 
terial growth. By the use of the modified methylene- 
blue reduction test it should be possible to examine the 
milk of every farmer at weekly or fortnightly intervals 
throughout the year at a cost only a fraction of that of 
the plate count. 

Whether the test is suitable for the examination of 
freshly pasteurised milk is doubtful, but there is reason 
to believe that it could well replace the plate count on 
bottled samples delivered to the consumer. 


Recommendation 


Whatever test is used, the report recommends that 
no attempt should be made to divide milk into more 
than three or four classes. The numbers and activity 
of micro-organisms in milk are determined by so 
many different factors that the establishment of 
numerous subdivisions is not only meaningless, but 
may be definitely misleading. From the public 
health point of view probably only two divisions 
need be made on the basis of cleanliness—namely, 
into (a) milk that is suitable and (6) milk that is not 
suitable for human consumption in the liquid state. 


THE LANCET] 


MORTALITY FROM PHTHISIS IN YOUNG ADULTS 


[san. 25, 1936 219 - 


After consultation with the Ministry of Health 
the Medical Research Council has accepted Prof. 
Wilson’s report as a statement of the scientific 
evidence on which possible administrative action 
may be based, 


MORTALITY FROM PHTHISIS IN 
YOUNG ADULTS 
A STATISTICAL STUDY 


THE Registrar-General’s mortality statistics for 
recent years have revealed an unfavourable trend 
in the death-rate from respiratory tuberculosis at 
young adult ages. In the enormous decline that 
took place in the death-rate from this cause during 
the latter half of the nineteenth century young 
adults had their full share, or even somewhat more 
than their full share. But between 1901-10 and 
1930 the mortality at these ages has declined amongst 
males at a slower rate than is apparent in any other 
age-group, while amongst females there has actually 
been a slight rise in mortality at ages 15-25, and 
at ages 25-35 the decline has been appreciably less 
than that observed in any other age-group. Division 
of England and Wales into its administrative areas 
shows that it is in the highly urbanised areas that this 
unfavourable change is most apparent. 

The basic figures illustrating this trend were set out 
in a paper read before the Royal Statistical Society 
on Jan. 21st by Mr. A. Bradford Hill, D.Sc., in which 
the author discussed various explanations of the 
present position. Some workers—e.g., F. J. H. 
Coutts—believe that the prodigious fall in the general 
death-rate from tuberculosis has led to a much 
lower level of infection in early life and this to a 
decline of immunisation in childhood, with the result 
that more persons must face the hazards of adolescent 
life with no acquired immunity. A more frequently 
accepted explanation attributes the relatively high 
mortality, especially of young adult females, to the 
entry of such persons into the “strain and stress of 
competitive wage earning,’ with the associated 
changes in their social life. Dr. Hill is unable to 
find much statistical support for either of these 
two hypotheses. Taking the death-rate from tuber- 
culosis at ages 0-5 as a measure of the pressure of 
infection in childhood, he finds that the course of 
this death-rate in a group of English counties is not 
related to changes in the mortality experienced at 
young adult ages in later years. Similarly, towns 
with a high death-rate from tuberculosis at ages 
0—5 do not appear to have a lower phthisis death-rate 
in young adult life fifteen to twenty years later than 
towns with a relatively low death-rate in childhood— 
general health factors being as far as possible equalised. 
With regard to occupational changes Dr. Hill shows 
first that in towns where the death-rate of young 
adult females has shown the greatest increase, there 
has been, on the average, a tendency for the rate of 
young adult males to increase also, or to show a 
slower rate of decline than in other towns. Where 
the female rate has declined substantially the male 
rate has also, on the average, declined substantially. 
Dr. Hill argues that this relationship implies a causal 
factor common to both sexes and suggests that the 
occupational changes in female life are therefore 
unlikely to be more than a partial explanation. He 
finds no correlation between changes in the volume 
of female employment over the years 1911 to 1931 
and changes in the phthisis death-rate of young 


adult females in the county boroughs. The changes 
in type of employment evident in recent years are 
more difficult to measure but the evidence available 
does not implicate such changes as a responsible 
agent. 

Failing to find support for these explanations 
Dr. Hill turns his attention to the question of internal 
migration and the consequent distribution of young 
adults in different parts of the country. In past 
years one striking aspect of the phthisis mortality 
of young adults in this country has been the higher 
death-rates registered in the rural areas as compared 
with the urban areas, a phenomenon observed only 
at these ages. In an investigation carried out by 
the author some years ago,! he concluded that the 
explanation of this position lay in the migration of 
young adults from the country to the town, and 
that the migrants form a physically select group, which 
strengthens the town population at young adult ages 
and leaves a physically weaker residue behind. It 
follows that changes in the volume of this migration 
would be expected to produce changes in the regional 
distribution of the phthisis death-rate. In fact, 
in recent years the excess mortality at the young 
adult ages in the rural areas has completely dis- 
appeared. At the same time the loss of population 
in the rural areas has turned to a gain. The rural 


‘exodus slackened at about the turn of the century, 


while, in addition, the population of many rural 
areas may have changed in type due to the improved 
methods of transport enabling persons to reside in 
such areas and work elsewhere. Similarly the 
migrants to towns may have changed in type—for 
instance, it appears that London tends now to recruit 
young adults from the depressed areas rather than 
from the rural areas. Are these changes in the move- 
ment of population related to the changes in the 
phthisis death-rate? Dr. Hill finds that, to some 
extent, they are. Those county boroughs which 
have attracted young adults have, on the average, 
shown a declining death-rate from phthisis in young 
adult life during the past decade, while those that 
have lost population have tended to show a rising 
death-rate. This association might, the author 
suggests, be due to the fact that towns that’ have 
ceased to attract population are in a less satisfactory 
economic position than those that still recruit young 
adults, and this lower economic level is reflected 
in their death-rates. Alternatively it may be that, 
in towns that are no longer recruiting physically 
fit young adults from the rural districts, the death- 
rate is now measured upon a physically different 
population from that of past years. The towns are 
no longer strengthened, or are less strengthened, by 
this selective recruitment, the rural areas are less 
depleted. 

Naturally, as we are dealing with a general phenom- 
enon, Dr. Hill does not put this forward as being 
more than a contributory factor. In the recently 
issued text volume of the Registrar-General’s 
Statistical Review for 1933, attention is directed to 
the association of increasing mortality at young 
adult ages with unfavourable housing standards. 


“ Grouping together areas with over 1 per room average 
density, phthisis mortality of females aged 15-25 increased 
from 1911 to 1930-32 by 25 per cent. in the county 
boroughs and 21 per cent. in the counties, whilst in 
London with a mean density about 1 per room it increased 
by 16 per cent. At densities of 0-85-1 per room the 
towns showed no change and the counties an increase of 


iyo Research Coun., Spec. Rep. Series No. 95, London, 
25. i 


220 THE LANCET] 


THE ARMY IN 1934 


[san. 25, 1936 


15 per cent., but at densities below 0-85 per room both 
showed improvement of the order of 20 per cent. On 
the other hand, at ages 25-45, the fall in mortality was not 
confined to the better housed areas, but occurred almost 
irrespective of density.” 


It will be realised that the. problem is intricate ana 
its solution involves, as a first step, the clear presenta- 
tion and careful analysis of statistical data. Dr. Hill’s 
paper is a mode! of such work and will be indispensable 
in further study. 


THE ARMY IN 1934 


THE Report! of the Director-General of Army 
Medical Services for 1934 makes, cheerful reading. 
Soldiering in that year was an even healthier occupa- 
tion than in 1932, previously a record year. The 
ratio of admissions to hospital fell to 402-6 per 
thousand compared with 412-5 per thousand in 
1932, and there were appreciable reductions in the 
death, invaliding, and constantly sick ratios. The 
most notable decrease in disease was that of the 
malaria-rate in India which fell to 67-5 per thousand. 
~ Among officers the admission-rate was 191, a slight 
increase on 1932. The mostimportant causes of illness 
were, in order, inflammation of areolar tissues and 
tonsils, fractures, dysentery, malaria, influenza, and 
appendicitis. The principal causes of admission to 
hospital were the same for the soldier as for the officer, 
except that for the soldier venereal disease appears in 
the third place while dysentery and appendicitis were 
less common than sprains, contusions, and inflamma- 
tions of the upper respiratory tract. Bacillary 
dysentery is now about five times as frequent as 
am cebic—a marked contrast to the position ten years 
ago. Treatment is very satisfactory; only three 
patients were invalided from the Service during the 
year. There has been a striking decrease in the 
enteric group of fevers, especially in India. Arrange- 
ments are being made to extend protective inoculation 
to children, among whom the incidence is still too 
high. Improved figures in India are also responsible 
for a general reduction in sand-fly fever. There has 
been a general decrease in venereal disease, except 
in Jamaica. Work on the treatment of gonorrhea 
tends towards substituting saline irrigation fluids 
for potassium permanganate. Specific infectious 
fevers were rather bad during 1934 and there were 
three deaths from diphtheria and two from scarlet 
fever. General immunisation of children at Black- 
down may have accounted for the complete absence 
of diphtheria on that station, and vigorous steps 
are being taken to spread this form of protection. 
The large increase of cerebro-spinal meningitis in 
the Indian civil population has not so far affected 
the troops. There was a high incidence of middle- 
ear disease in Jamaica, Malaya, and Egypt, probably 
associated with the fact that bathing is a chief 
recreation in these places. The reduction of tonsillitis 
is deemed to be of the utmost importance because 
heart disease of rheumatic origin is the cause of much 
wastage. 

There has been a steady increase during the past 
ll years in gastric and duodenal ulceration, and 
a smaller increase of appendicitis. The figures are 
believed to depend on improved diagnosis rather 
than on any real increase. There has been no change 
in the standard diet, but the etiological factor of 
dental sepsis is under increasingly better control. 


7 Report on the oe a he Anny, 1934. 
Office. Vol. 1xx. Pp. 


H.M. Stationery 


Young unmarried soldiers with ulcers which relapse 
twice after adequate medical treatment are being 
recommended for discharge. It is felt that young 
soldiers are liable at any time to military duties which 
may, and often do, nullify in a few days the results 
of the most careful treatment. Few of the factors 
important in maintaining freedom from ulceration 
are within the control of the individual soldiers 
themselves. While the best possible diet and cooking 
are provided, the men cannot always be kept from 
sudden exposure to fatigue or inclement weather or 
obtain, out of hospital, frequent regular meals specially 
adapted to their needs. Married non-commissioned 
officers of long service suffering from ulcer are, if 
possible, retained and the commissioned officers— 
apart from mobilisation or prolonged manceuvres— 
are in a more hopeful position. 

The typhus group of fevers is attracting special 
attention abroad and evidence is accumulating to 
show that in India there are several hitherto 
unrecognised sub-groups with differing serological 
attributes. 

K SURGERY 


There was an increase in the number of surgical 
operations performed during the year, the total 
being 9157, with a mortality-rate of 0-54 per cent. 
This includes pensioners and women and children. 
The chief facts that stand out from the Report are 
the importance of local injuries and diseases of the 
areolar tissues—notably boils and carbuncles. The 
latter are treated conservatively with magnesium 
sulphate compresses rather than by active interference. 
There is also a tendency to give up open operations 
on fractures and to rely more on skeletal traction 
by wire or pins. Local anesthetics are more widely 
used for setting fractures. The use of spinal anes- 
thetics and Evipan is on the increase, although 
inhalants are still by far the most popular. The 
commonest major operations, apart from hernia, 
appendicitis, and ulcer, were cholecystectomy and for 
intestinal obstruction. There were 349 operations 
for recent inguinal hernia and 8 for femoral hernia. 
Injuries of the knee-joint played a fairly large part 
in disability and in 36 cases the fluid was aspirated ; 
the time spent in hospital was considerably less than 
if the cases were treated by elastic pressure and 
conservative measures. ‘“‘ Out-patients’? forms a 
very important part of the work of the surgical 
specialist, and clinics for the injection treatment of 
varicose veins and hemorrhoids continue to be of 
great value. There has been a large increase in the 
work of radiological, massage, and electrotherapeutic 
departments, 


WOMEN AND CHILDREN 


There was an average strength of 18,508 women 
for which the Army Medical Department provided 
services during 1934, and of these over 3000 were 
admitted to hospital during the year. The principal 
causes of admission were abortion, cramp and 
spurious labour pains, malaria, and appendicitis, 
followed in frequency by inflammation of the tonsils, 
bronchi, and areolar tissue. In addition, 2660 
women were admitted to hospital for confinement 
and 13,845 received out-patient treatment. Of the 
29,521 children on the roll there were just over 5000 
admissions to hospital and 26,847 out-patients. The 
principal causes of admission were enlargement of the 
tonsils, scarlet fever, inflammation of bronchi and 
tonsils, pneumonia and measles, dysentery, diarrhoea, 
malaria, and inflammation of areolar tissue. The 
wives and children are not entitled to medical 


THE LANCET] 


attendance at public expense but are eligible for it 
under certain conditions. Military family hospitals 
are established at stations where the strength of the 
garrison is out of proportion to that of the civil 
population. All these hospitals have antenatal 
clinics and during 1934 more than 300 expectant 
mothers were admitted for observation and treat- 
Ment. The percentage of abnormal labours was very 
small; the morbidity-rate was less than 8 per cent. 
and the mortality-rate 0-3 per cent. Authority is 
being sought for the extension of facilities for dental 
work by the Army Dental Service to all expectant 
mothers. An increasing interest is being taken in 
mother and child welfare, and accommodation is 
becoming cramped, but neither authority nor funds 
exist at present for new construction. . 
The Report emphasises the immense value of the 
work of the nurses of the Soldiers’, Sailors’, and 
Airmen’s Families’ Association. As an example, 


in Egypt seven nurses are employed, and they paid. 


just under 40,000 visits during the year and gave 
an average of 514 hours’ work each to welfare centres 
and medical inspection rooms. During the autumn 
4 general supply of milk was instituted for children 
attending army schools in the Southern Command. 
Unfortunately there was some doubt for a time 
whether the Milk Marketing Board’s scheme was 
applicable to army schools, but the hope is expressed 
that it will soon be possible to continue the sale of 
milk at reduced rates. In the Aldershot Command a 
manufacturing firm has offered to supply a third of 
a pint of malted milk for each child at a cost of 
3d. a week. Fresh milk-supplies remain variable 
and only partly under control. 

Most barracks in Egypt are very heavily infested 
with bugs, and an experimental disinfestation with 
hydrocyanic gas proved to be extremely satisfactory. 

Research work has been continued on the effects 
of a new type of deep breathing exercises on the vital 
capacity of the lungs. The average gains of platoons 
on these exercises was 130 c.cm. greater than the gain 
of those on ordinary exercises. The research depart- 
ment of the Directorate of Pathology has been con- 
cerned with the production of a better typhoid 
vaccine. The demonstration that a typhoid septi- 
cxinia could be induced in mice, which could also be 
rendered more or less immune by vaccination, offered 
a new avenue of approach to the problem. It was 
found possible to enhance the virulence of different 
Strains and the corresponding vaccine by continued 
and rapid animal passage. A similar procedure was 
followed for the paratyphoid organism, and it is 
confidently expected that vaccines prepared from the 
highly virulent cultures will be as superior in human 
prophylaxis as they are for laboratory animals ; 
they were first used just before the trooping season 
of the year under review. Although inoculation is 
entirely voluntary, 98 per cent. of the troops availed 
themselves of it. Children from the age of 2 years 
upward tolerate the vaccine well. . 

The rate of rejection of the troops was nearly 40 per 
thousand lower than in 1932-33. It is hoped in future 
to maintain statistical records of those rejected at 
sight by the recruiting staff without medical examina- 
tion, in order to obtain a true picture of the physical 
state of the youth of the nation. In the London 
zone it is known that 1749 were rejected for obvious 
physical defects, making a percentage of 67-2. Of 
those medically examined, the figure for the whole 
army is 35-7 per cent. rejected for medical reasons. 


The total would therefore appear to be approximately 


50 per cent. of those applying. 


MEDICINE AND THE LAW 


[JAN. 25,1936 221 


MEDICINE AND THE LAW 


Lightning and Workmen’s Compensation 


THE risks of injury due to the weather have raised 
interesting questions under the Workmen’s Com- 
pensation Acts. If the workman is to recover com- 
pensation, his injury must have arisen not only in 
the course of his employment but also out of his 
employment. To be struck by lightning while at 
work is an injury arising in the course of the employ- 
ment; it is not necessarily an injury arising out of 
the employment. The leading authorities include 
cases of bricklayers struck by lightning when on a 
high scaffolding, or sailors affected by heatstroke 
while painting the ironwork of a ship in the heat 
of a tropical sun. A recent decision in the Bath 
county court illustrates the legal issue. A workman 
died while employed on the Bath corporation’s 
housing estate where a trench was. being dug for the 
laying of iron water-pipes. On June 25th there was 
a violent thunderstorm and work proceeded at 
intervals. The dead man had a steel shovel with a 
wooden handle in his hand and was stooping to throw 
soil forward, with the shovel slightly raised. A 
second man was similarly employed within a few inches 
of him; a third was a few feet away. A wooden 
wheelbarrow was a few yards off; it had a steel 
rim to the wheel. Suddenly the deceased was thrown 
on to his back on the ground ; there was a loud clap 
of thunder and a vivid flash ; a neighbouring work- 
man complained of shock. The county court judge 
was Offered a large body of scientific evidence as to 
the effect of the wheelbarrow, the shovel, the pipe 
line, and the stacked pipes. He rejected this evidence 
as largely speculative and partly incredible. He 
came to the conclusion that the deceased, who had 
been badly burned, was directly struck by the light- 
ning and that the electric discharge had not been 
attracted or conducted by the metal objects named. 
The parties agreed that the court had to decide 
whether the deceased, by reason of his occupation, 
was subject to a greater risk than usual. The judge 
found that there was nothing in the man’s employ- 
ment which added to the risk of his being struck. 
The deceased was in no greater peril that any other 
inhabitant in the city of Bath or immediate neigh- 
bourhood. The court was satisfied that the lightning 
which killed the workman had no kind of connexion, 
direct or indirect, with his employment. There was 
thus an award for the respondents, the Bath cor- 
poration, with costs. It is a pity that the experts’ 
evidence was not more fully reported. What, one 
wonders, are the professional qualifications most 
acceptable to a court in expert witnesses who are to 
deal with the effects of lightning ? : 


‘« Running Amok ” with a-Car 


The unsuccessful appeal in R. v. Mortimer, against 
a conviction for murder, disclosed strange facts and 
a neat point of criminal law. The accused stole a 
car at Aldershot and, next day, drove it along a 
lane where two sisters were riding their bicycles in 
single file ahead of him. Approaching them from 
behind, the car struck the rearmost cyclist and 
carried her and her bicycle along the road for about 
30 yards on the bonnet. ‘The woman then fell to 
the ground, dying later of her injuries, and the car 
drove on and disappeared. 

In ordinary human affairs knowledge of a man’s 
previous conduct and character is the first thing 
taken into account. If money has been stolen in 


222 THE LANCET] 


an office, a business man would at once suspect that 
a clerk who had been previously convicted of larceny 
had been the thief. The law carefully excludes such 
extraneous considerations. If a man is charged with 
theft, the prosecution is not entitled to offer evidence 
(except in certain carefully restricted contingencies) 
that the accused stole something else on some date 
earlier or later. One of the grounds for offering 
evidence of similar offences is the existence of a need 
to negative the idea of accident. In Mortimer’s case 
. the prosecution, having to prove that he intended 
either to kill or to cause grievous bodily harm, 
obtained permission at the trial to give evidence of 
three similar occurrences (two earlier, and one later, 
than the event which formed the subject of the 
present charge) in order to establish the intent and 
to negative the possibility that the event was an 
accident. The Court of Criminal Appeal decided on 


Jan. 13th that this parallel evidence was rightly . 


admitted. | 

The defence in a case of this kind is naturally at 
a disadvantage if it takes two different lines. Mor- 
timer’s counsel relied on certain discrepancies in the 
evidence as to the number of the car and the clothing 
worn by the appellant. It would probably occur 
to the average reader to say that a man must be 
mad who acts as Mortimer was proved to have acted. 
Insanity was not pleaded, but it remains to be seen 
whether this may not be one of the cases where the 
accused, though deemed sane enough to be convicted 
of murder, is deemed not sane enough to be hanged. 


Marriage of Girl under 16 


One of the first cases under the Age of Marriage 
Act, 1929, was heard in the Probate, Divorce and 
Admiralty Division last week. A woman who was 
married on Sept. 27th, 1930, after giving her age 
in the marriage register as 17, now petitioned for a 
declaration that the marriage was null and void 
because she was in fact one month short of 16 years 
of age at the time. The court granted the declaration 
invalidating the marriage. 


Food Preservative Prosecution 


Three companies were fined last week at Tower 
Bridge Police-court, on proceedings at the instance 
of the Bermondsey borough council, for the sale of 
‘*Drywite Potato Preparation ”? in contravention of 
the Public Health (Preservatives, &c., in Food) 
Regulations. The proceedings raised the issue 
whether the language of the label would be likely to 
lead to an offence inasmuch as the preparation 
contained sulphur dioxide. It was stated that the 
label made reference to the washing but not to the 
cooking of fish; the preparation was described as a 
powerful deodorant. Experiments were said to have 
shown that, if fish were fried after treatment with 
the preparation, or were washed whole, no sulphur 
dioxide was found; but that when fillets of cod 
were washed in the preparation and analysed without 
cooking sulphur dioxide was revealed in minute 
quantities. The significance of the matter, it was 
suggested, lay not in the quantity of the preservative 
but in the fact that its use might lead to the con- 
sumption of unwholesome fish, since the preparation 
was capable of masking the evidence of putrefaction 
by removing smell or otherwise. For the defendant 
companies it was admitted tlat, in view of the 
statements made by the prosecution, the label might 
lead to the sale of uncooked fish containing prohibited 
preservative. A formal plea of guilty was entered 
and the companies undertook to discontinue the use 


SCOTLAND 
i a ee eee 


[JaNn. 25, 1936 


of the offending label. Fines were inflicted with 
costs. A further summons for failure to label the 
preparation as prescribed by the regulations was not 
separately dealt with; this part of the case related 
to the allegation that the declaration of the contents 
of the preparation was printed in type of smaller 
size than prescribed. 


SCOTLAND 


(FROM OUR OWN CORRESPONDENT) 


X RAY EXAMINATION OF THE GASTRO- 
INTESTINAL TRACT 


Dr. Robert McWhirter, who was recently appointed 
radiologist to Edinburgh Royal Infirmary, read a 
paper to the Medico-Chirurgical Society of Edin- 
burgh last week on the examination of the gastro- 
intestinal tract by radiology. He said that while in 
the early days of X raying the stomach only gross 
lesions were detected, modern apparatus and tech- 
nique have enabled a very high degree of accuracy 
to be obtained in the diagnosis of diseases of the 
stomach and duodenum. The figures from the Mayo 
Clinic suggest that the degree of accuracy should be 
over 95 per cent.; this, however, is only possible 
with careful preparation of the patient and modern 
apparatus. While some radiologists like to have a 
full clinical history of the case before examination, 
Dr. McWhirter holds that no case notes should be 
supplied to the radiologist, in order that he may 
not be prejudiced by a clinical history. He proceeded 
to describe conditions of the oesophagus, stomach, 
and duodenum which can be diagnosed by X ray 
examination. In diseases of the stomach the prepara- 
tion of the patient is simple but very important. 
No fluid or food should be given from 10 P.M. the night 
before examination. No purgatives are necessary. 
It should be possible, he said, to detect an ulcer 
crater the size of a pin-head and a carcinoma the 
size of a thumb-nail. Clinicians do not fully appre- 
ciate the fact that the diagnosis of diseases of the 
stomach and duodenum is made by screen examina- 
tion alone and films are taken only for record 
purposes. The study of the mucous membrane 
pattern is of special importance in the detection of 
early diseases of the stomach. The presence of a 
residue in the barium in the stomach five hours after 
administration is often of no pathological significance. 
The diagnosis of pyloric stenosis can be made in five 
minutes on screen examination. In cases of duodenal 
uleer the finding of the actual ulcer crater is always 
evidence of active ulceration; when only ulcer 
deformity is present the appearance may be due 
entirely to a healed ulcer. Dr. McWhirter went on 
to say that in his opinion the diagnosis of chronic 
appendicitis by radiology was impossible, and that 
a large amount of time and money was _ uselessly 
expended in attempting to demonstrate chronic 
diseases of the appendix. After considering the 
diagnosis of diseases of the large intestine and 
emphasising the importance of careful preparation 
for this examination, Dr. McWhirter referred to the 
examination of the gall-bladder by X rays. He said 
that intravenous injection of the dye used was no 
longer necessary, and emphasised the fact that the 
administration of the fatty meal was not to demon- 
strate the contractility but to make more obvious 


negative shadows within the gall-bladder. Dr. 
MeWhirter’s communication was illustrated by 


beautiful X ray photographs. 


THE LANCET | 


A PHYSIOLOGIST ON MEDICAL EDUCATION 


Prof. E. W. H. Cruickshank, who has been appointed 
to the Chair of Physiology in Aberdeen University, 
delivered last week his .inaugural lecture entitled 
Some Views on Medical Education. He said that the 
first purpose of medical education was to turn out 
men well equipped in the art and practice of medicine 
in all its phases; and the second was to discover 
and train men in creative work. He emphasised 
the need for general cultural education as an intro- 
duction to medical studies. The rigid lecture system 
had led to the evil of elaborate note-taking by the 
students and should as far as possible be replaced 
by the conference method, which, if carried out in 
small groups, was valuable in training the student 
in critical inquiry and in arriving at reasoned 
conclusions, 

THE ‘‘OPEN-DOOR”’ POLICY 

The abuse of the ‘“‘open-door.”’ policy has led the 
Board of the Royal Infirmary, Glasgow, to make 
use of its almoner’s department for the purpose of 
giving patients who are able to pay the opportunity 
of contributing to the cost of their treatment. In 
so doing they are taking the step which the other 
large voluntary hospitals in Scotland will probably 
have to follow before long. The steady increase in 
the work done by the voluntary hospitals and the 
fact that all classes are going to make use of the 
treatment and advice that can be obtained in these 
hospitals will, in all probability, oblige them to 
make a charge to those who are able to pay, 


UNITED STATES OF AMERICA 


(FROM AN OCCASIONAL CORRESPONDENT) 


CONTROL OF PATENT MEDICINES 


THE seventy-fourth Congress now reassembling 
after its vacation has before it no less than nine bills 
for the better regulation of the manufacture, adver- 
tisement, and sale of foods, drugs, therapeutic 
devices, and cosmetics. The most important of 
these is Senate Bill No. 5 introduced by Senator 
Copeland, of New York, who is a physician. This 
is described as— 

“ An Act to prevent the adulteration, misbranding and 
false advertising of food, drugs, devices and cosmetics 
in interstate, foreign and other commerce subject to the 
jurisdiction of the United States, for the purposes of safe- 
guarding the public health, preventing deceit upon the 
purchasing public and for other purposes.”’ 


The bill has been critically analysed by the Bureau 
of Legal Medicine of the American Medical Associa- 
tion, who find that “there is grave danger of the 
enactment of an inadequate law—one that will not 
protect the consumer adequately, that will require 
expensive and prolonged litigation before it can be 
effectively enforced, and that may for another quarter 
century or more exclude from the statute books an 
effective law.” The influence of the lobbies repre- 
senting the cults is very obvious, and may well serve 
as a horrible example to English legislators. Thus 
“Drugs” as defined in the Copeland bill are so 
defined specifically for the purposes of this act and 
‘not for the regulation of the legalised practice of 
the healing art.” Why onearth not ? one might reason- 
ably ask. The only possible answer seems to be that 
certain State laws allow chiropractors to make adjust- 
ments but not to use drugs. Somebody seems to 
have been afraid that the Copeland bill by its defini- 
tion of drugs might help to convict a chiropractor 


UNITED STATES OF AMERICA.—BUDAPEST 


[yan. 25, 1936 223 


of using drugs contrary to the statute of his parti- 
cular State. The answer to the question When is a 
drug not a drug? will no doubt contribute to the 
cost of the ‘‘ expensive litigation’ referred to by 
the committee. 

Again, ‘‘medical opinion” is defined as ‘“‘the 


opinion within their respective fields of any branch - 


of the medical profession the practice of which is 
licensed by law .. .” and the term ‘“‘ medical pro- 
fession ’? means, despite appearances, “ the legalised 
professions of the healing art.” What becomes, 
then, of the bill’s prohibition of false advertisements, 
seeing that the advertiser has adequate defence if 
only he can show that his statements are supported 
by “substantial and reliable medical opinion ” ? 
Presumably most juries will accept as such opinion, 
and will be instructed to accept it, the evidence of 
any half a dozen naturopaths. These and other 
weaknesses in the descriptive provisions of the bill 
are not offset by any rigidity in the provisions for 
enforcement. On the contrary the Secretary of 
Agriculture is expressingly excused from prosecuting 
any ‘‘minor violations” if he thinks a “ written 
notice or warning” is to be preferred. Considering 
that no guidance is offered as to what constitutes 
a “major” and what a “minor” violation, and 
that in practice the decision of whether or not to 
prosecute will inevitably devolve upon subordinates, 
the weakness of this provision is apparent. 

The analysis by the American Medical Association 
will serve a useful purpose if it leads to correspon- 
dence between individual doctors or local societies 
and their representatives in Congress. It has not 
received and is unlikely to receive any notice in the 
lay press. Discussion of the provisions of the bill 
controlling advertisement, and of their present 
weakness, is not likely to be favoured by the powerful 
advertising interests. 


BUDAPEST 


(FROM OUR OWN CORRESPONDENT) 


UNEMPLOYED DOCTORS IN BARRACKS 


AT the request of the National Committee for 
Unemployed Graduates, the Ministry of Defence 
has provided shelter and board for 100 of these 
men, most of them doctors. They live in a vacant 
military barracks, inw dormitories of 5-15 beds, with 
no other furniture than a long trestle table and 
benches and chairs. Clothes and linen are kept in 
bags, and shelves for books have been placed over 
some of the beds by the men themselves. Here 
they live in true good fellowship, without jealousy 
or discontent, and the only disputes are on scientific 
subjects. They themselves arrange the day’s routine 
and discipline, which are scrupulously observed. 
In the morning after breakfast they scatter through 
the city in search of work. At noon they return to 
the barracks and after a simple meal they do domestic 
work. Needle and thread are taken out, and the 
hands trained to do operations now display great 
skill in repairing a solution of continuity in coat, 
shirt, or trousers. Some, lacking means to pay 
the shoemakers, show themselves able to sole and 
heel their boots. After further search for work 
they return early in the evening, having no money 
to spend in clubs, cafés, or music-halls. In this way 
the days and weeks are passed until some fortunate 
runs in, joyfully shouting that he has found a post 
as an assistant or parish doctor or in the health 


- 


924 THE LANCET] PUBLIC 
insurance service. Hurriedly packing his bag he 
leaves his place to another of. the unemployed, of 
whom the numbers are woefully great. There are 
no complaints, despite the contrast of barrack room 
and military food with their hopes when they 
qualified—hopes of appointments, assured status, 
Marriage, and family life. Most of them are young 
and expect sooner or later to get work and realise 
their dreams; the barrack-room life is only a 
transitory stage and in the end the majority find 
satisfactory work. r 


THE ELDERLY PRIMIPARA 
During the past 24 years Dr. Stephan Sztehlo, 
of the School of Midwifery here, has personally 
observed 5588 deliveries of primiparæ and has now 
reviewed them in order to determine the effect of 
age on labour. His findings agree with the general 
opinion of obstetricians that the influence of age is 
considerable. After thirty, a first labour is likely to 
be more troublesome, and one must be prepared for 
complications—especially in women who have become 
pregnant for the first time after many years of 
married life. The risk of long labours, inertia, post- 
maturity, hsemorrhage, and puerperal sepsis increases 
with the age of the patient, and from the point of 
view of pregnancy and labour, he thinks, the most 

favourable age for labour is 20-24 years. 


A RHEUMATISM LIBRARY 


In 1926 at Pistany, the thermal spa, the Inter- 
national League for the Campaign against Rheumatism 
was formed and it was then hoped that an inter- 
national institute for research into muscular and 
articular rheumatism might be founded. A leading 
physician in the town has made plans for such an 


HEALTH [san. 25, 1936 
institute, and they have been approved by the 
Ministry of Public Health. A. library is the first 
part of the scheme to be realised and building will 
begin in February. Its objects are to attract students 
to Pistany, to offer them facilities for studying the 
literature, and thus to help research workers in their 

investigations, 


MEAT CONSUMPTION IN HUNGARY 


An average of 116]1b. of meat per head was con- 
sumed in Hungary in 1934, a figure which cannot be 
considered low compared with those of other European - 
States. Financial stress caused only a slight decrease 
in meat consumption because of a simultaneous 
fall in the price of food, and particularly of meat. 
As might perhaps be expected; more is eaten in 
Budapest than in the countryside. Owing to the 
relative cheapness of beef, veal, and mutton, very 
little horse-flesh is now eaten, though it was once 
considered a delicacy. | 


l FREE MILK IN THE SCHOOLS . 
In the poorer parts of the capital the city council 
have introduced the free milk system and to every 
child about a third of a pint is distributed each day. 
A recent report of Dr. Endre Tudös, lecturer in the 
university, shows that this distribution has consider- 
ably improved the condition of delicate or anæmic 
children, and the teachers have noticed faster 
progress, keener attention, and quieter behaviour. 
The minister of education is accordingly anxious 
to introduce the system in rural districts, where 
children-badly need wholesome milk because, owing 
to the economic crisis, the small farmers with a 
few cows sacrifice their own and their children’s 
health by selling their entire stock of milk to the city. 


PUBLIC HEALTH 


‘Maternal Deaths in L.C.C. Hospitals 


THE strenuous efforts to improve the L.C.C. 
maternity services have caused an increased demand 
for admission and a lowered death-rate affecting 
almost every group. Dr. Letitia Fairfield,! reporting 
for the year 1934, records a total of 13,253 births, 
an increase of 1336 on the previous year, and a 
mortality-rate of 5:1 per thousand. The ante- 
natal care reaches a very high standard. The Council 
demands one special examination for all booked 
patients, but the great majority attend more or less 
regularly at borough clinics. The divided respon- 
sibility for maternal care has always created diffi- 
culties in London, but there has been a marked 
improvement in codperation during the past year. 
One of the chief difficulties of the Council is con- 
gestion, for Wassermann tests are now made on all 
women attending for the first time, and many more 
blood pressures are now taken than in earlier days. 
These precautions are justified by a comparison of 
the death-rate of those attending L.C.C. clinics with 
others. | 

Sepsis.—The mortality figures for the Council’s 
hospitals cannot be compared with the country 
generally because these institutions are the chief 
resort for cases of abortion, and they also receive 
an undue proportion of women suffering from general 
diseases. They show, however, that sepsis is the 
commonest single cause of death in the Council’s 
wards, as elsewhere. Deaths from true uterine 

2? L.C.C. Annual Report of the Council, 1934. Vol. iv., 


Part III. Public Health. Medical Supplement to the Report 
on the Hospital Services, p, 88. 


sepsis numbered 8 only (0-61 per thousand births), 
and of these only 5 were patients whose labour 
had been conducted entirely in the Council’s hospital. 
If deaths after Cesarean section and mastitis are 
included, the figure for 1934 is 1:18 per thousand 
births. There was nothing in the nature of an epi- 
demic during the year, and in only one case of sepsis 
was there evidence of the source of infection, but the 
prevalence of mastitis in certain localities continues 
to give rise to anxiety. Certainly forceps do not 
appear to be the cause of sepsis in the Council’s 
service. Dr. Fairfield thinks that one of the most 
important factors in the prevention of sepsis is the 
early detection and isolation of all cases of fever or 
other suspicious signs of early sepsis in a maternity 
ward. Improved accommodation is making this 
precaution possible in the Council’s hospitals, with 
increasing success. 

Apart from sepsis there were 4 ‘“‘accidents of 
childbirth”: 3 of the patients were admitted 
in extremis, one with a ruptured uterus and a shoulder 
presentation and two after ‘failed forceps.” The 
fourth had had antenatal care from the Council and 
died from shock after craniotomy. 

Accidental hemorrhage and placenta previa.—Of 
the 86 cases of accidental haemorrhage admitted only 
1 died, and she arrived moribund. . 

There were 98 cases of placenta previa with 
3 deaths, one from sepsis after several vaginal exami- 
nations made before admission. 13 Cesarean sections 
were performed for placenta pravia without a death. 

Anasthesia.—There was 1 death attributable to 
anwsthesia: percaine and a gas, oxygen, and ether 


THE LANCET] 


mixture. She died five minutes after induction 
began without warning, before the operation was 
started, and the heart muscle showed degenera- 
tion. Of the 13,061 women delivered 4424 were 
given light intermittent anesthesia, mainly by 
chloroform capsules, 850 had a general anesthetic, 
58 had a local anesthetic, and 325 had analgesia by 
drugs in combination with some form of anesthetic. 
Analgesia without an anesthetic was supplied to 
837 patients. 

Cesarean section was performed on 136 patients 
with 9 deaths. In most cases the indication was 
contracted pelvis and disproportion, but heart 
disease, placenta previa, and toxemia played their 
part. The operation was performed before labour in 
74 cases with 5 deaths, early in labour in 30 cases 
with 2 deaths, and late in labour in 32 cases with 
2 deaths. Four of the deaths were entirely due to 
the condition for which the operation was performed 
and the remainder were due to sepsis. Of the first 
group, one had very severe heart disease, one ful- 
Minating acute yellow atrophy of the liver, the 
third had chorea gravidarum, and the fourth a large 
pyelonephrosis. 

The large strides made in preventing eclampsia 
and torwmia have caused these diseases to be regarded 
as an indicator of the efficiency of antenatal care. 
Dr. Fairfield thinks that the argument can be pushed 
too far as, on the one hand, the patient may fail to 
recognise early symptoms however carefully she is 
instructed, or, on the other hand, the disease may 
be of the rare fulminating type which resists all 
treatment and gives no warning. During the year 
41 cases of eclampsia were admitted; 12 had had 
antenatal care in the Council’s clinics and 2 of these 
died; 29 had had care from other sources (or none) 
and 6 of these died. The time at which the fits 
developed illustrates the grave prognostic significance 
when the first fit is post-partum. In 11 cases the 
fits, began before labour and in 22 cases during 
labour, and in each group there were 2 deaths. In 
8 cases they began after labour, and half these women 
died. It is clear that periodic urine testing would 
not always provide an adequate warning : one 
woman who died never had any albuminuria at all, 
and in some cases the urine had been tested only a 
few days before the fits began and had shown nothing 
abnormal. The blood pressure is a valuable but not 
an infallible guide to the imminence of danger. 
Only one woman with eclampsia had a pressure 
below 130. Above this critical figure, however, the 
readings had little prognostic significance, as patients 
with a maximum of 140 died while those with pres- 
sures of over 200 recovered. 

Another group of deaths recorded is that 
associated with pregnancy and confinement; this 
includes every woman who died between the twenty- 
eighth week of pregnancy and four weeks after delivery. 
Some of the deaths were purely coincident, while in 
others childbearing played an obvious part. Dr. 
Fairfield points out that a quite extraneous cause 
such as an influenza epidemic might easily affect the 
maternal mortality-rate and create fallacious alarm, 
while over-careful certification might over-weight 
the figures. Instances have been known where a 
woman died from phthisis or heart disease weeks 
after childbirth and was classified as a *‘ maternal ”’ 
death. 

Dr. Fairfield concludes by remarking that the 
close inquiries into every maternal death in the 
Council’s hospitals show that no obvious or easily 
ehminated cause for a high mortality-rate exists. 


PUBLIC HEALTH 


[san 25, 1936 225 


The only possibility of a further reduction lies in a 
steady improvement‘ of staffing, accommodation, 
and organisation, together with loyal coöperation on 


the part of the patient. ` 


Speech Training and the C.A.M.W. 


An increasing number of local education authorities 
have made provision for the treatment of stammering 
and other speech defects; at the present time 
40 authorities provide classes which children attend 
for a period of about 50 minutes on two occasions 


` per week, while 10 authorities provide classes where 


full-time ‘attendance is arranged, but, as is pointed 
out in the C.M.0.’s recent report, many authorities 
still do not appreciate that inability to speak distinctly 
is an even greater reflection on the educational 
system than is failure to acquire the art of writing. 
The Central Association for Mental Welfare has, 
during recent years, arranged for an expert in speech- 
training to visit certain areas in order to investigate 
the problem of children with speech defects. Before 
her visit, ascertainment of the number of such 
children has been carried out by head teachers and 
the names of such children sent in to the education 
office. The speech expert, Miss Marion Fleming, has 
then examined the children in coöperation with the 
school medical officer, after which suitable children 
have been taught in classes arranged on the lines of 
those which are held in London. In addition to the 
actual training of children with stammering and other 
speech defects, Miss Fleming has lectured to teachers 
and others interested in the problem, given demon- 
stration lessons before teachers from the contributory 
schools, and she has also paid a number of home visits. 


The school medica! officer for Coventry has included 
in his annual report a statement by Miss Fleming of 
the incidence and histories of stammerers in the 
Coventry schools. In association with the assistant 
school medical officer information relating to 158 
stammering children was obtained, and the following 
conclusions were arrived at :— 

1. Of the stammerers investigated, 62 per cent. were 
either the eldest or the eldest but one in the family, while 
21-5 per cent. were the youngest members of their respec- 
tive families ; in the larger families containing stammerers, 
therefore, the incidence of stammering appears to be 
least among ‘ middle ” children. 

2. In about one-quarter of the cases, either the father 
or the mother was also a stammerer. 

3. It appears that there is no notable connexion between 
“ left-handedness ” and stammering. 

4. As expected, findings indicating stammering as a 
functional nervous disorder were numerous; among them 
75 per cent. of the cases were noted as being nervous and 
“ highly-strung ” ; 22 per cent. of the cases were nail- 
biters ; 62 per cent. of the cases were said to speak more 
easily at home than at school. 

5. In most cases, the cause of the stammer was not 
evident. The findings under the headings of causation 
are hardly compatible in some directions with findings 
under other headings. For instance, “imitation of 
others ” is given as the cause in but 5:7 per cent. of cases, 
whereas stammering in one or other of the parents, which 
is likely to elicit imitative response in the child, is recorded 
as occurring in as many as 22-7 per cent. of the cases 
investigated. 

Miss Fleming only remained for a period of from 
six weeks to two months in the area. This time, 
as she points out, is too short for definite results to 
be obtained in the treatment of stammerers. The 
great advantage of the arrangement, however, is that 
local interest was aroused, and in more than one of 
the areas which she visited it is proposed to appoint 
a whole-time teacher for children with stammering 
and speech defects. 


9 26 THE LANCET] 


(san. 25, 1936 


CORRESPONDENCE 


CONTROL OF MEASLES 
To the Editor of THE LANCET 


Sir,—Dr. J. D. Rolleston’s historical résumé of 
the subject of the serum prophylaxis of measles in 
your last issue (p. 168) was of great interest. Stating 
that Dr. Brincker was incorrect in his belief that the 
first attempt to modify measles in this way was first 
made only 40 years ago-he refers to Frances Home’s 
pioneer work on this subject in 1765. He then states 
that Dr. Hugh Thompson, of Glasgow, employed 
this method successfully in two cases (1890). I was 
able to discuss this with the late Sir Leslie Mackenzie 
just before his death, and he then informed me that 
Thompson had subsequently published a considerably 
larger series of cases with similar results, I am 
unfortunately unable to find any reference to this 
series, and it would be of considerable interest to 
hear if any of your readers are able to give information 
with regard to this. 

I believe that I am correct in saying with regard 
to the modern method of prophylaxis and attenuation 
of measles by means of convalescent serum that I 
was the first to introduce it to this country some years 
prior! to the epidemic of 1929-30 in which it was 
used with such success. 

I am, Sir, yours faithfully, 

Harley-strect, W., Jan. 20th. W. S. C. COPEMAN, 


SYNTROPAN IN SEA-SICKNESS 
To the Editor of THE LANCET 


Sır —May I draw your attention to the effectiveness 
of the new synthetic vagus depressor, Syntropan, 
in sea-sickness. As ship’s surgeon travelling between 
Australia and London, and vice versa, during two 
very stormy periods, I have had some rather intensive 
experience. The first trip, homeward bound, 
in November-December, was made in a severe 
Mediterranean storm, and a severe Atlantic storm 
in which the wind reached gale force, as recorded in 
the ship’s log, for the best part of ten days. Condi- 
tions aboard ship were at their worst, and most 
passengers were sick—some exceedingly sick. On 
the outward journey in July-August, the monsoon 
was at its height, a man being lost overboard from 
a sister ship passing us. There were seven days of 
bad weather and much sickness. 

A total of 140 cases of sea-sickness was treated, 
100 with Syntropan preparation No. 2190/14, and 
40 with Vasano, and with the usual mixture of 
hyoscyamine and bromide. Syntropan and vasano 
were equally effective in removing almost instantly 
the feelings of nausea that precede the sickness. The 
hyoscyamus mixture was not so effective in ambulatory 
cases. When vasano was replaced by syntropan, 
the passengers thereafter preferred the syntropan 
preparation because it did not give rise to the 
intensely dry mouth which is also produced by 
hyoscyamus. Two tablets, morning and afternoon, 
served to cure the worst cases. The usual difficulty 
in dealing with patients unable to keep the tablets 
down was overcome by using suppositories of the 
same material. Passengers who were occasionally 
overcome, when given two tablets of the syntropan 
preparation, were almost immediately restored, so that 
the efficiency of the preparation became a subject 


2 Jour. of Hyg., 1925, xxiv., 427 ; Proc. Roy. Soc. Med. (See. 
Epidem.), 1927, xx., 1609. 


of comment; one tablet sufficed in mild cases. More- 
over, I cured a fellow officer, and myself, just as 
rapidly, by taking two tablets when the stage of real 
discomfort had been reached. 

Why syntropan should act so effectively on the 
gastric vagus and have so little action on the salivary 
parasympathetic supply, is not at all clear; it may 
be a matter of differential rates of penetration of the 
drug into the neighbourhood of the various para- 
sympathetic endings that is the explanation. The 
result, however, is remarkable, and anyone knowing 
the discomfort of the dry mouth produced by 
hyoscyamine will agree that a remedy so effective 
as that reported is indeed worthy of mention. 

The composition of the preparation is as follows :— 


0°01 g. 
0°l g. per tablet. 


Syntropan.. 
Sedormid .. 


syntropan being phosphate of the 3-diethylamino- 
2-2-dimethyl-propylester of tropic acid. 


I am, Sir, yours faithfully, 


C. STANTON HICKS, 


Professor of Pharmacology and Human 


Nov. 6th, 1935. Physiology, University of Adelaide. 


DR. ALBERT GRAY’S TECHNIQUE 
To the Editor of THE LANCET 


Sir —May I in amplification of the account of 
Dr. Albert Gray’s work contained in your obituary 
notice last week add something about the method of 
making transparencies of the membranous labyrinth 
which he devised and emploved with such success 
in his work “The Labyrinth of Animals.” This 
process yields at one stage perfect casts of the bony 
labyrinth, but the finished product is much more 
than a cast and contains all the structures of 
the membranous labyrinth, perfectly cleared and 
preserved. I am, Sir, yours faithfully, 

C. S. HALLPIKE. 


Ferens Institute of Otology, Middlesex 
Hospital Annexe, Jan. 20th. 


COLLAPSE THERAPY IN PLEURISY AND 
PNEUMONIA 


To the Editor of THE LANCET 


SIR —I read with much interest the observations 
of Dr. C. Shaw in your issue of Dec. 7th, 1935 (p. 1280), 
on artificial pneumothorax for the relief of acute 
pleural pain. I made observations on 12 cases so 
treated (Calcutta Med. Jour., August, 1934) which 
did well and I remarked : 


“ It was quite reasonable to think that it should be so, 
becauso the partial collapse of the lung at once stopped 
friction between the two inflamed layers of the pleura, 
gave rest to the discased area, relieved local congestion 
and pain and hastened repair and convalescence. 
Further, by maintaining this state of partial collapse by 
giving more fillings afterwards, healing was perfect, and 
the chance of relapso or formation of adhesion or effusion 
was very much minimised. The author is in touch with 
some of theso cases for over two years and they are kecping 
perfectly fit.” 


I read with equal interest Dr. W. E. Robertson's 
paper in the same issue of TNE LANCET (p. 1282), for 
I had treated similarly 20 cases of pneumonia with 
excellent results—only 3 deaths—my main difficulty 
being to find a suflicient number of suitable cases. 
Since the influenza pandemic of 1918-19, the 
infective organisms of acute catarrh of the respiratory 


THE LANCET] 


ABDOMINAL VARICOSITIES.—VITAL STATISTICS 


(san: 25, 1936 227 


tract are usually of mixed character, true lobar 
pneumonia, in Calcutta at least, being comparatively 
rare.. The usual picture is one of acute bronchial 
catarrh, in some cases with patches of consolidation 
forming from day to day, which by fusion give rise 
to pseudo-lobar consolidation. In these cases as 
well as in true lobar cases A.P. treatment often gave 
a very favourable result. With Dr. Robertson I 
have found that (1) A.P. does confer almost instant 
relief upon those suffering from coincident pleuritis ; 
(2) it ameliorates cough and expectoration; (3) it 
frequently lowers the temperature, sometimes to a 
surprising extent. Dr. Robertson thinks that it does 
not cut short the attack of pneumonia, but in my 
cases I found that A.P. treatment nearly always 
brought down the pulse and the respiratory rate, 
lessened toxemia, and caused considerable improve- 
ment in general condition, thus shortening the course 
of the disease and reducing its mortality. 

Specific treatment with Felton’s serum is very 
expensive; typing is difficult, and once consolida- 
tion has been established serum is not so effective. 
In all late cases A.P. treatment is more suitable. 
Dr. Robertson has pointed out that it is innocent 
of any collateral ill-effects, to which I fully agree. 
Since 1932 in my wards in the Campbell Medical 
School and Medical College Hospitals it has been 
routine treatment to perform partial collapse in all 
cases of uncomplicated acute primary pleurisy and 
circumscribed lobar-like consolidation. The quantity 
of air introduced varies from 100 to 400 c.cm., depend- 
ing mainly on the amount of pleural space available. 
In some cases one operation was sufficient but in 
others it had to be repeated, and in bilateral cases 
partial collapse was maintained on both sides. 

I am, Sir, yours faithfully, 
Calcutta, Jan. 2nd. A. R. MAJUMDER. 


ABDOMINAL VARICOSITIES 
To the Editor of THE LANCET 


Sm, —In your issue of Jan. 11th Mr. A. L. d’Abreu 
describes two cases of varicose veins of the legs which 
showed by the presence of abdominal varicosities 
that some obstruction was present in the deep veins 
of the trunk, and states that he regards the existence 
of the latter as prohibiting the treatment of the leg 
veins. His view, however, is not securely founded 
either on theory or fact. If the saphenous veins 
show a positive Trendelenburg test they can be 
safely treated whether the patient has obstruction 
of the vena cava or not. Some years ago I obliterated 
the varicose veins in the legs of a similar case with 
satisfactory results and showed the man before a 
society, not because I regarded the treatment as 
unusual, but because the deep obstruction in the 
abdomen appeared to be congenital. Further, it is 
held by some, including Dickson Wright (Brit. Med. 
Jour., 1931, ii., 561), that even when the obstruction 
is in the deep veins of the leg itself the superficial 
varicosities are merely an added embarrassment 
to the circulation, and I have treated several such 
cases without regret. It would, of course, be generally 
regarded as bad treatment to deal with the abdominal 
veins, but V. Meisen (Varicose Veins and Hæmor- 
rhoids, London, 1932, p. 50) has done so in a case 
with deep abdominal thrombosis, and apparently 
without ill-effect, and with cure of the coincident 
eczema. It is a curious fact that these abdominal 
varicosities sometimes appear without any apparent 
cause for obstruction of the inferior vena cava or 
the iliac veins.—I am, Sir, yours faithfully, 

Birmingham, Jan, 16th. J. W. RIDDOCH. 


THE SERVICES 


ROYAL NAVAL MEDICAL SERVICE 


Surg. Comdrs. G. Kirker to Drake for R.M. Infirmary, 
Plymouth, and J. F. H. Gaussen to Lucia 

Surg. Lt.-Cmdr. W. A. Hopkins to be Surg. Cmdr. 

Surg. Lt.Cmdrs. J. C. Souter to Drake for R.N. Hospital, 
Plymouth, and A. M. Lawrence-Smith to Victory for 
R.N.B. and to Dolphin. 

Surg. Lt.-Cmdr. (D.) L. M. Hughes to Victory for R.N.B. 

Surg. Lts. H. G. Silvester to Duncan, A. E. Ginn to 
Herald, W. F. Viret to Tern, J. L. S. Steele-Perkins to 
Sandwich, and F. H. Lamb to Folkestone. 


ROYAL ARMY MEDICAL CORPS 


Short Service Commissions: Lts. J. G. M. A. Brunet 
and R. O. A. Leroux to be Capts. 


ROYAL AIR FORCE 


Medical Branch.—Wing Comdrs. P. T. Rutherford, 
O.B.E., to Headquarters, Fighting Area, Uxbridge, for 
duty as Principal Medical Officer, vice Group Captain 
K. Biggs, M.C., and E. C. K. H. Foreman to No. 10 Flying 
Training School, Ternhill, for duty as Medical Officer. 

Squadron Leader C. A. Lindup to No. 8 Flying Training 
School, Montrose, for duty as Medical Officer. 

Dental Branch.—Flying Officer Alexander 
L.D.S., is promoted to the rank of Flight Lt. 

Flight Lts. Hugh Bannerman, F. W. P. Dixon, and 
C. R. Palfreyman have been selected for permanent. 
commissions in the medical branch, subject to physical 
fitness ; they entered as flying officers in 1930-32. 


INDIAN MEDICAL SERVICE 


Lts. (on prob.) to be Capts. (on prob.): I. J. Franklen- 
Evans, J. Duffy, and K. Cunningham. 

Lt.-Col. B. Higham, C.I.E., retires. 

Indian Medical Department.—Maj. (Sen. Asst. Surg.) 
T. J. Gibson retires. 


Maben, 


INFECTIOUS DISEASE 


IN ENGLAND AND WALES DURING THE WEEK ENDED. 
JAN. 11TH, 1936 


Notifications.—The following cases of infectious: 
disease were notified during the week : Small-pox, 0 ;, 
scarlet fever, 2397; diphtheria, 1264; enteric fever, 
21; acute pneumonia (primary or influenzal), 1571 ;: 
puerperal fever, 58 ; puerperal pyrexia, 117 ; cerebro- 
spinal fever, 23; acute poliomyelitis, 7; ‘acute polio- 
encephalitis, 1 3 encephalitis lethargica, 7; dysentery, 
21; ophthalmia neonatorum, 91. No case of cholera, 
plague, or typhus fever was notified during the week. 

The number of cases in the Infectious Hospitals of the London 
County Council on Jan, 17th was 3850, which included : Scarlet 
fever, 1098; diphtheria, 1150; measles, 433; whooping- 
cough, 599; puerperal fever, 17 mothers (plus 11 babies) y; 
encephalitis lethargica, 280 : poliomyelitis, 4. At St. Margaret’s 
Hospital there were 18 babies (plus 8 mothers) with ophthalmia 
neonatorum, 


Deaths.—In 121 great towns, including London, 
there was no death from small-pox, 1 (0) from enteric 
fever, 43 (4) from measles, 5 (0) from scarlet fever, 
28 (5) from whooping-cough, 36 (7) from diphtheria, 
44 (12) from diarrhoea and enteritis under two years, 
and 110 (18) from influenza. The figures in paren- 
theses are those for London itself. 

The mortality from influenza is the same as last week, the- 
total deaths for the last six weeks (working backwards) being 
110, 110, 80, 67, 62, 45. They are scattered over 56 great towns, 
Birmingham reporting 8, Oldham 5, Bradford and Newcastle- 
upon-Tyne each 4, Luton, Leeds, Shefiicld, and Coventry 
each 3, no other great town more than 2. Liverpool and Man- 
chester each had 9 deaths from measles, Bristol and Nottingham 
each 4, Liverpool also reported 8 deaths from whooping- 
cough. Deaths from diphtheria were reported from 18 great 
towns: Liverpool 4, Hull 3, Darlington, Shetiield, Warrington, 
and West Hartlepool each 2. 


The number of stillbirths notified during the week 
was 246 (corresponding to a rate of 37 per 1000 total 
births), including 33 in London. 


928 THE LANCET] 


[JaN. 25, 1936 


OBITUARY 


ANDREW FRANCIS DIXON, M.B., B.Ch. Dub. 


THE death occurred on Jan. 15th of Andrew 
Francis Dixon, professor of human anatomy and 
embryology in the University of Dublin. Born in 
1868, he came of a well-known Dublin family. One 
of his brothers occupies the chair of botany in 
Dublin University and another until lately was 
professor of engineering in the City and Guilds 
College of Engineering, London, while his uncle, 
R. V. Dixon, was a fellow of Trinity College. 

Francis Dixon entered Dublin University in 1885 
and had a brilliant academical career, gaining a 
senior moderatorship and gold medal in natural 
science and securing many other distinctions, as well 
as obtaining in 1893 the medical degrees M.B., B.Ch., 
B.A.O. During the course of his medical studies 
he first came in contact 
with the late Prof. D. J. 
Cunningham who so 
greatly influenced his 
career. His early 
interests were in zoology 
and his first publications 
were concerned with the 
marine invertebrates, in 
which he was intensely 
interested all his life. But 
in 1893 his attention was 
turned more definitely 
towards human anatomy 
and he went to Leipzig 
to study under the late 
Prof. His. A year later 
he was appointed chief 
demonstrator in anatomy 
in Trinity College, Dublin, 
under Cunningham. In 
1897 he was appointed 
professor of anatomy in 
University College, Cardiff, 
but in 1903 he returned to his old college to 
succeed Cunningham as professor of anatomy and 
chirurgery in the medical faculty, and from that date 
his whole-hearted service and loyalty were devoted 
to Trinity College. In 1916 he was appointed the 
representative of the college on the General Medical 
Council; in 1922 he was appointed to the newly 
founded chair of human anatomy and embryology, 
and in 1924 he became dean of the Faculty of Physic. 
And perhaps his greatest work was his devotion to 
the interests of the students and the ardour with 
which he worked for them, especially in their early 
post-graduate years. He was keenly interested in 
all their activities and took a very large part in 
organising the Trinity College Association with the 
object of keeping them in touch with each other 
and with their college. He was also actively interested 
in the old O.T.C. and in the Dublin University Bio- 
logical Association, of which society he was president 
in 1904-05. 

Outside the University Prof. Dixon had a very 
wide circle of friends and interests. He was a life- 
long member of the Anatomical Society of Great 
Britain and Ireland, and was elected president of 
that society in 1934. From 1917 to 1925 he was a 
member of the council of the Royal Dublin Society 
and in the latter year was appointed a governor of 
the society. On six separate occasions he was 
elected a member of the council of the Royal Irish 


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Academy, and in 1919 and again in 1926-27 he was 
a vice-president. For thirty years he was a member 
of the council of the Royal Zoological Society of 
Ireland, and from 1927 to 1931 was their president. 
He was a fellow of the Royal Academy of Medicine 
in Ireland and in 1906-08 was president of the section 
of anatomy and physiology. In 1934 he was appointed 
warden of Alexandra College. His many personal 
friendships and his wide sympathies made him a 
very valuable link between the university and 
outside bodies. 

In his younger days Dixon published many 
interesting contributions to anatomical science. Our 
knowledge of the development of the fifth cranial 
nerve, of the course of the taste fibres, of the structures 
in the female pelvis, and of many interesting features 
in the skeleton has been considerably extended by his 
researches. But in later 
years pressure of adminis- 
trative duties and heavy 
responsibilities in directing 
the medical school neces- 
sarily curtailed his time 
for such work. But those 
who knew him realised 
that he possessed an 
amazing fund of original 
observations and accurate 
knowledge on many 
interesting points, and 
regretted that lack of 
time and his own modesty 
prevented him from com- 
mitting them to print. 

He will be remembered 
always as a very loyal 
and warm-hearted friend. 
His memory for faces was 
extraordinary, and Trinity 
men revisiting the college 
after a lapse of many 
years were always sure of a warm personal welcome 
from the dean. For the college itself he enter- 
tained such a loyal devotion that no task was 
either too large or too menial for him to undertake 
if he felt that its interests were concerned. 


lee ALLO 


We have received from our Dublin correspondent 
the following estimate of Dixon’s great services, not 
only to his University but to the scientific world :— 


“For nearly half his life—thirty-two years—Francis 
Dixon was head of the department of anatomy 
in the School of Physic; for nineteen years he 
represented the University of Dublin on the 
General Council of Medical Education and Registra- 
tion, and for eight years on the Irish Medical Registra- 
tion Council; he represented the professors of the 
university on the board—the governing body—of 
Trinity College ; he was for many years past dean of 
the School of Physic. It is clear that the character 
of the school during the last thirty years must have 
been largely influenced by him. It is difficult for any 
but his colleagues to realise how sound and con- 
structive was that influence, and how kindly, wisely, 
and unselfishly it was exercised. With an essentially 
conservative outlook and with a firm confidence in 
the mode of education which was traditional in 
Dublin, he never ceased his determination to keep 
that education in touch with modern requirements. 
He insisted on his students learning their anatomy 


THD LANCET] 


soundly, but he never forgot that his first duty was 
to fit them for medical practice. At the same time 
any senior student or young medical man who 
desired to study anatomy more deeply or to investi- 
gate any particular problem of anatomy with a 
clinical bearing received every encouragement and 
facility. When he was appointed in 1903 to the 


chair he succeeded two great anatomists—Alexander 


Macalister and Daniel John Cunningham; in his 
hands the reputation of the school of anatomy, both 
as a teaching institution and as a centre of research, 
was not only maintained but increased. He contri- 
buted frequently to the various scientific journals, 
and he always had something solid to contribute. 
His publications were marked by clarity, precision, 
and modesty. His teaching of his anatomy class 
had the same characters, and he held the attention 
and roused the interest of his students without 
apparent effort. He contributed the section on 
urogenital anatomy to Cunningham’s ‘ Text-book of 
Anatomy,’ and gave much assistance to the editor in 
the production of the first edition. He-also wrote 
a ‘Manual of Human Osteology ’ which has become a 
favourite text-book in many schools. His chief 
interests in original work lay in the fields of embryo- 
logy and comparative anatomy. 


“ His responsibility as dean of the school kept 
him in touch with the work of all his colleagues. 
His influence on them and their work was more that of 
an elder brother than of an official of the university. 
He never intruded and never interfered, but his advice 
and help were at the disposal of all of them, and 
it is only since his retirement that they realise how 
much they had come to rely on him. They knew 
that his advice would be wise, and would be given 
without any slightest touch of self-interest or self- 
seeking. A shy man and a modest, he never liked 
pressing his opinions on others, but nevertheless he 
held strongly to his own convictions, and when a 
difference of opinion occurred he stated his views 
clearly and tersely, and then left it to others to 
make their decision according to their conscience as 
he had made his. 


“ His relations with his pupils were of the happiest. 
He did not tolerate slackness and he insisted on a 
high standard of work, but it was only in the rarest 
cases that he adopted disciplinary measures. Many 
a respected and respectable practitioner, inclined in 
his youth to idleness or folly, can look back to the 
help and guidance of Dixon as one of the important 
influences in his career. 


‘‘Dixon’s friends will remember with pride his 
honourable career, his achievements, his services to 
his University, and to medical education. Their 
pride will, however, be lost in their affection for 
the man, the wise counsellor, the trusty friend whose 
friendship never stood out so strong as in time of 
trouble or anxiety.” 


JOHN BRIGHT BERRY, M.D. Edin. 


Dr. John Berry, who died on Jan. llth at the 
age of 79, was the doyen of the medical profession 
at Keighley. He graduated as M.B., C.M. Edin. in 
1880, proceeding at a short interval to the M.D. 
degree. He practised for a time at Bradford, but 
some 40 years ago went to Keighley and pursued 
his vocation there until he retired in 1920. During 
a great part of his life in Keighley Dr. Berry held 
an honorary consulting position to the Victoria 
Hospital and he was closely connected with the 
Bradford Medico-Chirurgical Society of which he 


OBITUARY 


[7an. 25,1936 229 


was past-president. He always showed himself a 
skilful and progressive surgeon and was the first 
man to excise a diseased joint at the Keighley 
Hospital, while it is a matter of interest that he 
should have attended Lister’s last course of lectures 
in Edinburgh. A correspondent writes: “Dr. Berry 
was the .real doctor, available to anyone at any 
time, fee or no fee, and many of the older generation 
in Keighley will remember him with feelings of real 
affection.” 


STEWART RANKEN DOUGLAS, F.R.C.P. Lond., 
F.R.S. 
DEPUTY DIRECTOR, NATIONAL INSTITUTE FOR MEDICAL 
RESEARCH, HAMPSTEAD 

WE regret to announce the death of Captain S. R. 
Douglas, deputy director of the National Institute 
for Medical Research, Hampstead, and director of 
the department of experimental pathology, who died 
at his residence in Buckingham-gate, London, on 
Monday, Jan. 20th, at the age of 64. 

Stewart Douglas was born at Coulsdon Grange, 
Caterham, in 1871, the son of the late Mr. J. A. 
Douglas. He was educated at Haileybury, and 
proceeded for his medical training to St. Bartholo- 
mew’s Hospital.. He qualified with the English 
double diploma in 1896 and entered the Indian 
Medical Service as a surgeon-lieutenant. He did good 
work quite early 
in his career 
under the Plague 
Commission, and 
served with the 
China Expedition 
in 1900-01, being 
promoted captain 
and receiving @ 
medal for his ser- 
vices. After the 
expedition he was 
invalided home 
much broken in 
health, but he deter- 
mined to return to 
work and pursue a 
career of medical 
research that had 
already deeply 
attracted him. At 
this period he came 
into a close asso- 
ciation with Sir 
Almroth Wright at 
St. Mary’s Hospital, and from 1907 for seven years 
was assistant director of the inoculation department 
at this hospital and a member of the medical staff 
of the institution as lecturer on bacteriology in the 
medical school. His status as a teaching patho- 
logist was thus established. In 1903 he com- 
municated to the Proceedings of the Royal Society 
in collaboration with Sir Almroth a paper on 
the experimental investigation of the rôle of the 
blood fluids in connexion with phagocytosis. In the 
next year followed further observations on the rôle 
of the blood fluids and a communication on the pro- 
tective substances elaborated in the blood in response 
to inoculation with a tubercle vaccine. These papers 
were also read before the Royal Society, while he 
published in THE Lancet (this in association with 
Major F. W. Hardy) some valuable pathological 
observations on bilharzia diseases, and in 1907, also 
in THE LANCET, a report on infective endocarditis 


CAPT. S. R. DOUGLAS 
[Photograph by Elliott & Fry 


230 


cured by the inoculation of a vaccine prepared from 
organisms found in the patient’s blood. 

Thus at the outbreak of -war Captain Douglas’s 
scientific reputation. was well established. On 
August Ist, 1914, he had been appointed to the 
bacteriological staff of the Medical Research Council 
but instead of taking up this work he took a 
commission in the R.A.M.C. and was for a time 
engaged in research work in France. But here the 
duties proved beyond his physica] strength and 
he was soon invalided home, but only to continue 
his work enthusiastically. He was engaged in the 
laboratories of St. Mary’s Hospital in organising the 
production of vaccines for the use of the troops and 
in making special researches on, among other things, 
infection in wounds and dysentery ; for these valuable 
labours he was decorated and appointed also Chevalier 
de Ordre Couronne, Belgium. | 

In 1922 Douglas was elected F.R.S. and appointed 
director of the pathological department at the National 
Institute for Medical Research, later becoming deputy 
director of the institute. 

' In 1920 he married Frances, née Dayrell, widow of 
Dr. J. B. Nias, but leaves no children. 


‘To the many who came into personal contact 
with him, as to ourselves, Douglas’s genial manner, 
unvarying kindness, and aptitude for friendship 
made an appeal that will not be forgotten. In the 
tributes which follow these characteristics of the man 
are displayed. 


THE LANCET] 


Sir Henry Dale, Sec. R.S., writes :— 

“The sudden news of the death of my staunch 
friend and dearly loved colleague S. R. Douglas 
reached me by cable while I was in Holland at the 
week-end. I had known and liked him at casual 
meetings for some years, before we became in 1914, 
just before the war, fellow members of the then 
newly appointed nucleus staff of the future National 
Institute for Medical Research. War activities 
separated us, and it was not till the institute begun 
its work at Hampstead, in 1920, that our intimate 
association began. Douglas was then acting director 
of the institute’s largest department, dealing with 
bacteriology and experimental pathology, and was 
made full director of it a year or two later ; Leonard 
Hill, John Brownlee, and I directing the other three 
departments, as originally conceived. Brownlee’s 
death, and Hill’s retirement by seniority some years 
ago, had left Douglas and myself the only remaining 
members here of the original staff. The organisation 
of the institute and with it the official form of 
Douglas’s relation to myself have undergone some 
changes in the years that intervened ; but never has 
there been any hint of change in the confidence and 
loyal friendship, in the quiet and unselfish help and 
coöperation, which he has given to me, as to every 
member of our growing staff of colleagues, through 
the sixteen years of our close collaboration. We 
had all come to know even much more of Douglas’s 
scientific worth than his modest self-effacement 
showed outside our circle, and we all know that we 
have lost a colleague whose genius for friendship 
and unselfish instinct for adjustment have been of 
priceless value to the happy coöperation of our 
community.” | 


Sir Patrick Laidlaw, F.R.S., writes :— 

“Tt has been my great privilege to know Captain 
Douglas for the last fifteen years. This may seem a 
fair period but I feel it was not nearly long enough. 
Throughout most of this time I worked under him 
or with him at the National Institute for Medical 


OBITUARY 


[yan. 25, 1936 


Research, and to me, as to ali other workers in the 
department of experimental pathology, which he 
largely helped to build, he was unfailingly kind 
in giving advice, encouragement, or criticism. For 
example, both Dunkin and I are greatly indebted to 
him for assistance in the distemper investigation. 
He was in close touch with all the virus studies under 
progress in his department, and indeed: initiated 
some and frequently guided a whole research, though 
his name did not appear on the final publication. 
He brought to the study of virus problems a mind 
ripe with bacteriological knowledge and experience 
gained in India, China, and at St. Mary’s Hospital 
with Sir Almroth Wright, to the great benefit of less 
mature research workers. 

“Douglas was always keenly interested in ‘ acid- 
fast’ bacilli and diseases produced by them. He 
developed special synthetic media for the cultivation 
of the tubercle bacillus and produced a stock of 
tuberculin prepared from such a medium for use in 
a projected international inquiry. He was greatly 
interested in biochemical studies in connexion with 
tubercle bacilli, and assisted the late G. A. C. Gough’s 
chemical studies by growing the necessary bacilli in 
large quantities, suggesting and assisting in new lines 
of work. The work on Johne’s disease of cattle 
carried out by Dunkin at the institute farm at Mill 
Hill was helped forward by Douglas in the early 
stages. The same story might be repeated ; Douglas 
in the background initiating new studies, encouraging 
his juniors, allowing them full freedom to develop 
their own ideas, and kindly to a fault even when 
criticism was necessary. Apart from pathology, 
which was his life work, Douglas was a keen field 
naturalist particularly interested in bird life and 
migration—e.g., he published two papers on the 
migration of woodcock. He was an ardent fisherman 
and enjoyed a good day’s shooting. At the institute 
there is a gap which will never be filled, and my 
colleagues and I feel we have lost a very good friend.”’ 


Dr. Leonard Colebrook writes :— 

“ My: recollections of ‘Dougie’—most lovable 
of men—range over the years 1906 to 1921. I see 
him in the early days of the ‘opsonic’ era at the 
midnight tea parties at St. Mary’s along with ‘The 
Old Man’ as we always called Sir Almroth Wright 
(he was then only 45), delighting us all with good 
stories, and banter, and shrewd comment upon 
whatever the work of the day had thrown up. From 
the tea parties we went back to a further bout of 
counting of phagocytic films, and Douglas perhaps to 
wrestle with some problems of technique till 2 or 3 
in the morning. In technical skill he was our 
recognised master, for, without any special training, 
he had acquired an uncanny sense of how a job should 
be done. Hence it was that he contributed not a 
little to the ‘technique of the teat and the capillary 
glass tube,’ although the fundamental ideas and the 
stimulus to work them out came nearly always from 
Sir Almroth. 

‘“At the outbreak of the European war, Douglas 
was quick to see the urgent need for bacteriological 
media that would yield better crops than those in 
current use if we were to produce the huge quantities 
of typhoid vaccine which were required for the 
Allied armies. This matter had been simmering in 
his head for some time and in the early autumn 
of 1914 he was able to publish in THE LANCET a 
description of the tryptic digest medium which usually 
bears his name and has been so widely employed ever 
since. This must rank as one of his most useful 
achievements, It was something of a calamity 


THE LANCET] 


TREATMENT AND DISPOSAL OF LONDON SEWAGE 


[san. 25, 1936 231 


when he went to Boulogne with Wright a few months 
later and started to create a laboratory in ai damp 
cellar for the study of wound infections. Very 
severe sciatica soon sent him home and crippled him 
for years, but in spite of constant pain and want of 
sleep he carried on all through the war with cheerful 
curses, but never a complaint, and did valuable 
work at St. Mary’s directing researches on Gallipoli 
dysentery and on wound infections. In this work 
I think he was at his best—and very happy—for he 
had a real flair for clinical observation and wise treat- 
ment—seeing always the man as well as the disease. 

“ I count it great good fortune to have been so 
closely associated with one so disinterested and so 
essentially efficient in all he undertook. For the rest, 
it may be truly said of him that he ‘ warmed both 
hands before the fire of life.’ ”’ 


JEFFREY ALEXANDER AMHERST ORLEBAR, 
M.B., B.Chir. Camb. 


Dr. J. A. A. Orlebar, whose death occurred on 
Jan. Ist at Hove, was honorary physician in charge 
of out-patients at Brighton and Preston Dispensary. 
He was 56 at the time of his death. Dr. Orlebar 
was the son of the Rev. J. E. Orlebar, rector of 
Glencarse, and was educated at St. John’s School, 
Leatherhead, and Magdalene College, Cambridge, 
whence he proceeded for his medical training to 
St. Thomas’s Hospital. He obtained the double 
English diploma in 1905 and graduated as M.B., 
B.Chir. Camb. in the same year. After holding an 
appointment at the Tewkesbury Hospital and acting 
as medical officer of health to the Brixworth rural 
district council, he was appointed house physician 
at the Royal Sussex County Hospital, Brighton, 
filing also the posts of assistant pathologist and 
bacteriologist. During the war he held a commission 
as temporary captain, R.A.M.C., and served in 
Suvla Bay, when his experience in the treatment of 
malaria led to his appointment as medical officer 
in charge of a tropical diseases clinic in connexion 
with the Ministry of Pensions. Apart from his 
purely professional work he took a practical interest 
in the St. John Ambulance Brigade and in the local 
activities of the British Medical Association. 


MURDO BUCHANAN, M.B., Ch.B. Glasg. 


Dr. Murdo Buchanan, who died on Jan. 9th at- 


Darlington, was born on the island of Lewis and was 
educated at the Nicolson Institute, Stornoway, 
and the University of Glasgow. At Glasgow he 
graduated as M.B., Ch.B. in 1907, and on qualification 
became for a time surgeon to the St. Helen’s Collieries. 
Later he practised at Bishop Auckland, Durham, 
but since 1916 was a partner in a practice in Darlington. 
He enjoyed a high local reputation as physician and 
surgeon and was appointed deputy coroner some 
three years ago. He was also keenly interested in 
ambulance work. Although only 53 years of age 
his death was not unexpected, as he had been in 
failing health for some time. 


EDWARD ARGENT SAUNDERS, M.R.C.S. Eng. 


THE death is announced at the age of 50, after a 
short illness, of Dr. Edward Argent Saunders, medical 
otficer of health for Pembroke. The son of a well- 
known Welsh physician, he was educated at Epsom 
College and entered the medical school of the 
Middlesex Hospital, where he held the Freer Lucas 
scholarship. He took the English double diploma 
in 1912 and served as house surgeon at the Middlesex 


Hospital when he returned to practice in Pembroke 
where in the course of a busy: and successful career 
he obtained a large number of public appointments, 
being at the time of his death medical officer of health 
and school medical officer forithe borough of Pembroke, 
civil medical officer in charge of the R.A.F. station at 
Pembroke Dock, in charge of the county fever 
hospital, and medical officer of: the Post Office. 
He was actively interested in the work of the 
St..John Ambulance Association and of the local 
infant -welfare clinic. Dr.. Saunders was a keen 
sportsman, good with gun and rod, and his unexpected 
death occurred on return from a shooting expedition. 


FRANCIS EDWARD ‘FERNIE, M.R.C.S. Eng. 


Dr. Francis Fernie, who died on Jan. 9th at Stone, 
at the age of 68, was a well-known and respected 
figure in the Stafford district. He was the eldest 
son of the late Dr. Edward Fernie, of Stone, was 
educated at Wellingborough school, and received 
his medical training at St. Bartholomew’s Hospital. 
On qualifying with the English double diploma in 
1893 he was for a time house surgeon at the Stockport 
Infirmary, returning to go into partnership with his 
father. As a young man Dr. Fernie was a prominent 
footballer, while to the end of his life he was a remark- 
ably fine horseman. 


TREATMENT AND DISPOSAL OF 
LONDON SEWAGE 


At a sessional meeting of the Royal Sanitary 
Institute, held on Jan. 14th, Mr. J. H. Coste, chief 
chemist to the London County Council, described 
some improvements which had been made in treat- 
ment of the ever-increasing flow of sewage from the 
London main drainage system. The method of 
sedimentation, with or without the aid of chemical 
precipitants, which has been ‘in use since the days 
of Sir Joseph Bazalgette and Mr. W. J. Dibdin, has 
been remarkably successful, but recently experience 
has shown that the calls which are being made upon 
the London main drainage system and on the capacity 
of the River Thames as the final place of disposal 
have reached a point when further steps should be ` 
taken. In his paper Mr. Coste described the large 
activated sludge plant designed on lines suggested 
by Lieut.-Colonel W. Butler and Mr. E. H. Tabor, 
M.I.C.E., as the result of long-continued research by 
the L.C.C.’s officers. This plant, in which aeration 
for treatment is almost entirely effected at the 
interface between the mixture of activated sludge 
and the sedimented effluent which is to undergo 
further purification, is so arranged that the liquid 
flows through a two-tiered long channel, divided into 
66 compartments, alternately being exposed to air 
and plunging into the lower compartment. By 
details of construction there is imparted to it a 
swirling motion, so that the air-liquid interface is 
continually renewed and absorption of oxygen from 
the air goes on rapidly. After travelling 6400 feet 
(over a mile) the issuing liquid goes to sedimenting 
tanks of two types: pyramidal, which yield better 
separation of solid from liquid and shallow Dorr 
tanks with scrapers which yield a denser sludge ; 
thence the liquid part flows into the common effluent 
channel and the sludge to reaeration tanks. These 
are fitted with diffuser tiles which have been found 
better adapted for aeration of sludge than the surface 
absorption used for the treatment itself. The plant 


932 THE LANCET] MEDICAL NEWS [san. 25, 1936 


was constructed in the hope that it would suffice 
for treatment of from 5 to 10 million gallons a day. 
Since July, 1932, with very little intermission, 
10 million gallons a day have been treated. At 
first it was sought to obtain a stable effluent ; experi- 
ment has shown that the greatest effect of purification 
is obtained by producing a less purified effluent in 
greater amount. 

A second direction of improvement has been 
explored in the form of sludge digestion, by means 
of which a large volume of gas of high calorific power 
is obtained, available for the production of heat and 
power, and a sludge of reduced organic content. The 
principal source of gas seems to be the mixture of 
fatty acids, present in part as soap in the sludge, 
and Mr. Coste and his colleagues have shown by 
micro-combustion and the difficulty in liquefying the 
gas that methane is the only hydrocarbon present 
in appreciable amount—a fact which has hitherto 
been assumed but not demonstrated. A large sludge 
digestion plant is to be constructed at the northern 
outfall, but this will supplement and not supplant 
disposal at sea; also five more units of activated 
sludge plant of the same capacity and on similar 
lines to that now in use are being constructed. 

During the recent dry summers it has been found 
that some more thorough process than sedimentation, 


supplemented by the use of ferrous sulphate as a 
fixative for sulphuretted hydrogen, was needed for 
the hot dry months of the year. Experiments made 
in the winter of 1934 with a variety of oxidising 
agents showed that ferric salts were the most suitable 
for such emergency treatment. It was found, how- 
ever, that the quantities required—hundreds of tons 
a week—could not be obtained commercially. Experi- 
ments were, therefore, initiated on the chlorination 
of ferrous sulphate, which was obtainable. These 
were successful on the laboratory scale and at once 
plant of sufficient size was constructed at the southern 
outfall, followed by an improved plant at the northern. 
The work was not completed sufficiently early in the 
year 1935 for an unsatisfactory condition of the 
river to be avoided entirely, but the character of 
the effluent was undoubtedly improved and it is 
hoped that with the ability to start treatment at 
any moment, the condition of the Thames may 
remain satisfactory during the summer months. 
When the five activated sludge units under construc- 
tion are completed still better conditions should be 
secured. Mr. Coste expressed his personal opinion 
that further improvements should be in the direction 
of better sedimentation and coagulation of sewage 
which had been brought to the outfalls in a non-septic 
condition. 


MEDICAL NEWS 


University of Cambridge 


A course of lectures on human genetics will be delivered 
during the Lent term by Dr. L. S. Penrose, research 
medical officer of the Royal Eastern Counties Institution, 
Colchester. The lectures will be given on Fridays, at 
5 P.M., and the first will be on Friday, Jan. 24th. 


University of London 


Prof. B. A. McSwiney has: been appointed to the 
university chair of physiology at St. Thomas's Hospital 
medical school. 

Dr. McSwiney, who was born in Chicago in 1894, received his 
medical education in Dublin. In 1915 he was awarded the 
Reuben Harvey scholarship by the Royal College of Physicians 
of Ireland for his work as student demonstrator in the school 
of physiology, but his work was interrupted by service as a 
naval surgeon-probationer. Returning to complete his medical 
course, he graduated as M.B. in 1917, worked for a time as 
assistant scientific adviser to the Ministry of Food, and in 1918 
. saw further war service with the R.A.M.C. After a brief period 
as assistant professor of physiology at Trinity College, Dublin, 
he went to Leeds in 1919 as university lecturer in experimental 
physiology, being appointed to the same post at Manchester 
a year later. He returned to Leeds in 1926 to fill the chair of 
physiology, and during his tenure of it has acted as examiner 
for the universities of Oxford, Cambridge, and Manchester. 
and for the National University of Ireland. His work has 
been largely concerned with pulse-wave velocity and the physio- 
logy of plain muscle, and he became a D.Sc. of Dublin in 1928. 


Two lectures on perimetry will be given by Dr. H. M. 
Traquair, lecturer on diseases of the eye in the University 
of Edinburgh, at 5.30 P.M. on Feb. 10th and llth, at 
University College Hospital medical school. On March 3rd, 
6th, and 10th, at the same hour, Dr. Kuczynski, formerly 
director of the statistical office, Berlin-Schénberg, will 
lecture at University College on recent population trends. 
Lord Dawson will take the chair at his first lecture. 


Society of Apothecaries 


A livery dinner of this society will bo hold at Apothecaries’ 
Hall, Water-lane, London, E.C., on Tuesday, Feb. 25th, 
at 7. 30 P.M., when the Lord Mayor and sheriffs intend 
to be present. 


Papworth Village Settlement 


Dr. Walter Pagel will give a demonstration on the 
experimental production of early pulmonary tuberculosis 
in the Sims Woodhead memorial laboratory at Papworth 
Village Settlement on Saturday, Feb. 15th, at 3 P.M. 
All who are interested and wish to attend should com- 
municate with Dr. Pagel at Papworth Hall, Cambridge. 


Society of Public Analysts 

A joint meeting of this society with the food group of 
the Society of Chemical Industry will be held on Wednes- 
day, Feb. 5th, at the Chemical Society’s rooms, Burlington 
House, Piccadilly, London, W. The afternoon session 
begins at 5 P.M. and the evening session at 8.15 P.M., and 
both will be devoted to a discussion on tea and coffee, 
with special reference to their tannins and alkaloid. The 
first paper of the evening session will be read by Dr. 
G. Roche Lynch, who will speak on the pharmacology of 
caffeine and of tea and coffee. 


Dr. Barnardo’s Homes 


Last year 1396 children were admitted to Dr. Barnardo’s 
Homes, among whom was the 118,000th child to be 
welcomed under the charter “ no destitute child ever 
refused admission.” The number at present in the 
Homes is about 8300, of whom 1455 are under 5 years 
of age. : 


Prince of Wales’s Hospital, Plymouth 


Lord Onslow recently opened at this hospital a new 
administrative and paving patients’ block which has 
cost £40,000. Twenty-six paving patients can be accom- 
modated and there are now enough rooms to enable all 
the nurses to sleep in hospital. 


Ella Sachs Plotz Foundation 


The trustees of this foundation are anxious to make 
known the resources of their fund for the advancement 
of scientific investigation. The foundation seldom or 
nevor offers stipends to investigators ; nor does it provide 
apparatus and materials which are ordinarily part of 
laboratory equipment. Its special purpose is to give 
grants for the purchase of apparatus and supplies required 
for special investigations and for the payment of unusual 
expenses, including technical assistance. The research 
should bear closely on medicine or surgery, and the 
maximum sizo of grants will usually be less than $500. 
In the twelve years of its existence the foundation has 
made 252 grants and investigators have been aided in 
26 countries. Applications for assistance should arrive 
before Mav Ist, including statements about the nature of 
the investigation, the amount of money wanted, and the 
way in which it will be spent. The secretary of the 
executive is Dr. Joseph C. Aub, Collis P. Huntington 
Memorial Hospital, 695, Huntington Avenue, Boston, 
Massachusetts, U.S.A. 


THE LANCET] 


King Edward’s Hospital Fund for London 


In aid of this Fund five special tours have been arranged, 
beginning with a visit to the Board of Admiralty and 
the Foreign Office, conducted by Mr. D. B. Smith and 
Mr. C. Howard Smith, on Feb. 8th. The other places to 
be visited will be the Houses of Parliament (Feb. 19th), 
the India Office (March 7th), Westminster Abbey 
(April 22nd), and the Zoological Gardens (May 8th). 
Tickets may be had from the secretary of the Fund, 
10, Old Jewry, London, E.C.2. 


German Congress for Actinotherapy 


The third International Congress for Actinothorapy 
will bo held in Wiesbaden from Sept. lst to 7th under the 
presidency of Prof. W. Friedrich, director of the Institut 
für Strahlenforschung of the University of Berlin. 
Problems relating to the biology of light, to biophysics, 
and to the therapy of light will be discussed. Further 
information may be had from the secretary-general of 
the Congress, Dr. H. Schreiber, Robert Koch-Platz 1, 
Berlin, N.W.7. 


~ 


Fifty Years of Public Service 


On Jan. 17th Dr. Henry Lloyd received a dentia 
to commemorate his 50 years as poor-law medical officer 
for St. Asaph and district, an appointment he has: held 
since the age of 25. Dr. Lloyd’ s brother, the late Dr. David 
Lloyd, was for many years medical officer for Denbigh, 
and he has two daughters in the medical ‘profession, Dr. 
Muriel Radford and Dr. Katherine Quinby. The presen- 
tation was made by the Lord-Lieutenant of Flintshire. 


Hospital Extensions at Southend 


Southend borough council have decided to spend 
£304,000 on improving and extending the municipal 
hospital. There has been much opposition to the scheme 
on the ground of expense and the measure was passed only 
by a majority of 2. 


Boscombe Hospital 


The enlargement of the nurses’ hostel of this hospital 
will probably be finished in April and two new operating 
theatres, a new ward with 24 beds, and three observation 
wards are also in course of construction. It is hoped to 
build a new maternity block later in order to free ence 
and surgical wards. 


Paying Patients at Swindon 


A scheme known as the Swindon and North Wilts 
Hospital Private Ward League is being inaugurated this 
month. An annual subscription of £1 ls. entitles a single 
man and £2 2s. a married man with a family to assistance 
in the cost of maintenance in the private wards of Swindon 
Victoria Hospital or in nursing-homes. X ray examina- 
tions and other expenses are included in the scheme. 
Full seale benefits are only payable after a year’s 
membership. 


Society for Relief of Widows and Orphans of 
Medical Men 


At a meeting of the court of directors held on Jan. Ist 
the president, Mr. V. Warren Low, being in the chair, 
the deaths of five members were reported and five new 
members were elected. Four widows of deceased members 
applied for relief; a grant of £60 a year was voted to 
each, one widow over 65 receiving an additional £15 a 
year; two orphans had grants of £50 a year each. A sum 
of £2082 10s. was voted to cover the half-yearly grants 
to the 55 widows and 10 orphans in receipt of relief. 
The distribution was reported of £625 as a Christmas gift 
to the widows and orphans, each widow over 75 receiving 
£15, under 75 £10, and each orphan £10. A legacy of £45 
had been received from the executors of the late Dr. 
W. Culver James, a vice-president of the society. 
Particulars of membership, which is open to any 
registered medical man who at the time of his election is 
residing within a 20-mile radius of Charing Cross, may 
be obtained from the sBerotary at 11, Chandos-street, 
London, W. 1. 


MEDICAL NEWS.-——APPOINTMENTS 


[san. 25, 1936 233 


Scottish Board of Control 


Dr. Laura Margaret Dorothea Mill has been appointed 
a deputy commissioner of the General Board of Control 
for Scotland. 


Fellowship of Medicine and Post-Graduate Medical 
Association 


Advanced courses will be held in proctology at St. 
Mark’s Hospital (Feb. 3rd to 8th); in chest diseases at 
the Brompton Hospital (Feb. 10th to 15th); in gynæco- 
logy at the Chelsea Hospital (Feb. 10th to 22nd); and in 
anatomy and physiology for the F.R.C.S. (primary) in 
the Infants Hospital (Mondays, Wednesdays, and Fridays 
at 8 P.M., Feb. 24th to April 24th); and a M.R.C.P. 
clinical class will meet at the National Temperance 
Hospital, Hampstead-road, on Tuesdays and Thursdays 
from Feb. 25th to March 12th at 8 P.M. An all-day 
course in neurology will be given at the West End Hospital 
for Nervous Diseases (Feb. 3rd to 8th), and week-end 
courses include one in physical medicine at the St. John 
Clinic and Institute of Physical Medicine (Feb. 8th and 
9th), one in children’s diseases at the Princess Elizabeth 
of York Hospital (Feb. 22nd and 23rd), and one in chest 
diseases at the Brompton Hospital (March 7th and 8th). 
Courses are open only to members and associates. Full 
particulars and detailed syllabuses can be obtained from 
the secretary of the fellowship, 1, Wimpole-street, London, 
W.1. 


‘British Red Cross Society and Order of St. John 


Hospital Library 

The organising secretary of this movement (48, Queen’s- 
gardens, Lancaster Gate, London, W.2) announces the 
delivery on four Wednesday evenings at 5.30 P.m. of the 
following addresses at the Foyle Art Gallery, Charing 
Cross-road, London, W.C.2. On Jan. 29th Miss Ann 
Bridge will speak on the novel and the conventions ; 
on Feb. 12th Miss Dorothy Sayers will speak on the 
importance of being vulgar; on Feb. 26th Mr. Humbert 
Wolfe will give readings from his own works; and on 
March llth Mr. Maxwell Fry, A.R.I.B.A., and Mr. A. R. 
Duncan, A.R.I.B.A., will start a debate, the former 
instructing the audience how to live and the latter taking 
up the attitude that we should live as we like. Tickets 
for the course are 2s. 6d. for a single lecture and 8s. 6d. 
for four lectures. The hospital library run under the 
ægis of Red Cross and the Order of St. John merits all 
the support that medical men can either personally give it 
or direct towards it. The organisation already sends gifts 
of books to over 2000 hospitals, and the amount of pleasure 
and profit which patients derive therefrom must be 
extremely large. 


INDEX TO “THE LANCET,” VoL. II., 1935 


THE Index and Title-page to Vol. II., 1935, which 
was completed with the issue of Dec. 28th, is now in 
preparation. A copy will be sent gratis to sub- 
scribers on receipt of a post card addressed to the 
Manager of THE LANCET, 7, Adam-street, Adelphi, 
W.C.2. Subscribers who have not already indicated 
their desire to receive Indexes regularly as published 
should do so now. 


Appointments 


GoopwIN, AUBREY, M.D. Lond., F.R.C.S. Eng., has been 
appointed Obstetric Surgeon to the W estminster Hospital. 

HEWLETT, R. F. L., M.B., Pathologist at the Group Laboratory, 
Lambeth Hospital, L. C.C. 

Mackay, J. S. B., M.B. Aberd., D.P.H., Assistant Tuberculosis 
Otticer for Manchester. 
McNab, G. H., M.B. Edin., F.R.C.S. Eng., Surgical Registrar 
at the Hospital for Epilepsy and Paralysis, Maida Vale. 
MILLER, ARTHUR, F.R.C.S. Edin., Consulting Oto-laryngologist 
to tbe W imbledon Fever Hospital. 

MILNER, J. G., M.B. Camb., F.R.C.S. Eng., Assistant Surgeon 
to the Roy al W estminster Ophthalmic Hospital. 

RUNDLE, Francis, M.B. Sydney, F.R.C.S. Eng., 
Registrar at the Westminster "Hospital. —— 


Surgical 


234 THE LANCET]. 


3 Medical: . Diary 


Information to be included in this column should reach us 
in proper form on, Tuesday, and cannot appear tf tt reaches 
us later than the first post on Wednesday morning. 


SOCIETIES 


ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W. 
Monpay, Jan. 27th. 
Odontology. 8 P.M: Mr. Cyril Howkins: The Blood- 
supply of the Lower Jaw. Mr. R. Bradlaw: Innerva- 
tion of the Teeth. 


TUESDAY. 
Medicine. 5 P.M. Dr. Otto Leyton: The Morbid Con- 
ditions which Cause Progressive Hyperglyceemic 


Glycosuria and the Circumstances which Modify its 
Course. Dr. J. Graham Willmore, Dr. H. P. Hims- 
‘worth, and Dr. T. C. Hunt will also speak. 
MEDICAL SOCIETY OF LONDON, 11, Chandos-street, W. 
MONDAY, Jan. 27th.—8.30 P.M., Mr. V. Zachary Cope: 
The Treatment of Acute Appendicitis. 
SOCIETY OF MEDICAL OFFICERS OF HEALTH, 1, Thorn- 
haugh-street, W.C. 
FRIDAY, Jan. 3lst.—Mr. A. Felix, D.Sc., and Dr. C. J. 
McSweeney: The Scrum Treatment of Typhoid 
= Fever. (Fever group.) 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 


ROYAL COLLEGE OF SURGEONS OF ENGLAND, Lincoln’s 
_Inn Fields, W.C. 

Monpay, Jan. 27th—5 P.M., Mr. E. P. Stibbe: The 

Anatomy and Surgery of the Subtentorial Angle. 

WEDNESDAY.—5 P.M., Mr. R. T. Payne: Pyogenic Infec- 
tions of the Parotid. 

FRIDAY.—5 P.M., Mr. George A. Mason: 
the Lung. (Hunterian lectures.) 

UNIVERSITY OF LONDON. 

FRIDAY, Jan. 31st.—11 A.M. (London School of Hygiene, 
Keppel-street, W.C.) Mr. H. E. Magee, D.Sc.: 
: Nutrition. 

ROYAL INSTITUTION, 21, Albemarle-street, W. 

FRIDAY, Jan. 31st.—9 P.M., Prof. E. Mellanby, F.R.S.: 

Advances in the Treatment of Disease. 
HAMPSTEAD GENERAL AND NORTH-WEST LONDON 
HOSPITAL, N.W. 

WEDNESDAY, Jan. 29th.—4 P.M., Dr. A. J. Scott Pinchin : 
Points in the Diagnosis and Treatment of Pulmonary 
Tuberculosis. 

LONDON SCHOOL OF DERMATOLOGY, 5, Lisle-street, W.C. 

TUESDAY, Jan. 28th.—5 P.M., Dr. J. L. Franklin: Bullous 
Eruptions. 

WEDNESDAY.—5 P.M., Dr. I. Mucnde: Histopathology. 

THURSDAY.—5 P.M., Dr. W. K. Sibley : Electrotherapeutics. 


HOSPITAL FOR SICK CHILDREN, Great Ormond-:street, 
W.C i 


WEDNESDAY, Jan. 29th.—2 P.M., Dr. Wilfrid Sheldon : 
Medical Aspects of Empyema, Pulmonary Abscess, 
and Pyopneumothorax. 3 P.M., Dr. W. W. Payne: 
Blood Chemistry in Normal Respiration. 

Out paviont clinics daily at 10 A.M. and ward visits at 
P.M. 

NATIONAL HOSPITAL, Queen-square, W.C. 

MONDAY, Jan. 27th.—3.30 P.M., Dr. Hinds Howell: Neuro- 
syphilis (I.). 

TUESDAY.—3.30 
Disease (I.). 

WEDNESDAY.—3.30 P.M., Dr. 
Demonstration. 

THURSDAY.—3.30 P.M., Dr. Carmichael : 
bined Degeneration. 

FRIDAY.—3.30 P.M., Mr. Elmquist: 
Re-educational Methods. 

Out-patient clinic daily at 2 P.M. 

FELLOWSHIP OF MEDICINE AND POST-GRADUATE 

MEDICAL ASSOCIATION, 1, Wimpole-strect, W. 

. MONDAY, Jan. 27th, to SATURDAY, Feb. 1st.—ST. JOHN’S 
HOSPITAL, 5, Lisle-street, W.C. Afternoon course in 
derinatology. (Open to non-members.) —ST. PETER’S 
HosrrraL, Henrictta-street, W.C. All-day course in 
urology.—NATIONAL TEMPERANCE HOSPITAL, Hamp- 
stead-road, N.W. Tues., 8.30 P.M., Mr. Hamilton 
Bailey: Neck. Thurs., 8.30 P.M., Mr. A. Dickson 
Wright: Skull and Brain.—Courses are open only to 
members of the fellowship. 

SOUTH-WEST LONDON POST-GRADUATE ASSOCIATION. 

WEDNESDAY, Jan. 29th.—4 P.M. (St. James’s Hospital, 
Ousceley-road, S.W.), Mr. George Perkins : Fractures 

dn General Practice. 

LEEDS GENERAL INFIRMARY. 

TUESDAY, Jan. 

partum Hemorrhage. we 
LEEDS PUBLIC DISPENSARY AND HOSPITAL. 

WEDNESDAY, Jan. 29th.—4 P.M., Mr. A. D. Sharp: Ear, 
Nose, and Throat—Selected Cases. 

UNIVERSITY OF DURHAM. | 


Extirpation of 


P.M., Dr. Critchley: Cerebral Vascular 
Kinnicr Wilson: Clinical 
Subacute Com- 


Demonstration of 


SUNDAY, Feb. 2nd.—10.30 A.M. (Newcastle Gencral 
Hospital), Mr. J. Collingwood Stewart: Selected 
Cascs. z 


GLASGOW POST-GRADUATE MEDICAL ASSOCIATION. 
WEDNESDAY, Jan. 29th.—4.15 P.M. (Eye Infirmary), Dr. 
J. Barbour Stewart: Squivt and its Treatment. 


MEDICAL DIARY.—VACANCIES 


l `- West 
28th.—3.30 P.M., Mr. Jeaffreson: Ante- 


[JaxN. 25, 1936 


“Vacancies 


For further information refer to the advertisement columns 
Abyssinia (Gondar).—Two M.O.’s.. Each £600, E i 
Ayr Royal Burgh.—M.0.H. £800. © to 0> 
Barry Surgical Hospital.—Res. Surg, O. .£350. 

Bath, Royal United Hospital.—H.S. At rate of £150. 
Beckenham, Bethlen i 24 
sue Cre ae w pouor Hospital, Monks Orchard.—Jun. 


Birmingham City Maternity and Child Wel) - 
M.O. £10 per week. : Velfare Dept.—Temp. 


Birmingham, Romsley Hull Sanatorium.—Res. Asst. M.O. £240. 


Blackburn, Brockhall Institution for M J =; 
E O 0 Deerns, LANNO; 


Blackburn and East Lancashire Ro ai 
Peet l yal Infirmary.—Res. Surg. O. 


Bradford Royal Infirmary. —Ħ.S. At rate of £135. 

Bridport and Lyme Regis Boroughs, &:c.—M.O.H. £800. 

Buxton Clinic for Rheumatism and Allied Diseases.—H.P. At 
rate of £200. i , as 

Caune Ti Kent and Canterbury Hospital.—H.P. At rate of 


Central London Throat, Nose, and Ear Hospital , - 
IV.C. —Third Res, H.S. At rate of £75.” ATAU PERRERA; 
EA oval I ip laa Age Sek and H.S. Each £150. 
‘olchester, Loya astern Counties’ Instituti 
x cae bie E ba M.O. £350. Sa Bi E TERENY 
oncaster loyal Infirmary.—H.S. to Eye 
a Throat Depts. EiT y one Ear, Nose, and 
ownpatrick, Down Mental Hospital.—Jun. Asst. M.O. 
Dulwich Hospital, S.k.—H.P. At rate of Srv MRi eee 
East Ham Memorial Hospital, Shrewsbury-road, E.—H.P. At 
Ed De a oer Middl 
Sdmonton, North Middlesex County Hospital.— Z 7 
g SEO N rate ac £250, k Yy pita Jun. Res. Asst. 
enerul Lying-in Hospital, York-road, Lambeth, S.E.—Jun. 
M.O. and Anæsthetist. At rate of £100. E 
Gloucestershire Royal Infirmary, &c.—H.S. At rate of £150. 
Hertford, Ware Park Sanatorium.—Asst. M.O. £300. 
Hove General Hospital.—Hon. Phys. to Brighton Branch. 
Ipswich Sanatorium, Forhall-road.—Asst. M.O. £350. 
Lambeth Hospital, Brook-street, S.E.—Asst. M.O. £350. 
Leeds General Infirmary.—Hon. Asst. Phys. 
Leicester City General Hospital_—Two Res. M.O.’s. Each £300. 
een Al nro AAPA Ree Asst. M.O. £200. 
iver poo sanatorium, clamere Forest, Frodsham.— 
rieehaet: Med, Supt,” £200; ia 
tverpool, Smi wn-road Hospital.—Res. Asst. M.O. £200. 
Liverpool, Walton Hospital.—Res. Asst. M.O. £200. ay 
London County Council.—M.O. for Henniker House, Parsons 
Green, £100. 
Maidstone, Kent County Ophthalmic and Aural Hospital.— 
H.S. to Ear, Nose, and Throat Dept. At rate of £200. 
Manchester Eur Hospital, Grosvenor-square, All Saints’. — H.S. 
At rate of £150. 
Middlesec County Council.—Asst. M.O. £600. 
Mile End Hospital, Banecroft-road, E.—Asst. M.O. £350. 
Newer UPON L UNE: Hospital for Sick Children.—Res. Surg. O. 
5 


- r 


Northampton County Mental Hospital, Berrywood.—Second Asst. 
M.O. £450. 

Paddington Hospital, Harrow-road, W.—Asst. M.O. £3 
Plymouth City.—Deputy M.O.H. £750. m 

a rd rightington Hospital, Appley Bridge.-—Jun. Asst. M.O. 


Princess Louise Kensington Hospital for Children, St. Quintin- 
avenue, IV.—H.P. At rate of 2100. , pia 

Queen’s Hospital for Children, Hackney-road, E.—Res. M.O. 
rat ee of £200. Also H.S. and Cas. O. Each at rate of 

Romford, Oldchurch Hospital.—Asst. Res. Radiologist and 
Jun. Res. M.O. Each £250. Also General Consulting 
Phys. £300. é a 

Royal National Orthopedic Hospital, 234, Great Portland-street 
IV .—Asst. Res. Surg. for Country Branch, £250. i 

Royal Naval Medical Service.— Eight vacancies. 

St. Alfege's Hospital, Vanbrugh Hill, S.E. —Asst. M.O. £350. 

St. Armndirews, Devons-roud, k.—H.P. At rate of £120. 

St, George-in-the-hast Hospital, Rainc-street.—Asst. M.O. £350, 

St, John’s Hospital, Lewisham, S.E.—Res. H.P. Atrate of £100 

St. Peter's Hospital, Vallance-road, E,.—Asst. M.O. £350. ° 

St. Thomas’s llospital, S.E. —Reg. and Tutor to Obstet. Dept. 
£250, Also Reg. to Ophth. Dept. £150. — 

Salisbury General Infirmary.—H.S. At rate of £125. 

Shrewsbury, Loyal Salop Infirmary.—Res. H.S. At rate of £160 

Shrewsbury, Salop Mental Hospital,—Asst. M.O. £350, i 

Southend-on-Sea General Hospital.—Cas. O. At rate of £100. 

Stirling District Mental Hospital, Larbert.—Jun. Asst. M.O. £300 

Stockport Infirmary.—U.S. £150. ` 

Stoke-on-Trent, Stanfield Sanatorium.—Res. M.O. £250. 

London Hospital, Hammersmith-road, W.—Half-time 
Pathologist. At rate of £300, 

West Riding of Yorkshire County Council.—School Medical 
Inspector. £500, 

Western Ophthalmic Hospital, 
Sure. to Inoculation Dept. 

Woolwich and District War Memorial Hospital, Shooters Jill 
S.i.—H.P. At rate of £100. 3 


Worcestershire County Council. —County Analyst and Bacterio- 
logist. £800. 


The Chief Inspector of Factories announces vacancies for 
Certifying Factory Surgeons at Coggeshall, SSex : 
Frodingham, Lincs; and Auchtermuchty, Fife. ó 


Marylebone-road, N.W .—H on. 


Ee ate? 


"THE LANCET] ` 


[san. 25,1986 235 


NOTES, COMMENTS, AND ABSTRACTS | 


A STUDY OF 
MILK CONSUMPTION IN AN 
LONDON SUBURB 


‘By E. H. R. Surruarp, M.D. Lond., D.P.H. 


MEDIOAL OFFICER OF HEALTH, SOUTHALL 


OUTER 


THE district council of Southall-Norwood has for 
many years supplied wet (as well as dried) milk, free 
or at half cost according to an economic circum- 
stances scale, to expectant and nursing mothers and 
to children under three years of age attending the 
infant welfare centres. Children over three and under 
five years of age are also granted milk if there are 
definite medical reasons for its use. The procedure 
has been to write an order on a milkman chosen. by 
the family, and as free choice has always been allowed, 
this has meant that the usual family milkman has 
supplied the milk and has been paid by the council. 


The health department has been increasingly 
careful about the maintenance of cleanliness in the 
dairies of all retailers and there is no doubt that a 
great improvement has been made in the cleanliness 
of the milk retailed. From time to time, however, 
consistently unsatisfactory bacteriological results 
have been obtained from the milk of certain dairy- 
men, and so it was decided to institute an investi- 
gation into the safety or otherwise of all the milk 
consumed in the district. The primary object of 
this investigation was in order to see if sufficient of 
the milk consumed. was “‘safe” to warrant con- 
fining the council’s payments to retailers who sold 
safe milk ; the results may be of more general interest 
in showing the amount of milk consumed in an average 
London suburb. 

Southall is a district, on the fringe of greater 
London, which has grown rapidly in recent years. 
There are about 100 factories of varying size in the 
area, but a proportion of the working population 
appears to be to an increasing extent of the dormi- 
tory type. The population, as calculated to the middle 
of 1934 by the Registrar-General, was nearly 47,000. 
It is almost certain that it is now (at the time of the 
investigation) just about 50,000. Of this figure, 
3000 are resident in a mental hospital in the district, 
and this hospital, which has its own milk-supply, 
has been excluded from the figures given below, thus 
leaving a net population for the purpose of this 
investigation of 47,000. The area forms a convenient 
unit of its own with natural boundaries except in 
two small districts, and the figures given for the total 
consumption of milk may be taken as reliable. 


The figures of milk consumed have been obtained 
from the retailers, in confidence as far as their names 
are concerned, and where the retailers have served 
both this and a neighbouring district an assessment 
has been made of the amount consumed in this 
district. I have no reason to doubt the reasonable 
accuracy of the totals submitted. 


GRADING 


Table I. gives the grouped results of the investi- 
gation. ‘Two columns have been included which 
show the difference between the largest and the 
smallest amounts of classified milks sold by individual 
retailers. 

Of the pasteurised milk, excluding that dong by 


the flash method, only 18, per cent. is pasteurised 
in the district, ‘the rest’ being imported from firms 
outside. The milk so imported comes from eight 
different firms. ‘Dalrymple: Champneys 1 has PR 


TABLE I 


Mülk retailed during first week in October, 1935. Number of 
retailers, 21; total number of retail shops, 41 


Amount sold 
in pints by 
| Number| retailers. . Total sold— 
Description. of Pints ann 
retailers. La Small- | percentage. 
est. est. 
1. Legally pasteur- 
ised (including 
Grade A Past.) 28,555 780 100,936 (62°15) 
2. Otherwise pas- 
teurised— 
(a) Ordinary 7,680 | 1,200 34,244 (21°08) 
(b) Flash wie — ,000 (8°31) 
3. Certified 124 3 127 (0°08) 
4. Grade A (T.T:). 237 12 553 (0°34) 
5. Grade A l 200 16 772 (0'48) 
6. Sterilised 2,912 12 4,506 (2°78) 
7. Homogenised .. 1,254 8 2,946 (1°81) 
8. Sun ray — — 8 
9. Raw 2,800 10 4,810 (2°99) 
Total 162,402 


in detail the requirements for the proper supervision 
of milk pasteurising plants, but it has been felt for 
some time that a check on the end-result, more 
simple and reliable than’ bacteriological counts, 
which may be completely unreliable (Howell?) or 
which may appear satisfactory even when the milk 
is not properly pasteurised, is required. Kay and 
Graham, of the National Institute of Research in 
Dairying at the University of Reading, have recently 
evolved a simple test which they claim will show— 

(a) whether milk has been heated to 14° F. below the 
minimum temperature for pasteurisation, or 

(b) whether it has been heated (at 145° F.) for twenty 
minutes or less, instead of the required thirty minutes, or 

(c) whether raw milk (down to 0-25 per cent.) has been 
mixed with properly pasteurised milk. 


The principle is the hydrolysis of a phosphoric ester 
when incubated with milk containing phosphatase, 
and the colorimetric determination of the end- 
products. The enzyme phosphatase is a constant 
constituent of raw milk but is destroyed on heating 
to a certain temperature. This test, the phosphatase 
test, should prove very useful in checking the mini- 
mum requirements of a pasteurising plant. It does 
not however apparently indicate whether the maxi- 
mum temperature (of 150° F.) has been exceeded, 
or by how much, or for how long, but this is 
immaterial when the only question is that of the 
safety of the milk examined. 

Most of the pasteurised milk (legally, flash and 
otherwise) sold in this district was examined in this 
way by the National Institute of Research in Dairy- 
ing, and of the sixteen samples submitted three 
failed to pass the test. Two of these were samples 
of flash pasteurised milk; the other was a sample 
of milk stated to be pasteurised but not sold as such. 
This related to a dairy selling 1600 pints of the above 


236 THE LANCET] 


total, 
certainty that raw milk had been added to it. 

Excluding the milk to which these unsatisfactory 
results relate and also Nos. 7, 8, and 9 in Table I., 
a total of 139,738 pints is left (86 per cent. of the 
whole) which can be regarded as safe milk. 


BACTERIOLOGICAL RESULTS 


A check was also made at the time, and has been 
repeated subsequently, by obtaining bacterial counts. 
These are well known to be frequently inconsistent, 
but in this district, using the same outside labora- 
tory, quite consistent results are usually obtained. 
In the period under review the results appeared 
particularly consistent and they are shown in 
Table II. 

TABLE II.—Bacterial Counts 


\ 
Samples in 


Bacterial count. | which B. coli 


Number found in 
Description. of 
samples. | 5a 604 
Highest. | Lowest. comde cm. 
1. Legally pasteur- 
ised oe ate 4 85,000 8,300 1 0 
2. Otherwise pas- 
teurised— 
(a) Ordinary 5 800,000* 51,000 4 0 
(b) Flash 4 31,200 9,000 2 1 
3. Certified 1 3,400 0 0 
4. Grade A (T.T.). 4 91,600 | 10,000 1 0 
5. Grade A 4 4,000 100 0 0 
6. Sterilised 2 200 100 0 0 
7. Homogenised .. 1 6,000 0 0 
8. Sun-ray 1 1,000 0 0 
9. Raw 5 enone 92,000 5 4 
(3) 


*All the other samples were under 100,000. 


These results are rather striking in that the only 


samples containing B. coli in 0-01 c.cm. are of raw 


milk (all except one of the samples submitted) and 
of flash pasteurised milk. The samples, too, in which 
B. coli were found in 0:1 c.cm. were mostly from 
dairies where the conditions generally obtaining 
were not such as to make these results unexpected. 
On the other hand, the sample of Grade A (T.T.) 
containing 91,000 organisms and B. coli in 0-1 ¢.cm. 
was a little surprising, and there must have been a 
slip up in the technique (although the result is well 
within legal standards). Some doubt, too, may be 
cast.on a sample of Grade A milk containing only 
100 organisms, but although it is not suggested that 
these analyses are of suflicient number to do more 
than indicate the gross differences between different 
milks, they are carried out at the same laboratory, 
and, as stated above, with similar conditions very 
consistent results are obtained. 


AMOUNT OF MILK CONSUMED 


The Astor Committee * found that in January, 
1918, the average consumption per head per day in 
London was just under a third of a pint. In August, 
1925, the then Minister of Agriculture stated that 
the milk consumption per head of the population 
was 20 gallons a year. This is equivalent to about 
0-44 pint per day, but probably did not take into 
account the amount used in manufacture of other 
articles for home consumption and for export. Vari- 
able figures for different towns and areas in Scotland 


NOTES, COMMENTS, AND ABSTRACTS 


and further inquiry revealed a reasonable — 


[yan. 25, 1936 


are quoted by Paton and Findlay. These ranged 
from 0-27 pint per man-value per day in a part of 
Glasgow in 1921, to 1-31 pints per man-value per 
day in an agricultural population in Ayrshire in 
1924. These figures are roughly equivalent to 0-2 
and 1-0 pints per head of population per day. Other 
investigations have been made from time to time into 
the amount of milk consumed per head of the popu- 
lation. In 1932 the Ministry of Health Advisory 
Committee on Nutrition ê reported that the con- 
sumption per head was still less than half a pint a 
day. More recently Leighton and McKinlay ” find 
that in large Scottish burghs the consumption was 
0:417 pint, and in Scotland as a whole it was 0-479 
pint. The Milk Marketing Board ® this autumn 
(1935) state that the consumption is 0:38 pint per 
head per day, but that this is only approximate. 

The figures in this present communication show 
that in Southall, taken as a whole, the average con- 
sumption per head per day is just under half a pint. 
There are, however, three modifying factors which 
should be considered : 


1. The amount of milk used in food factories (artificial 
cream, bakeries, margarine works, &c.) and likely to be 
consumed in the district. Inquiry shows that approxi. 
mately 200 pints should be deducted from the total on 
this account. 

2. The amount of milk consumed by persons while 
working outside the district. This will cover lunch and 
possibly tea, and to a large extent it will be offset by the 
fact that another large number of people (in the factories, 
&c.) have lunch and tea in the district although living 
outside, 

3. The amount of dried milk used. During the week 
in question 107 lb. of dried milk (equivalent to 616 pints) 
were sold from the infant welfare centres. I have also 
ascertained that almost exactly the same amount of dried 
milk (109 lb., equivalent to 627 pints) was sold at shops 


(chemists, &c.) in the district during the week in question. 


These extras make practically no difference to the 
daily consumption, which is 0-497 or just under half 
a pint per head. It will be seen, therefore, that the 
consumption per head per day appears a little larger 
than in the Scottish burghs and definitely larger 
than for the country as a whole. 


COMMENT 


~. Much opposition has been experienced from time 
to time by local authorities in obtaining powers for 
compulsory pasteurisation of milk. This has usually 
been based on the alleged rights of small traders, 
cost of plant, &c. The figures quoted in this com- 
munication are probably typical for any part of the 
metropolitan police area (covering 8,000,000 people) 
and indicate that there are in fact very few retailers 
who do not sell either pasteurised or otherwise safe 
milk, and that the total quantity of pasteurised or 
otherwise safe milk sold is a very high proportion 
of all milk sold. The time probably is at hand when 
standing committees on private bills, or even the 
Ministry, may be persuaded more easily to accept 
the principle of compulsory pasteurisation for all 
milk which is not otherwise bacteriologically con- 
trolled. 


SUMMARY 


1. The milk-supply of an outer London suburb 
with 50,000 population is analysed. 

2. The milk consumption per head is just under 
0:5 pint daily. 

3. The amount of efficiently pasteurised milk sold 
is - per cent. of the whole. 

. The amount of “safe” milk sold is at least 

a per cent. of the whole. 


THE LANCET] 


5. The phosphatase test has been found useful in 
deciding whether a pasteurising plant is turning out 
safe milk, 

REFERENCES 


1. Dalrymple-Champneys, W.: Min. of Health, Reps. Pub. 
Henith and Med. Subjects No. 77, H.M. Stationery Office, 


2. Howell, J. B.: THE LANCET, 1934, ii., 1073. 

3 Ear H: Deane Graham, W.R. Jun.: Jour. Dairy Research, 

i ’ Vv es 3 3 

4, Quoted by Leighton and McKinlay: Milk Consumption in 
Scotland, Edinburgh, H.M. Stationery Office, 1934. 

5. Med. Research Counci), Spec. Rep. Ser. No. 101, H.M. 
Stationery Office, 1926. 

6. Report on Diets in Poor-law Children’s Homes: Memo- 
randum on the Criticism and Improvement of Diets, 
H.M. Stationery Office, 1932 

7. Leighton and McKinlay: Loc. cit., 

8. Private communication through Mr. H. E. Magee, D.Sc. 


THE REFORM OF MEDICAL STUDIES IN ITALY 


THE proposals of the commission nominated by the 
Italian Ministry of Education have been published 
in the Italian medical press. The report recognises 
the grave gaps apparent in the education of the 
present general practitioner, and finds as causes (1) the 
licence which permits students to attend their later 
studies .before passing the earlier examinations ; 


(2) the number of natural sciences taught in the 


first two years; (3) the number of examinations 
in special subjects in the last year; and (4) the 
lack of practical clinical training. The commis- 
sion recommends that the medical curriculum of 
six years should be divided into three periods of 
two years. During the first anatomy and physiology 
are to be studied for two years, and chemistry, physics, 
and biology for a year apiece. The student must 
pass in all five subjects before being admitted to the 
study of the subjects of the second period. In their 
second period are two-year courses in (1) general 
pathology, (2) special medical pathology, (3) special 
surgical pathology, and (4) pathological anatomy and 
histology with a course of one year in pharmacology 
and materia medica. Again the student must pass 
in all five subjects before entering on the last period 
of his training. In the last two years there are 
11 compulsory and three. special subjects. The com- 
pulsory subjects are: (1) clinical medicine, and (2) 
clinical surgery, in each case a two-year course, to be 
followed by six months of practical training. Diseases 
of children, obstetrics and gynecology, hygiene, and 
forensic medicine are each to be studied during one 
year. Nervous and mental diseases, skin and venereal 
diseases, eyes, throat, nose and ear, and dental disease 
are each to be taught in a course of 25 lecture-demon- 
strations. In addition, the student must select, and 
be examined in, at least three of the following extra 
subjects: (1) biological chemistry, (2) general histo- 
logy and embryology, (3) microbiology, (4) parasi- 
tology, (5) experimental psychology, (6) tuberculosis, 
(7) tropical diseases, (8) orthopedics, (9) radiology, 
(10) infectious diseases, (11) industrial medicine, 
(12) history of medicine, (13) urology, and (14) surgical 
anatomy and operative surgery. The instruction 
given in each of these subjects will also be in the 
form of 25 lecture-demonstrations. 

It will be seen that the Italian student will now 
have to pass 24 examinations in order to obtain his 
degree in medicine and surgery. This is of interest 
to us as Italy is at present the only continental 
country whose medical degrees are registrable in 
this country. 


ARTIFICIAL PNEUMOTHORAX CENTRES IN 
HUNGARY 


On behalf of the Hungarian sanatorium and dis- 
pensary doctors Dr. Sandor Puder ! has made a survey 
of pneumothorax treatment in the kingdom and of 
the centres where refills can be given. Questionnaires 
sent to hospitals, sanatoriums, dispensaries, and 


1! Cjabb Szempontok a Tuberculozis Elenikuzdelemben, 
Budapest, 1935. a 


NOTES, COMMENTS, AND ABSTRACTS 


[yan. 25, 1936 237 


practitioners—274 in all, of whom 60 per cent. replied 
—showed that at the end of 1933 there were 2183 
cases undergoing collapse therapy. It seems that 
there are each year 20,000 deaths from tuberculosis 


which, at three open cases to a death, would make 


60,000 cases of open tuberculosis in the country. 
At a modest estimate 30 per cent. of these, or 18,000 
cases, might be suitable for that form of treatment. 
How desirable it is that they should get it is evident 
from Dr. Puder’s statement that 60 per cent. of cases 
so treated lose their bacilli. Every medical institu- 
tion in the country should, he thinks, have an artificial 
pneumothorax centre, and where there are none 
new dispensaries should be provided: There should 
be specialists at the centres where the first puncture 
should always be made, but practitioners could, after 
some special training, do the refills. The patients 
should if necessary have their travelling expenses 
paid, the cost of the scheme being met in equal 
shares out of the taxes, rates, and national insurance, 
with the help of a special tuberculosis stamp. 


THE CLIMATE OF PENMAENMAWR 


Dr. DENNISON PICKERING, medical superintendent 
of Pendyffryn Hall, Penmaenmawr, writes: ‘‘ During 
the spells of foggy and wintry weather which have 
occurred this winter the wireless and newspaper 
reports have described fog and wintry conditions 
as general, the only places specifically mentioned at 
various times as being free from such conditions 
being places in the south of England, particularly 
on the coasts. During the whole of this time, at 
Penmawnmawr, we have had no fog; snow on one 
occasion for a few hours only ; frost perhaps four or 
five times, and only once lasting after breakfast 
time, and never more than a few degrees. There 
have also been a large number of bright sunny days. 

“ It seems hardly fair that this state of affairs 
on the North Wales coast should be passed over 
without comment, and that this district should be 
included in the general North Wales weather reports, 
which apply almost entirely to the inland moun- 
tainous districts. We are trying to obtain recogni- 
tion of the fact that a portion of the North Wales 
coast enjoys a climate entirely different from the rest 
of North Wales, and comparing favourably with any 
other winter climate in the kingdom.” 


AN ARMLESS VIOLINIST 


THE autobiography of Hermann Unthan, a German 
born without arms, is worth reading.! Thanks to 
the remarkable character of his father and to his 
own determination he learned, among many other 
things, to play the violin with his feet and finally 
succeeded in supporting himself as a vaudeville 
artist. The story of his travels makes an excellent 
story,and Unthan overcame his disability to such an 
extent that the reader, absorbed in following his 
adventures, will occasionally tend to forget its 
existence. There are a few crumbs for the anatomist 
and the surgeon interested in the training of the 
physically handicapped, but the chief attraction of 
the book is in the personality of its courageous author 


CHILDREN IN TROUBLE 


FRANKNESS in sex education is requisite for stem- 
ming sexual crime, not only by satisfying precocious 
curiosity and preventing early misconceptions of 
sex, but also by encouraging free discussion and 
sound thinking among adults. This is the wider 
aim of the Federation of Children’s Moral Welfare 
Committees which, besides rescuing the victims of 
sexual perversion, provides speakers at meetings 
for mothers and social workers, and is willing to 
promote discussions in public-houses and working- 
men’s clubs. The work is hindered by the passive 
resistance of uninformed people who regard it as 


1The Armless Fiddler. By C. H. Unthan. London: George 
Allen and Unwin, Ltd. 1935. Pp. 287. 10s. 6d. i 


238 THE LANCET] NOTES, COMMENTS, AND ABSTRACTS.——BIRTHS, MARRIAGES, AND DEATHS ([JAN. 25, 1936 


meddlesome. The Holborn, St. Pancras, and Hamp- 
stead committee, of which .Dr. Alan Moncrieff. is 
chairman, had 99 new cases to deal with in 1935; 
of these 33 were preventive, the remainder were 
nearly all the results of indecent assault. Some of 
the children, whose circumstances and temperament 
make it desirable, are sent to institutions, but the 
majority are kept under the supervision of workers. 
The committee has been able to ensure special accom- 
modation for the children when they appear at 
police-courts and stations, and their examination by 
women doctors. There is a great need for voluntary 
workers, both men and women, and the hon. secretary 
Ta gladly receive offers at 7, Ampthill-square, 
.W.1. | 


ON BEING AN INVALID ! 


THE musings of a musician whose practice of her 
art was hopelessly prevented by her condition. of 
invalidism, make interesting reading, though many 
will be irritated with the extravagant terms of 
Monsieur Pierre Sanson’s preface. The pages record 
the self-communings of the patient who appears to 
have been condemned to die by a famous professor 
in a few months or at longest in a year, but who 
none the less has survived for 15 years. The first 
section of the book entitled ‘‘ The drama of the 
inher self ”?” contains little that might not have been 
the experience of many chronically sick. The second 
part entitled ‘‘ The drama of the environment ”’ is 
more worth reading. Some of the sections on 
familiarity with disease, the obtuseness shown by 
the healthy towards it, the isolation from friendships, 
the risks of egoism, and the pain which may be 
inflicted upon the well by the ill contain much 
suggestive reading. 


** CONTENTMENT ” 


Messrs. CIBA LTD., 40, Southwark-street, London, 
S.E. 1, have issued an ornamental calendar for 1936, 
adorned with a pictorial frontispiece of unintentional 
medical significance. It is a delineation of ‘‘a fine 
old English gentleman, one of the olden time,” 
sleeping off his dinner, and the details supplied by 
the artist suggest why the well-to-do classes in the 
earlier days of the Georges had a shorter tenure of 
life than their descendants of to-day enjoy. The 
artist, Mr. W. L. Grace, has produced a costume 
picture of a hearty squire who has dined and wined 
according to the standards of his time, has laid down 
his churchwarden, has drunk a final glass of toddy, 
and is now sleeping off the results. The picture, 
which is thoroughly well painted, judging by an 
effective reproduction, is labelled ‘‘ Contentment ”’ ; 
it ought to be labelled ‘‘ Beware,” for undoubtedly 
the self-indulgent gentleman is asking for much 
pathological trouble. | 
' “ CELLONA TECHNIQUE ” is the name of a hand- 
book published by T. J. Smith and Nephew Ltd. 
(Neptune-street, Hull), which describes the use of 
their Cellona bandages in the treatment of fractures 
and also in veterinary practice. The text mainly 
consists of selections from papers appearing in 
English medical journals, and nearly all the illus- 
trations are reproduced from Mr. K. H. Pridie’s 
article on plaster technique, published in THE LANCET 
last autumn (1935, ii., 680 and 732). The Cellona 
bandage contains 90 per cent. (by weight) of plaster- 
of-Paris; it is moistened in about 10 seconds and 
sets firm in 5-10 minutes. The standard widths are 
from 1 to 6 inches, and in addition Cellona plaster 
slabs, Cellona lacquer (for waterproofing), and Cellona 
hook tape are obtainable. The handbook concludes 
with an informative article on fracture treatment 
taken from the Medical Annual of 1935. 


~ THE DENMAN THUMB-GRIP DEVELOPER is held in 
the closed hand in such a way that a spring knob 


1 Tho Glorious Bondage of Illness... By .France Pastorelli. 
London: George Allen and Unwin Ltd. 1936. Pp. 224. 6s. 


' added artificially. 


at one end is pressed inwards by the thumb. This 
exercises many muscles besides those of the thumb 
and finger, and it is claimed that nervous control 
as well as strength of hand and arm can be increased 
by keeping a pair in the pocket and gripping them 


‘occasionally. The training indeed may be helpful 


for golf or other games; but the producers (Denman 
Products Ltd., 169, Regent-street, London, W. 1) 
are perhaps unduly hopeful when they go on to sug- 
gest that the mental and physical concentration 


obtainable will ‘‘ rebuild shattered nerves.” 


UNDER the title, ‘‘ Suggested Standards for Milk 
Foods in Infant Feeding,” Messrs. Cow AND GATE 
Lro. (Guildford, Surrey) issue an attractive account 
of their aims and methods. They point out that 
their foods are prepared from Somerset and Dorset 
milk, and sold in sealed and dated tins. Poor or 
dirty milks produce powders which are low in solu- 
bility and high in acidity and do not keep well, and 
the’ Cow and Gate booklet describes the bonus 
schemes, farm inspections, and continual testing 
which ensure that the 9 million gallons used by the 
firm: are fully satisfactory. Prepared by the ‘‘ im- 
proved roller process ”? the powder is exposed to 
heat treatment at 98° C. for less than 3 seconds, and 
contains on an average 250 international units of 
vitamin D per pint of reconstituted milk, none being 
Particulars are given of the 
18 forms of dried milk manufactured, ranging from 
the standard full-cream and half-cream powders to 
such preparations as Caprolac, a goat’s milk powder 
recommended for infants intolerant of cow’s milk. 
Members of the medical profession are invited to 
visit the factories. 


Births, Marriages, and Deaths 


BIRTHS 


Fox.—On Jan. 8th, at Guernsey, the wife of Dr. Maurice D. 
Fox, of a daughter. 

FRANKLIN.—On Jan. 15th, at Devonshire-place, W., the wife 
of Richard H. Franklin, F.R.C.S. Eng., of a son. 

O’RIORDAN.—On Jan. 15th, at Plymouth, the wife of Surgeon 
Commander T. J. O’Riordan, R.N., of a son. 

Snow.—On Dec. 20th, at Poona, the wife of Captain J. E. 
Snow, R.A.M.C., of a son. ` 

STEEL.—On Jan. 20th, at Hillingdon, Middlesex, the wife of 
Dr. W. Arklay Steel, of a son. | 

WiLson.—On Dec. 3rd, at Sydney, Australia, the wife of Dr. 
Harold Wilson, of a daughter. 


MARRIAGES 


BLACK—CHRISTMAS.—On Jan. 17th, at St. Mary-le-Strand, 
Charles Black, M.B., Ch.B. Glasg., of Alexandria, Dum- 
bartonshire, to Mary Elizabeth, daughter of Mr. John 
Christmas, Blythwood, Enfield. 

DAY—BaILEY.—On Jan. llth, at Jullundur, Punjab, India, 
‘Capt. Peter Leigh Day, R.A.M.C., to Jean Metcalfe Bailey. 

McMULLAN—WaARD.—On Jan. 9th, at the Priory Church, 
Great Malvern, William McMullan, L.R.C.P., D.P.H., to 
Rosamund Mabel, only child of Mr. A. H. Ward, O.B.E., 
Great Malvern. 

STEVENS—Davis.—On Jan. lith, at St. Mary’s Church, Twy- 
ford, T. Russell Stevens, F.R.C.S. Eng., Dorchester, only 
child of Thos. G. Stevens, F.R.C.S., to Enid, younger 
daughter of Mr. Stanley Davis. 

SwWAN—WHITE.—On Jan. 14th, at Ballymore Parish Church, 
Tandragee, Dr. William David Swan, son of the late Mr. 
John Swan and of Mrs. Swan, Ballyshannon, to Dr. Eliza- 
beth Barrington White, younger daughter of the late Mr. 
T. H. White and of Mrs. White, Orange Hill, Tandragee. 


DEATHS 


BERNARD.—On Jan. 19th, at Fishponds, Bristol, Claude Bernard, 
M.R.C.S. Eng., aged 67. 

Bonp.—On Jan. 18th, at Woodbridge, Suffolk, of pneumonia, 
porum Wiliam Bond, M.B. Durb., M.R.C.S. Eng., 
RBO « 3 

DouaGcLas.—On Jan. 20th, at Buckingham-gate, S.W., Stewart 
Ranken Douglas, F.R.C.P. Lond., F.R.S., youngest son 
of the late James Alexander Douglas. 

FisHErR.—On Jan. 10th, at Oreston, near Plymouth, Herbert 
Wortley Fisher, M.R.C.S. Eng., son of the late John Fisher, 
Inspector-General R.N., aged 59. 

VERNON.—On Jan. 19th, at a nursing-home, Ethel Miller 
Vernon, M.D. Lond., of Millbank, S.W., eldest daughter 
of the late Thomas Heygate Vernon. ° 


N.B.—A fee of 78. 6d. is charged for the insertion of Notices of 
Births, Marriages, and Deaths. 


THE LANCET] 


[FEB. 1, 1936 


ADDRESSES AND ORIGINAL ARTICLES 


THE SURGERY OF CORNEAL GRAFTS 


WITH LATE REPORTS 


By B. W. Rycrort, M.D. St. And., F.R.C.S. Eng., 
D.O.M.S. 


ASSISTANT SURGEON AND PATHOLOGIST TO THE ROYAL EYE 
HOSPITAL, LONDON ; OPHTHALMIC SURGEON TO THE KING 
GEORGE HOSPITAL ILFORD ; LATE HUNTERIAN PROFESSOR, 
ROYAL COLLEGE OF SURGEONS OF ENGLAND 


(WITH ILLUSTRATIONS ON PLATE) 


THE latter half of the nineteenth century saw a 
rapid expansion in all branches of ophthalmic surgery, 
largely stimulated by the successful work of von 
Graefe and his pupils, and at this time great interest 
was taken in early experimental keratoplasty. 
Although de Quengsy in 1789 had mooted the idea 
of a transparent glass implant in the cornea, it was 
not until 1824 that Reisinger attempted to graft 
living cornea in rabbits. He was not successful, and 
further attempts by Mulbauer and Durr in 1877, 
also using rabbits, met with similar results. 

A. von Hippel was the first surgeon to demonstrate, 
at the International Congress in Heidelberg in 1888, 
a successful case of corneal graft in a rabbit. He 
described two methods: (1) that in which a partial 
thickness of the cornea was employed (lamellar); (2) 
that in which the whole thickness of the cornea was 
removed (circumscribed penetrating) (Fig. I. a and b). 
He used a circular trephine of his own device 
but without any method of fixation of the 
craft. It is on this worker’s pioneer technique that 
the modern operation of keratoplasty depends. The 
lamellar method, which appeared safer in those 
early days, was used by several workers, and the 
first successful case of human corneal grafting by it 
was demonstrated by Zirm in 1906, in a case of dense 
corneal scarring following a lime burn. Modifications 
followed in rapid succession. Lohlein in 1909 used 
a vertical strip of cornea together with attached 
conjunctiva. Wiener removed superficial scars and 
allowed the raw surfaces to epithelialise, but the 
method of partial keratoplasty was finally abandoned 
since the implants were not permanently transparent. 


Ẹ 


FIG. II.—Elschnig : Circumscribed pene- 
trating keratoplasty with bridle fixa- 
tion suture. Miosis. 


About the year 1910 Elschnig and his assistants 
commenced a series of operations which in 1930 had 
reached a total of 172 cases. Their results, which 
have never been surpassed, removed the operation 
of keratoplasty from the experimental to the thera- 
peutic stage. These workers claimed successes— 
that is to say, clear corneal grafts—in 22 per cent. 
of all cases and in 73 per cent. of cases of interstitial 

5866 


FIG. IlI.—Thomas: Corneal fixation 
suture, bevelled graft. 


keratitis. Several patients were improved to a 
vision of 6/6. The technique of the operation 
constituted rigid preliminary aseptic routine, 


van Lint facial block, retrobulbar anesthesia, 
and the Elschnig fixation suture (Fig. II.) A 
Hippel trephine was used to prepare the graft and 
the whole of the thickness without any bevelling 
of the edges was employed, the pupil being in a 


A a Li a 
FIG. I—Von Hippel: (a) lamellar keratoplasty : he fete oS 
scribed penetrating with no special method of fkxatian. Le j 
V s Sn 
state of miosis. The size of the trephine was 4=5 mm.” 
Thereafter the graft was kept between layers-of dry 
gauze and fixation was obtained by a bridle suture 
running over the graft; in 22 cases, flaps also had 
to be employed (Fig. II.). The conclusions which 
Elschnig reached were that the penetrating method 
of keratoplasty was the method of choice, that the 
blood group of host and donor had no relationship 
to the subsequent transparency of the graft, that the 
graft could be removed from an eye which was not 
necessarily healthy provided it was transparent at 
the time of removal, and that the younger donors 
provide the better grafts. 

Within the last five years there have been many 
modifications of this method. Filatoff uses ribbon 
flaps of conjunctiva to keep the graft in place, having 
previously protected the lens and iris by a strip 
of celluloid inserted behind it. Egg membrane 
is also used as a protective. Tudor Thomas 
(Fig. III). bevels the edge of the graft and employs a 
slightly larger trephine to cut the bed. Olive oil is 
used as a'vehicle and protective dressing, and corneal 


- - 
Da "S 
2 ` 
2 ` 
3 ` 
’ S 
: ` 
, A ze.. ` 
é ‘ ' ry 
( ‘ 
J Y) 
o] 
(3 
‘ $ ' p 
` ba w aal e 
` e 
o 
ar se 
Pid 
` r 
TO ta 


FIG. IV.—Castroviejo : Rectangular graft. 


Miosis. Vertical flap. 


sutures are used for fixation (Fig. III.). Castroviejo 
uses parallel knives and cuts a rectangular graft 
using conjunctival flaps for fixation (Fig. IV.). The 
procedures of Morax and Kraupa should be noted 
at this stage (Fig. V.). _Morax employs auto-trans- 
plants from the same cornea. This is necessarily 
of the lamellar type, and there is an interchange of 
corneal dises so that the opaque disc is placed at the 
E 


240 THE LANCET] MR. B. W. RYCROFT: SURGERY OF CORNEAL GRAFTS [FEB. 1, 1936 


periphery and a clear disc is placed over the nebula. 
Kraupa employing the circumscribed penetrating 
method rotates the graft, which is composed partly of 
scar tissue and partly of clear cornea. Rotation brings 
the clear segment of the graft intothe pupillary line and 
diverts 
the scar- 
red por- 
tion tothe 
periphery. 
Key had 
attempt- 
edto graft 
the whole 


T ae m of the cor- 

- V.—(a) Kraupa : otation of graft. (b) 

_Morax: Transposition of graft. Lamellar nee but 
method. without 


Success, 


The Author’s Method 


I employ the following method (Fig. VI.). A general 
investigation of the host and donor is undertaken ; 
gross focal sepsis is removed and general disease 
eliminated ; the Wassermann reaction in the donor 
must be negative. There must have been no active 
disease in the eyes for at least a year before kerato- 
plasty can be undertaken. The usual preliminary 
cataract precautions are taken such as ensuring 
patency of the lacrymal ducts and sterility of the 
conjunctival sac; there must be no severe cough 
or prostatic obstruction. Preliminary treatment is 
carried out for one week, with four-hourly irrigations 
of hydrarg. oxycyanide lotion 1 : 8000, together with 
local ultra-violet radiation of three minutes’ duration 
daily by the full spectrum of the mercury-vapour 
lamp. The projection of the eye is accurately 
measured and the response must be brisk. Retro- 
illumination determines the position of the pupil 
and the presence or not of gross lens opacities ; this 
is important in determining the precise site for the 
graft. On the day before operation the state of 
the bowels is attended to in the usual way, and 
atropine is instilled at night into the host’s eye. 
I have given up the use of miotics for reasons stated 
later. On the morning of operation Medinal grs. 7} 
is given one hour before the projected time of opera- 
tion. The patient is operated on in bed and not 
lifted on to an operating table. 


OPERATION 


The preparation of the site in the host and the 
enucleation of the donor’s eye are begun simul- 
taneously.. Anzesthesia is obtained by 4 per cent. 
cocaine and retrobulbar injection of novocain with 
adrenaline so as to reduce the tension of the eye 
and prevent expulsion of the intra-ocular contents. 
Facial akinesis by the method of O’Brien is a routine 
procedure. In the host a complete flap is prepared 


circumscribing the limbus and separated well back 


to the equator of the globe. A purse-string suture 
(No. 1 black silk Mersuture) is inserted close to the 
edge of the conjunctiva in such a way as to render 
the aperture eccentric when tightened. A 4 mm, 
circular graft is delineated over the precise site of 
the pupillary aperture which has previously been 
determined and may have been marked on the 
nebula by methylene-blue (Elschnig), and the whole 
thickness of the cornea is cut through. In early 
cases I practised the shelving method of Tudor 
Thomas but recently I have-abandoned this because 
there is little risk of losing the disc, and the shelf 
of up to 1 mm. reduces the available portion for vision 
of the 4 mm, graft to 2 mm. posteriorly and there is 


a risk of Descemetitis covering this small aperture 
later. During these manœuvres the eye is constantly 
irrigated by normal saline at body temperature, and 
when the graft is cut through in one portion. the 
aqueous is slowly evacuated, and the section com- 
pleted by scissors and fine protected forceps. The 
same procedure is carried out in the enucleated eye 
using Tudor Thomas’s apparatus for holding the 
globe. 

The graft is then transferred to normal saline 
lotion at body temperature, and from there to the 
bed by means of a lens spoon, care being exercised 
to see that it is not turned upside down. It is 
manceuvred into position by means of the iris 
repositor, the assistant at the same time gradually 
tightening the purse-string suture so that the graft 
gradually disappears from view as the conjunctiva closes 
overit. When the conjunctiva is tied off and allowed 
to fall back the graft is held securely in position by 
the natural strap over the cornea. No suture touches 
the graft since it is entirely covered by conjunctiva. 
A retention stitch fixes the upper lid to the eheek 
and ordinary postoperative cataract routine is insti- 
tuted. 

Aspirin, ers. 10, is given after the operation, and as a 
rule there is no pain and very little discomfort. The 
eye is not dressed for three days, after which the graft 
usually appears opaque and can be dimly seen through 
the widening conjunctival aperture. At the end of 
the first week more of the graft is visible, and it is 
slowly beginning to clear; on the tenth to the 
fourteenth day the stitch either cuts out or is removed 
and the conjunctiva slides back. Atropine mydriasis 
is continued : 
from the first 
dressing. It 
is of import- 
ance to keep 
the patient 
in bed for 
at least a 3 
month, since 
the linear 
scar is weak 
and there is 


a tendency si yore ss patel eE pone raie 
9 ceratoplasty. omplete conjunctival tap. 
to prolapse if Mydriasis. 


the patient 
in his enthusiasm attempts to do too much. 


INDICATIONS 


Indications for the graft of a cornea are clearly 
defined. 


(1) Vision must be reduced, to perception of hand 
movemonts, by a corneal scar. 

(2) Uveal tissue must not adhere to the scar; this 
must be separated off before a graft is undertaken. 

(3) The pupillary aperture must be bright and mobile 
by retro-illumination, although successful cases of graft 
have subsequently had a cataract removed. 

(4) Glaucoma must be absent. 

(5) The projection of light must be accurate and brisk. 

(6) There must be an absence of disease in the host 
and of syphilis in the donor. 


Suitable cases result from chemical burns, healed 
interstitial keratitis and corneal ulceration without 
iris prolapse, and the definition of a successful case 
is that the graft is in place one year after operation 
and has retained transparency throughout that year 
with a maintenance of vision, Filatoff put the period 
of nine months. Donor grafts may be obtained fron. 


THE LANCET] 


cases of sarcoma, detached retina, absolute glaucoma 
without cdema, old iritis, and cases of recent injury. 


OPERATIVE COMPLICATIONS 


1. Prolapse.—In one case a large graft of 6 mm. 
was used and a prolapse occurred at the end of the 
first week. This was excised satisfactorily but the 
transparency of the graft was affected by the trauma. 
With 4 mm. grafts there has been no prolapse, and 
it would appear that a larger wound takes longer 
to heal and the risk of prolapse is correspondingly 
greater. 
the preventive before, during, and after the opera- 
tion, since with the loss of aqueous the pupil contracts 
in any case and protects the lens so that miosis 
seems to be unnecessary; it appears to favour 


incarceration of the iris in the wound two or three. 


hours after operation. 

2. Difficulty of fixation of the graft—I now use a 
complete graft without bevelling of the edges follow- 
ing the method of Elschnig, who had only 1 mis- 
placed graft in 172 cases. Furthermore this shelving 
tends to make the accurate fixation of the graft 
dificult and certainly diminishes the posterior 
visual aperture of the cornea and increases the linear 
scar area. Corneal sutures predispose to a localised 
opacity and cross stitches may interpose themselves 
between the lips of the graft (Castroviejo). The 
object of the complete conjunctival flap as described 
is to give a uniform pressure over the graft with an 
absence of irritating foreign substances. The swelling 
of the graft rapidly fixes it in position in the cornea, 
and the same size of trephine is used for host and 
donor. 

3. Sepsis does not occur frequently.—Elschnig gives 
one case of necrosis in his series, and with careful 
preliminary technique it is possible to avoid this, 
especially if the site of the graft is carefully covered 
by conjunctiva. 

4, Opacification of the graft.—There are three types 
of opacity. The first comes on during the first week, 
and is the result of the imbibition of aqueous humour 
into the substantia propria; it rapidly clears up 
towards the end of the first week. The second is 
due to vascularity from the spread of superficial 
vessels towards the end of the second week; this 
takes longer to clear but is not permanent. The 
third opacification comes about the end of the first 
fortnight, and is due to a failure of nutrition in the 
graft, and is permanent. In successful cases the 
area outside the graft also clears to a certain extent. 


The Use of Animal Grafts 


For many years the earlier workers were hampered 
by the limitations of their material. Von Hippel 
employed grafts from rabbits and dogs without 
success. This has been often repeated with the same 
results up to the present day, and it appears quite 
definite that grafts from animals cannot be success- 
fully employed in the human. Grafts from cadavers 
may be employed provided they are taken within 
an hour of death as described by Filatoff. Magitot 
has kept a graft transparent for four weeks in hemo- 
lysed serum. Salzer and Ortin after many experi- 
ments have come to the conclusion that autotrans- 
plants—i.e., transplants from the same person or 
same cornea (Kraupa, Morax)—are best, that homo- 
transplants from the same species may be successful, 
but that heterotransplants from different species are 
never successful. Tudor Thomas has reported the 
use of devitalised corneal tissué in rabbits and has 
pointed out that there is a general firm union with 
the thinning of the linear scar and very little reaction. 


MR. B. W. RYCROFT: SURGERY OF CORNEAL GRAFTS. 


Furthermore I now employ mydriasis as ` 


[FEB. 1, 1936 241 


Illustrative Cases 


The following three cases are examples of corneal 
grafts after six, nine, and twelve months. 


CasE 1.—-A man, aged 52, in 1930 had a severe attack 
of interstitial keratitis of the right eye and was treated 
by Mr. N. L. Pines who recommended the removal of 
unerupted wisdom teeth. The result of this operation 
was that the acute condition subsided, and in 1932 the eye 
became quiet with a vision of perception of light (Fig. VII. a 
on Plate). In May, 1935, keratoplasty was decided upon, 
although the condition was unilateral, and preliminary 
investigation was undertaken. For many weeks con- 
junctival culture showed Staphylococcus aureus until finally, 
by vigorous ultra-violet radiation, silver nitrate, and the 
usual applications, a clean culture was obtained. A 
4 mm. graft was employed, the donor being a woman who 
had suffered complete retinal detachment and old iritis. 
The patient has made an uninterrupted recovery and six 
months later is able to go about by the aid of this eye 
alone which has vision of 6/60 and a full field. Colour 
vision is normal, and he is able to read the headings in a 
newspaper. The cosmetic result is excellent and the graft 
is steadily clearing (Fig. VII.b). 

CasE 2.—A woman, aged 49, has suffered since the age 
of 7 from ulceration of both eyes and was treated for 
some years by curettage of the cornea and instillations 
of dionine. Since 1930 there has been no treatment. 
On admission to hospital for keratoplasty both corner 
showed a central nebule of medium density; vision was 
perception of light, and in each eye there was no organic 
disease of the patient. The tension of the right eye was 
30 and of the left 26, and the left was accordingly chosen 
for corneal graft. With the technique described, using 
a 6 mm. graft, keratoplasty was carried out. Five days 
after the operation the patient was able to see a dim 
form in a bed across the ward, to make out the windows 
of the ward, and to see chimneys on adjacent houses. But 
on the tenth day there was a prolapse of the iris which 
had to be excised. Thereafter the transparency of the 
graft failed and the vision to-day has been reduced to 
counting of fingers, which was better than it was before 
the operation. 

Case 3.*—The third case was shown to the section of 
ophthalmology, Royal Society of Medicine, in January, 
1935. The patient was a woman, aged 48, who had had 
the right eye removed for tuberculous keratitis, and whose 
left cornea showed healed opacity which had reduced 
her vision to perception of light (Fig. VIII. a on Plate). She 
had been certified for the Blind Register and had ceased 
treatment in November, 1934. Complete investigation was 
carried out, and a 4mm. corneal graft was obtained from an 
accident case and inserted into the patient’s cornea by the 
above method. Convalescence was uneventful, and we 
demonstrated the case at a vision of 6/24 with correction 
and J 6 (Fig. VIII.b). One year after operation the graft 
has still maintained its transparency ; there is a good deal of 
thickening of Descemet’s membrane on the posterior cor- 
neal surface but the pupillary gap remains wide enough to 
afford a vision of 6/36; the anterior chamber and iris 
are seen to be normal. There is no ectasia of the scar 
and the tension is normal, Vascularisation is absent 
except for a few superficial conjunctival vessels. 

During the last year the patient has gone about the 
streets on her own and made bus journeys alone. She 
is able to read newspapers and write good manuscript. 
She. attends and enjoys the cinema, and is able to do her 
own housework. For reading fine print, J 4, she employs 
telescopic spectacles, but for ordinary purposes the 
unaided eye is used. She reports that she finds it difficult 
to express her feelings at being able to see again after 
having resigned herself to a life of blindness. 

I have received much valued assistance from the 
senior house surgeons at the Royal Eye Hospital, 
Mr. G. Handelsman and Mr. R. If. Rushton who 
were responsible for the preliminary investigations 
and for assistance during the actual operations; to 
them I am gratefully indebted. 

* The history of this patient up to last March has been recorded 
in the British Medical Journal (1935, i., 919). 

(Bibliography at foot of next page) 


242 THE LANCET] 


EFFECT OF SEX HORMONES ON THE 
PROSTATE OF MONKEYS 


By S. ZUCKERMAN, D.Sc. Lond., M.R.C.S. Eng. 


BEIT MEMORIAL RESEARCH FELLOW ; AND 


Sc.D. Camb., F.R.S. 


(From the Department of Human Anatomy, Oxford, and the 
National Institute for Medical Research, London) 


A. S. PARKES, 


I.—The Effects of Male Hormone 


ALTHOUGH a beginning has been made in the 
clinical use of male hormone preparations, our 
experimental knowledge of the effects of the hormone 
on the accessory reproductive organs relates only 
to small rodents. The present investigation on 
immature monkeys provides information about 
corresponding effects on accessory reproductive organs 
homologically similar to those of man. 

Such an investigation does not appear to have been 
made as yet, and indeed there have been practically 
no studies even of the secondary sexual characters 
-of monkeys and apes, in many species of which 
they are exceptionally well marked. Antonius? 
reports that the very conspicuous cape of hair of male 
hamadryas baboons disappears, and the pelage 
changes to the female type after castration. We 
can confirm his statement on the basis of a similar 
experiment of our own, but apart from these two 
observations, we know of none that relates to the 
endocrinology of the testis in subhuman primates. 


INVESTIGATION 


Material.—Seven normal immature male rhesus monkeys 
(Macaca mulatta), whose weights and approximate ages 
are given in Table I., were used in this study. One was 
injected daily with 10 capon units * of ‘‘ Enarmon ” urine 
concentrate, for which we thank Dr. Itoh, Teikokusha 
Institute, Kawasaki. Three were injected with an oil 
solution of “synthetic ”’ androsterone,” and three with an 
oil solution of “synthetic” androstanediol*® (di-hydro- 
androsterone). (See Table I.) For both these prepara- 


* At the time this assay was made no standard of reference 
was available, but 1 ‘‘capon unit” as then used by us is 
now known to correspond almost exactly to the activity of 100 y 
of androsterone, the prospective international unit of myle 
hormone activity. 


DRS. ZUCKERMAN AND PARKES: EFFECTS OF SEX HORMONES 


[FEB. 1, 1936 


tions we are greatly indebted to Prof. L. Ruzicka and 
Messrs. Ciba Ltd. 

An extensive control series of normal animals was 
available. 


TABLE I 


Administration of Male Hormone to Immature Male 
Rhesus Monkeys 


No | | 
* | Body- Approx. Nat f Amount | 
; ‘weight’ age in ute. injectedii 
aL. (g.). months. preparation. daily. 
‘*Enarmon.’’ 


10 ! 3200 38 


| 2680 


2 4 1800 20) 1 he 
6 | g | 5 mg 
30 | 2700 24 i a l 9-5 ,. 
31 ' 2700 | 24 PRORA ND a d 
52 | 2700. 24 a. eae 
53 | 3800 | 24 ,{) Andro- {| 5 3) | 
78 24 stanediol. (! 5 ae a 
| 


EXPERIMENTAL RESULTS 


External changes.—Swelling and coloration of the skin 
of the external genital organs, anus, and surrounding 
areas, such as develop during injection of cestrone, did 
not occur during any of the present experiments with 
male hormone. The external genitalia were unexceptional 
in all the monkeys except MM. 53, which differed from the 
other experimental animals in that its testes at autopsy 
were at the base of a well-developed scrotum. Since, 
however, the testes were still undescended in MM. 78, 
in which injections of androstanediol were continued for 
longer than in the case of MM. 53, it is difficult to ascribe 
the position of the testes in the latter to the injections, 
and it is possible that the animal had already reached the 
age for testicular descent. 

“There was a suggestion in the behaviour of MM. 78 
that its responses became more aggressive, and its social 
position in the cage, which it occupied with two other 
males of the same age, more dominant towards the end 
of the treatment. 

Internal changes.—With the exception of MM. 10, the 
prostate and seminal vesicles of all the injected animals 
are larger than those of the normal controls. The seminal 
vesicles show the usual characters associated with the 
administration of male hormone in rodents * and need 
not be discussed here. Essentially they comprise rapid 
glandular development, and a relative and parallel 
decrease in the fibromuscular tissue (Fig. 1). The degree 
of response roughly corresponds to the number of units 
administered.5 

The prostatic changes are confined to the prostatic 
glands proper and to their fibromuscular stroma, and, 


~ 


(Continued from previous page) 
MR RYCROFT: BIBLIOGRAPHY 


Ascher, K. W.: Arch. f. Ophth., 1919, xcix., 339 1922, evii., 
241 and 439.. 

Bicringer, S.: Klin. Monats. f. Augen., 1933, xc., 43. 

Castroviejo, R.: Amer. Jour. Ophth., "1932, xv., 535 and 905; 
1934, xvi., 932. Proc. Stat Meet. ‘Mayo Clin., 1931, 
vi., 417. Jour. Med. Soc. New Jersey, 1935, xxxii., 80. 

eign Tye Augenarztliche Operationslehre (Elschnig), Berlin, 

Elschnig, A.: Arch. Ophth., 1930, iv., 16 

Filatot!, W.: And There Was Light, 
vestnick, oftal., 1933, ii., 136 and 217; 1934, iv., 3, 192, 
and 222; 1934, v., 454; 1935, vi., 22) Arch. f. Augen., 
1930, cii., 716; 1933, evii., 153. Arch. Ophth., 1935, 
xiii., 321. Eyo, Ear, ‘Nose, "and Throat Monthly, 1933, 
xii., 273, Ann. d’ Ocul., 1934, clxxi., 721. Arch, de oftal. 
Hisp. Amer., 1934, xxxiv., 451 and 475. Zeits. f. Augen., 
1929, Ixix., 279. Vrach. delo., 1933, xvi., 409. 

Filatott W., and Velter, T.: Arch. f. Augen, . 1932, cvi., 467. 
Sovet vestnick. oftal., 1932, i., 13 and 15; 1934, iv., 6 

Friede, W.: Klin. Monats. f. Augen., 1933, xci., 75 and 87. 

Arch. f. Augen., 1934, eviii., 568. 
ie ee 117. 


5. 
1933, ii., 18. Sovet 


Galante, E.: Ann. de ottal. e clin. oeul., 
Gradle, I S.: Amer, Jour. Ophth., 1921, iv 

v. Graefe, A.: Trans. Ophth. Soc. U. K., 1934, liv., 119. 
vV. Hippel, A.: Arch. f. Ophth., pee xxxiv., 108. 
Katz, D. Aree Ophth., 1933, ix. » 331. 

Kirwan, È. O.: Ind. Med. Gaz. S ib33 lxx., 61, 

Key, B. W.: Trans. Ophth. Soc. U.K., 1930, xxviil., 29. 
Ophth., 1931, v., 789. 
Klauber, F.: Casop. lek. cesk., 1933, lxxii., 498. 
Kraupa, M.: Zecits. f. Augen., 1914, xxxviii., 132, 


Arch, 


Lagarev, V.: Sovet. vesatnick. oftal., 1934, iv., 337. y 

Liebsch, W.: Arch. f. Augen., 1930, ciii., 603. 

Lohlein, W.: Ibid., 1910, lxvii., 398. 

Magitot, A.: Jour. Amer. Med. ” Assoc. . 1912, lix., 18. 

Manes, A. J.: Semana méd., 1929, i., 1209, 

Morax, V.: Clin. Ophth., 1912, XİN., 108. 

Nizetu, H. : Klin, Monats. f. Augen., 1934, xciii., 89. 

Ortin, G. L.: Atlas de la Soc. oftal. Hosp. ~Amer. (Barcelona), 
1914, evil. 161. 

prides skay a, E. 1., and Velter, S. L.: Sovet. vestnick. oftal., 
1935, iii., 8. 

de Quengsy, P.: Quoted by Ortin, Med, Ibera, 1931, xx., 213, 

Rosengren, T Hygiea, 1930, xlii., 826. 

RAR : Augenarztliche Operationslebre (Elschnig), Berlin, 
192. 

Rycroft, B. ee : oe Med. Jour., 1935, i., 919. Proc. Roy. 
Soc. Med., 

Sauchez, M. Rov. do cir, de Buenos Aires, 1934, xiii., 367. 

Salzer, F.: Zeits. f. Augen., 1900, iii., 516. 

Stallard, H. B.: Brit. Med. Jour., Jan, 18th, 1936, p. 106. 

Thomas, J. W. T.: Proc, Roy. Soc, Med., 1930, xxiii., 75 ; 
1933, xxv., 5973; 1934, xxvii., 195. Trans. ‘Ophth. Soc. 
U.K., 1930, i., 127; 1924, liv., 119; 1931, li., 96. TRE 
LANCET, 1931, i., 335. Brit. Jour.’ Ophth’, 1933, xvii., 
aa 1934, xviii., 129. Proc. Roy. Soc., B, 1933, eviii., 

Vasy wkis A.G.: Sovet. vestnick. oftal., 1935, vi., 29 

W sear M.: E. Jackson Birthday Volume, Wisconsin, 1926, 


Wright, R F.: Brit. Jour. Ophth., 1935, xix., 341. 
Zirm, E. Atel f. Ophth., 1906, ixiv., 580. 


THE LANCET] 


as with the seminal vesicles, the degree of response 
is roughly proportional to the number of units 
administered. The muscle cells and nuclei are more 
swollen than is normal,and mitoses are frequent in the 
stroma, which is also unusually vascular. 

The prostatic glands, especially in those specimens 
which had been in- 
jected with andro- 
stanediol, are much = ' 
larger than normal. 
The increase in 
their size can be 
attributed mainly 
to an increase in 
the size of the cells 
of the glandular 
epithelium. These 
cells, especially in 
the best developed 
glands, are much 
larger and more 
regularly columnar 
than in the normal, 
with oval basal 
nuclei and a con- 
spicuous inner zone 
of cytoplasm. The 
cells do not charac- 
teristically show a 
central paler zone 
in the inner cyto- 
plasm such as is 
described in the rat 
after treatmentwith 
male hormone,’ but 
this may be due . 
to the fact that no special technique was followed in the 
staining of the sections, which were treated with Meyer’s 
hemalum andeosin. Although the glands are more open 
than in the controls, and contain more secretion, they are 
not in any specimen as dilated as in fully mature malo 
primates. Moreover, although there are numerous mitoses 
in the glandular epithelium, it is doubtful whether the 
number of individual glands is greater than in the control 
material (Fig. 2). 

In none of the experimental animals are there any 
changes in the utricular epithelium, epithelium of the 
terminal parts of the common ejaculatory ducts, or 
epithelium of the dorsal part of the lower half of the 
prostatic urethra, tissues which respond to cestrone. 


CONCLUSION 


The essential changes occasioned by male hormone 
in the seminal vesicles and the prostate of the 


DRS. ZUCKERMAN AND PARKES: EFFECTS OF SEX HORMONES 


FIG. 1,—(A) Seminal vesicle of immature normal rhesus monkey (MM. 11). 
immature rhesus monkey (MM. 53) after injection of androstancdiol (see Table I.). (x 


[FEB. l; 1936 243 


(B) Seminal m of 


immature monkey are similar to those which occur 
in the true prostatic tissue of rodents—i.e., the 
hormone promotes rapid growth in the size of the 
organs by acting both on their fibromuscular stroma 
and on their individual glandular elements, which are 
rapidly transformed to a mature type. In its lack 
of influence on the epithelium of the uterus masculinus, 
which responds to œstrone, male hormone obeys the 
principle laid down by Moore and Price ” that “‘ gonad 
hormones stimulate homologous reproductive 
accessories, but are without effect upon heterologous 
accessories ° 

The small number of specimens studied and the 
difference in the treatment of the various animals 
make it difficult to compare the relative potencies 
of the various preparations used, but the maturest 


oS 


wr A x ` 


~ 


$ 
ae 


ms CS 
i a 
d vee 4 


FIG. 2.—(A) and (B) prostates corresponding to seminal vesicles in Fig. 1. (x 157.) 


944 THE LANCET] DRS. ZUCKERMAN AND PARKES: EFFECTS OF SEX HORMONES [FEB. 1, 1936 


prostates were those of the animals injected with 
androstanediol. The animal injected with enarmon, 
on the other hand, showed very few changes. Although 
the activity of enarmon on rats per capon unit is at 
least three times that of crystalline androsterone, the 
lack of effect in the present instance is not surprising, 
since the total amount of enarmon injected could 
not have equalled in potency much more than 30 mg. 
of androsterone.® 


II.—Suppression of Effects of @strone by 
Simultaneous Administration of Male Hormone 


The possibility that the epithelial changes induced 
by estrone in the prostate of monkeys ® may throw 
light on the etiology of glandular hyperplasia of the 
prostate in man makes it urgent to inquire whether 
or not these changes in the monkey can be inhibited 
by male hormone, in the same way as similarly 
induced changes in the prostate of mice.!®!* The 
immediate importance of this problem hes in the 
homological similarities of the monkey and human 
prostates, and in the present uncertainties as to the 
true relationship of the organ called prostate in mice 
to the primate organ of the same name. The general 
significance of the problem is complicated by the 
doubt as to the nature of the wstrogenic substance 
found in the male mammal. Esterified estrone is 
certainly excreted by the stallion, but whether 
or not it is by other male mammals is unknown. 
Biological examination of testis extracts!’ suggests 
strongly that the ostrogenic substance elabo- 
rated by the bull is neither cestrone nor cestriol. 
Moreover, one of the two compounds possessing 
male hormone activity which have been isolated 
from human male urine (trans-dehydroandrosterone) 
is cestrogenic (Butenandt!*), and the cestrogenic 
property of human male urine may be partly or 
wholly accounted for by its presence. Whether or 
not trans-dehydroandrosterone can produce prostatic 
effects in the male primate similar to those of cestrone 
remains to be seen. Our first experiment has proved 
negative (MM. 80). 

The present investigation deals with a group of 
monkeys in three of which the effects of oestrone were 
undoubtedly inhibited by means of male hormone. 


INVESTIGATION 


Material.—F ive immature male rhesus monkeys, whose 
weight and approximate age are given in Table II., were 
used. Two received an oil solution of ‘synthetic ” 
androsterone as well’ as an oil solution of crystalline 
cstrone. The remaining three animals received an oil 
solution of androstanediol (di-hydroandrosterone) which 
is three or four times more potent on castrated rats than 
androsterone, in addition to the estrone. These two 
male hormone compounds were available through the 
courtesy of Prof. Ruzicka and Messrs. Ciba Lid. 

Injections were made once daily for the periods indicated 
in Table II., and autopsies were made on the day after 
the last injection. Preparations from normal malo 
rhesus monkeys and from male monkeys injected with 
similar amounts of oestrone alone and with similar amounts 
of male hormone alone were available as controls. 


EXPERIMENTAL RESULTS 


External changes.—Only MM. 55 presented any clear 
evidence that the external effects of cstrone had been 
suppressed by the male hormone. The other four animals 
all showed marked oedema of the scrotum and anus, as 
well as swelling and coloration of the surrounding skin. 
In MM. 55 the swelling was practically restricted to the 
anus, and in view of the internal condition (see below) 
there seems little doubt that the androstanediol with 
which this animal was injected had in some way prevented 
the oestrone from producing its usual external effect. 


Prostatic and urethral changes.—The prostate, uterus 
masculinus, and upper urethra in MM. 32 and MM. 33 
are not different histologically from corresponding tissues 
taken from animals injected with cestrone alone. In 
both cases the prostate is much larger than in normal 
animals of the same age, and there is considerable stratifica- 
tion of the utricular epithelium. The general prostatic 
stroma appears to be relatively increased in amount, 
and the prostatic glands in no way resemble the glands of 
monkeys injected with male hormone alone. The urethra 
also shows the typical stratification induced by cestrone. 

MM. 55, MM. 57, and MM. 74, on the other hand, show 
the characteristic prostatic changes associated with the 
administration of male hormone alone, and do not present 
any specific features which could be ascribed to the action 
of estrone. Thus the uterus masculinus in all three is 
normal in appearance, its epithelium varying between 
one and three cells deep (Fig. 3). Similarly, the urethral 
epithelium is normal and completely unlike the heavily 
stratified epithelium found in the urethra following the 
injection of cestrone alone. 

On the other hand, the prostatic glands are much more 
conspicuous than those of normal animals of the same age. 
The individual glands are larger and more distended, and 
characteristically lined by regularly set large columnar 
cells with basal nuclei. Mitotic figures are numerous, 
both in the glandular tissue and in the fibromuscular 


TABLE II 


Simultaneous Administration of Male Hormone and Cstrone 
to Immature Male Rhesus Monkeys 


: B23 52 
Ta > o> N ; 
ES) Body- y E| Ż57| Nature | += |28| Condition 
es lweight| S2| 58> of male 35 |g9|_ of uterus 
os =<"! 225 | hormone. | Z |AS|masculinus. 
© anj A 5 = 
4 < 
(g.) (mg.) 
32 | 2700 | 24 | 200 |) Andro- 2:5 |16 |, Extensive 
. ` gterone { stratin- 
33 | 2700 | 24 | 200 J . 2-5 !16 |Í cation. 
55 | 25 24| 100 1) Ang (| 50 |14 
57 | 2800 | 25 | 100 |; nero; | 50 |14 | Normal. 
74 | 2580 | 28 | 109 |/ stanediol U 5.0 | 14 


stroma. As with most male monkeys injected with 
cestrone and male hormone, either separately or together, 
the prostate is much bigger in these three animals than 
in normal controls of the same weight and age. The 
prostate of MM. 74 is almost twice as large as that of a 


‘ control animal slightly heavier than itself. 


DISCUSSION 


The absence in MM. 55, MM. 57, and MM. 74 of 
any of the characteristic prostatic epithelial changes 
induced by ostrone can leave little doubt that 
androstanediol in the proportions given (50 parts by 
weight to 1 part by weight of ostrone) is able to 
inhibit the prostatic effects of ostrone. Although 
it is well known, as we have already noted, that 
androstanediol is a more potent form of male hormone 
than androsterone, our experiments do not permit the 
conclusion that it is more potent in suppressing the 
effects of oestrone, since we employed relatively four 
times as much androstanediol as androsterone per 
unit of oestrone. It is also uncertain whether andro- 
stanediol has a specific effect in suppressing the 
changes induced by estrone. Probably other com- 
pounds of the androsterone-testosterone series would 
have the same effect if given in adequate amounts. 
There 1s also some indication that progesterone 
may have a similar antagonistic effect (see below), 
The actual mechanism by which ostrone is prevented 
from exercising its normal effects by androstanedio] 
is a matter for conjecture, and it is of interest that 
the hormone did not suppress all the effects of 


THE LANCET] 


estrone in our 
experiments. 
Animals MM. 
57 and MM. 74. 
showed promi- 
nent external 
changes, and 
this implies 
that the œs- 
trone threshold 
of the skin of 
the scrotum 
and of the 
surrounding 
parts of the 
rhesus mon- 
key is lower 
than that of 
the prostate. 
It may, how- 
ever, be noted 
that the semi- 
nal vesicles of 
the present 
experimental 
group of monkeys roughly corresponded, from the 
point of view of suppression of cestrone effects, to 
the prostates. 

Our data do not allow any clear inference as to any 
possible synergistic action of cestrone and male 
hormone. In those cases in which the effects of 
cestrone were dominant (MM. 32 and MM. 33) there 
were no changes which could be clearly ascribed 
to male hormone, and the reverse also holds (MM. 55, 
MM. 57, and MM. 74). The only effect common 
to both groups of animals in our present experiments 
is the increase in the size of the prostate itself and 
in the amount of fibromuscular stroma, and this is 
an effect also obtained when either cestrone or male 
hormone is given separately. In failing to demon- 
strate a synergistic relation between cestrone and 
male hormone, our findings are in harmony with 
those of Moore ® and Callow and Deanesly è on the 
seminal vesicles and prostate of rats, but in some 
disagreement with observations made by Freud,}® 
Korenchevsky and Dennison,!® and Overholser and 
Nelson.?!? 

Male hormone is not only able to inhibit the 
prostatic effects of cestrone when injected simul- 
taneously with the latter; as the following experi- 
ment shows, it can also cause the disappearance of 


(xX 47.) 


stanediol daily for 14 days. (x 47.) 


eS 


Sn, i S NS, Y Sa he ; 
SOY UY = CaS 


DRS. ZUCKERMAN AND PARKES: EFFECTS OF SEX HORMONES 


[FEB. 1, 1986 245 


FIG. 3.—(A) Uterus masculinus of rhesus monkey (MM. 77) receiving 100 y oestrone daily for 14 days. 
(B) Uterus masculinus of rhesus monkey (MM. 55) receiving 100 y cestrone plus 5 mg. andro- 


already established prostatic changes induced by 
estrone, even in spite of the latter’s continued 
administration. 


Two immature rhesus monkeys, MM. 81 and MM. 82, 
both 3 kg. in weight and about 2} years old, were injected 
with 1007 of cstrone daily for 67 days. From the 
29th day of the experiment, by which time the prostatic 
changes induced by cestrone would have been well estab- 
lished, until the end of the experiment 39 days later, 
MM. 81 was given, in addition to the oestrone, 5 mg. of 
androstanediol daily.: The first effect of this additional 
treatment was the diminution of the swelling and colora- 
tion in the circumgenital and circumanal skin, which was 
very pronounced in both animals after the first 28 days 
of estrone. As the experiment proceeded these external 
changes became less and less conspicuous in MM. 8], and 
at the close the scrotum and surrounding skin were almost 
normal in appearance. On the other hand, the external 
response became more and more extensive in MM. 82, 
which was on oestrone alone. 


The prostates of the two animals showed corresponding 
differences. That of the monkey which had received only 
cestrone showed very advanced changes induced by this 
treatment.® For example, the uterus masculinus had 
grown enormously, and its wall had become excessively 
thick. In contrast to this, the prostate of the animal 
which had been given male hormone as well was manifestly 
healthy, and provided an excellent picture of the effect 

male hormone has on 
the prostatic glands 
of the immature mon- 


mor Lama SLE key. Practically no 
Tes ors e See ee er x . . 
ER ONS TEAS sign remained of the 


SNe changes which must 

= have been produced 
during the first 28 days 
of the experiment when 
estrone alone was 
administered, nor was. 
there any evidence that 
the ostrone injected 
during the last 39 days 
had had any effect. 
Except at its blind tip 
and at its mouth, 
where the epithelium 
was slightly deeper 
than normal, the uterus 
masculinus was no 
different from that of 
an uninjected animal. 


FIG. 4.—(A) Uterus masculinus of rhesus monkey (MM. 49) receiving 50 y cestrone plus 300 y 
progesterone daily for 14 days. (x 47.) (B) Uterus masculinus of rhesus monkey (MM. 65) 
receiving 50 y cstrone plus 1 mg. progesterone daily for 14 days. (x 47.) 


The urethral epithe- 
lium, too, though still 


2948 THE LANCET] 


DRS. CRAMER & HORNING : EXPERIMENTAL PRODUCTION OF TUMOURS 


[FEB. 1, 1936 


tions so far. A sixth tumour was found in a castrated 
male mouse of this strain which had been painted 
with keto-hydroxy-cestrin for 19 weeks. An apparently 
paradoxical result is that none of the females of this 
strain developed a tumour after treatment with 
estrin lasting for more than 6 months, although 
tumours appear in 60-70 per cent. of untreated 
females of this strain when they are over six months 
old. Of the mixed strain, neither the males nor the 
females have so far developed a tumour. 

The results confirm the observations of Lacassagne,} 
who first demonstrated the appearance of mammary 
carcinoma in male mice by injections of cestrin. 
While these experiments were in progress, Burrows ? 
has also recorded the development of mammary 
cancer in 2 male castrated mice out of 20 mice of a 
mixed strain, after painting the skin with cestrin 
for a period of 25 weeks and 41 weeks respectively. 
No tumour had appeared in 110 male non-castrated 
mice of the same strain, which showed a very low 
incidence of spontaneous mammary tumours in the 
female. In our experiment, the cestrin-painted mice 


EXPLANATION 


Fic. 1.—Naked-eye view of pituitary gland of normal 
male mouse, showing size and relation of gland to the 
optic nerves. 

Fic. 2.—Naked-eye view of pituitary gland of male mouse 
of D.Z. strain after 6 months’ painting with cestrin 
(Ref. No. 202 in Table of text), showing intense conges- 
tion of the pars anterior and compression of optic nerve. 

Fia. 3.—Section through anterior lobe of gland illustrated 
in Fig. 2, showing large hemorrhagic areas. 

Fia. 4.—Section through anterior lobe of normal mouse 
pituitary at a magnification slightly higher than in Fig. 3, 
to illustrate degree of enlargement of the adenoma. 


demonstrates equally clearly the importance of the extrinsic 
carcinogenic factor, in this case cestrin. ` 

4. The sensitiveness of the male mamma in its carcino- 
genic response to cestrin, contrasted with the great insen- 
sitiveness to ostrin of the female mamma in animals of 
a pure strain in which the female mamma develops cancer 
spontaneously in a very high percentage, suggests that 
either the female organism is able to destroy effectively 
the excess of cestrin administered experimentally, or that 
the carcinogenic response of the mammary epithelium 
depends on an indirect and not on a direct interaction 
between cestrin and the cells. 

The second object of this communication is to 
record the occurrence of changes after the prolonged 
administration of cestrin which extend beyond the 
sex organs and which have not been recognised 
previously. It was found that an outstanding change 
in mice treated with cestrin over a prolonged period 
was the complete disappearance of fat, in fact a 
condition of cachexia. There were also extensive 
degenerative changes in the adrenal (Fig. 6), with 
active secretion of adrenaline by the medulla, and a 
hypertrophy in the islets of Langerhans. These 


OF PLATE 


Fic. 5.—Section through testis of a mouse after 6 months, 
application of cestrin, showing absence of spermatids 
and spermatozoa, and arrest of the process of cell 
division, so that practically all the cells are immobilised 
in mitosis. 

Fic. 6.—Adrenal gland of a male mouse after 5 months’ 
application of œstrin. Osmic vapour fixation. Round 
masses of degenerating cells are conspicuous around 
the medulla. In a more advanced stage they almost 
completely replace the medulla. There is active 
secretion of adrenaline in the medulla. 


showed the extensive changes in the uterus and 
vagina in the females and the atrophy of the testicles 
in the males which have been described previously. 
Scrotal hernia was observed to occur only in the 
males of the high cancer strain. The histological 
examination of the testis disclosed a condition which 
does not appear to have been described previously : 
cestrin inhibits the formation of spermatids and of 
spermatozoa and at the same time arrests division 
in the primary and secondary spermatocytes, the 
great majority of which present themselves in the 
process of cell division (Fig. 5). C€£strin therefore 
appears to arrest the process of cell division in the 
testis. 

These results will be described in greater detail 
in a separate publication. For the present we wish 
merely to emphasise the following conclusions as 
being of general significance :— 

1. Gstrin is absorbed by the unbroken skin without 
producing in it any carcinogenic effect. 

2. Unlike the other carcinogenic substances so far 
studied experimentally, the carcinogenic effect of cestrin 
is restricted to a tissue remote from the site of applica- 
tion of the carcinogenic agent, but possessing a specific 
physiological sensitiveness to it. The action of cestrin 
resembles that of the other carcinogenic agents in pro- 
ducing first a hyperplasia of the tissue in which the cancer 
subsequently develops—the precanccrous condition—and 
in the long period of time necessary to induce cancer. 

3. The striking difference between the carcinogenic 
response to cestrin of male mice belonging to two different 
strains demonstrates clearly the importance of the factor 
“ susceptibility,” which in this case is genetic in origin, 
in the atiology of cancer. The fact that cancer develops 
here in a site in which it never appears spontaneously 


? Lacassagne, A.: Compt. rend. Soc. de Biol., 1932, exev., 630. 
? Burrows, H.: Amer, Jour. of Cancer, 1935, xxiv., 613. 


effects will be described in greater detail in subse- 
quent publications. 

The spleen was sometimes reduced’ to a thin red 
ribbon, and the thymus was atrophied. The changes 
in the testis have been mentioned above. These 
changes suggested a general effect of cestrin, and 
further search led us to a systematic examination 
ofthe pituitary. During this experiment we have so far 
examined the pituitary gland of 12 mice treated with 
estrin over a prolonged period. Of these, only 
1 gland was normal to the naked eye, 8 were macro- 
scopically enlarged without an alteration in the general 
shape of the organ and without gross pathological 
lesions in the gland, and 3 were definite adenomatous 
tumours, nodular, round, deeply congested and 
haemorrhagic, and from five to ten times the size 
of the normal gland, so that the tumour extended 
over the optic nerves and in one case (No. 217) 
compressed them, producing degenerative changes 
in the nerve (Fig. 2). Even with the naked eye it 
could be seen that the changes affected mainly, if 
not entirely, the anterior part of the gland. The 
experimental details concerning the three animals 
in which these tumours were found are given in the 
following Table :— 


Treat- ; 
Ref.) otm: : Prepara- Condition of 
No. Strain. Sex. ment with Uon anii, 
vestrib, 
202 L.Z. Male. 25 weeks.| a-folli- Mamma 
culin, carcinoma. 
215) Mixed. Male, 44. ,, vs Mama well 
castrated. developed but 
no carcinoma. 
217| D.Z. 5) 19 Keto- Mamma 
hydroxy- carcinoma. 
cestrin, 


Tor LANCET, Feb. 1, 1936 


TUMOURS AND OF MAMMARY CANCER BY PAINTING THE SKIN WITH CESTRIN 


THE LANCET, Feb. 1, 1936 


MR. RYCROFT : CORNEAL GRAFTS MR. HOSFORD : KUMMELL’S DISEASE 


MONTEITH: BEDSIDE RADIOGRAPHY FOR A FRACTURE 


s 
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G "i 25 r awe Se 
MR. COSBIE ROSS: LIPIODOL IN SURGERY OF BILIARY PASSAGES 


THE LANCET] 


MR. J. P. HOSFORD : KUMMELL’S DISEASE 


[FEB. 1, 1936 249 


The pituitary tumours were found, therefore, in mice 
of both strains and in mice with and without the 
presence of a mammary cancer. 

‘The detailed histological examination of the 
pituitaries has not yet been completed, but a pre- 
liminary microscopic examination of the three 
adenomata has shown extensive hemorrhages and 
congestion, confined almost entirely to the pars 
anterior and disorganising it (Fig. 3). There was also 
an excessive number of the chromophobe type of 
cell, so that the condition may be described as a 
hemorrhagic chromophobe adenoma of the anterior 
part. This was associated with a general condition 
of the animals, which is generally taken to be hypo- 
pituitarism. In man also chromophobe adenomas 
are known to produce a state of hypopituitarism.*® 
The condition produced by us experimentally re- 
sembles in many respects the syndrome of a disease 
in man known as Simmonds’ disease. This disease, 
which is found more frequently in women than in 
men and is said often to follow parturition,‘ is asso- 
clated with an extensive destruction of the anterior 
part of the pituitary. 

According to the prevailing conception, the pitui- 
tary presides over the whole endocrine apparatus, 
and it is therefore probable that the changes observed 
by us in the other endocrine organs are secondary to 
the changes in the pituitary. But if the pituitary 
presides, its position is not that of a dictator but 
rather of a primus inter pares. For as our experi- 
ments show, it is itself susceptible to hormonal 
influences coming from another part of the endocrine 
apparatus. Since in these experiments the changes 
in the pituitary and the development of malignancy 
in the mammary gland are both produced by cstrin 
it is reasonable to suspect that the two may be 
ætiologically related. Further investigations are 
necessary to determine how the chain of events is 
linked together. 

As this paper is a preliminary communication we 
have restricted ourselves to statements on new and 
outstanding changes which we believe to have estab- 
lished on a sufficiently large material, and we have 
refrained from mentioning observations which will 
have to be repeated and checked by further experi- 
ments. Since cstrin preparations are now being 
used extensively in gynecological practice it may be 


3 Cushing, Harvey : The Pituitary Body, &c., Baltimore, 1932, 


p. 15. 
4 Graubner, W.: Zeits. f. klin. Medizin., 1925, c., 249. 


well to point out that the carcinogenic changes here 
described were produced by the administration of 
œstrin prolonged over a period representing a con- 
siderable fraction of the normal span of life of a 
mouse and corresponding in man to a period of from 
7 to 10 years, while the therapeutic administration 
of œstrin preparations in man is, in skilled hands, 
limited to short periods of a few weeks or months. 
The development of mammary cancer described in 
this paper should not, therefore, be used as an argu- 
ment against the therapeutic application of cestrin 
preparations. The discovery that the sphere of 
action of cstrin preparations extends beyond the 
generative organs and embraces the whole endo- 
crine apparatus is likely to enhance greatly their 
therapeutic importance. | 


KUMMELL’S DISEASE 
By Jonn P. Hosrorp, M.S. Lond., F.R.C.S. Eng. 


ASSISTANT DIRECTOR, SURGICAL PROFESSORIAL UNIT, 
ST. BARTHOLOMEW’S HOSPITAL 


(WITH ILLUSTRATION ON PLATE) 


In 1894 Kiimmell gave an account of six cases of 
a condition of the spine which he said had not 
previously been described. Actually Verneuil had 
described it in 1892. Since that date Kimmell 
has published several more papers on the subject 
and other writers have reported many cases. The 
condition has come to be known as Kimmell’s 
disease (Kiimmellsche Krankheit). 

Kimmell divided the course into three stages, 
but Cardis, Walker, and Olver have described five 
stages. Briefly they are :— 

1. History of an injury.—This may be quite slight, or 
severe enough to keep the patient in bed. The injury 
is not usually directly to the spine but affects it indirectly 
by sudden forced flexion, as, for example, a doubling-up 
injury when a mine shaft collapses on a man, or a fall 
on to the buttocks from a height causes a sudden jar to 
the spine. 

2. Post-traumatic period.—This also is very variable. 
There may be no symptoms. On the other hand, there 
may be local pain in the back and rarely even paraplegia 
is seen. 

3. Latent period.—During this stage there are no 
symptoms. Any pain or paraplegia has disappeared 


EXPLANATION OF PLATE 


MR. RYCROFT 


Fia. VII. (Case 1).—Before operation (left) the right 
cornea, is completely grey and opaque. The graft 
(right) is not bevelled and its appearance should be 
compared with that of the bevelled graft shown in 
Fig. VIII. 

Fic, VIII. (Case 3).—The condition of the only eye. 
The vacant staring appearance contrasts with that 
after operation shown on the right. 


MR, MONTEITH 


Fic. I.—Fracture: paratrochanteric and of shaft and 
lesser trochanter. 

Fie. I1.—Protraction, abduction, and flexion : 
ment of lesser trochanter. 

Fic. IHI .—Metal stay incorporated, maintaining abduction 
and flexion without protraction: reposition of lesser 
trochanter. 

Fic. IV.—State of femur seven months after iniury. 


detach- 


MR. HOSFORD 


Compression fracture of ninth dorsal vertebra in case. 
clinically and radiographically resembling Kiimmell’s 
disease. 

MR. COSBIE ROSS 


Fie. I. (Case 1).—The narrower tube is the one 
draining the common bile-duct. The radiogram shows 
the lipiodol, part of which is filling the duct, and the 
remaining part in the duodenum. 

Fia. II. (Case 2).—The common duct is outlined by a 
thin column of lipiodol, part of which has passed on into 
the duodenum. The two translucent smaller areas are due 
to air bubbles which entered with the lipiodol. 

Fic. III. (Case 3).—This reveals the second part of the 
duodenum clearly outlined by lipiodol, while the 
common duct is barely seen. 

Fic. IV. (Case 4).—In this case the whole biliary tract 
is outlined, there is dilatation of the common duct but 
free entrance to the duodenum. 

Fic. V. (CASE 5).—This again reveals free passage of the 

. lipiodol into the ee 
E 


250 


It is very variable in length and may be anything from a 
few days to months or even years. 

4. Onset of fresh symptoms.—These are chiefly pain in 
the back and a sharp kyphosis at the site of the affected 
vertebral body which in a skiagram is seen to have 
collapsed. 

5. The last stage depends on the institution of proper 
treatment or otherwise. If treatment is neglected there 
is complete collapse of the affected vertebra, whereas if 
satisfactory treatment is carried out any collapse of 
the bone is prevented and there is a resolution of 
the pathological change. 


THE LANCET] 


A number of theories have been advanced from time 
to time to account for this post-traumatic collapse 
of a vertebra. It will suffice to mention a few of 
these. | 

Kimmell originally believed it to be a “‘rarefying 
osteitis’? of inflammatory origin following a dis- 
turbance of nutrition of the bone. Later he took the 
view that there was always some damage to the bone. 
In two further papers in 1928 he refers to Schmérl’s 
work on prolapse of the nucleus pulposus of the 
invertebral disc into the body of the vertebra, as 
having some bearing on Kiimmell’s disease. 

Henle believed that the changes in the bone were 
due to vasomotor disturbances brought on by trauma. 
Mikulicz held that trauma caused intra- and extra- 
dural hematomata which, by infiltrating nerve- 
roots and ganglia, brought on trophic changes which 
caused a softening of the bone. Ludloff found rupture 
of vessels of the lumbar segments and considered that 
the subsequent changes in the bone were due to 
nutritional impairment. 

In the last few years post-traumatic atrophy has 
been widely discussed, and it has been suggested that 
Ktimmell’s disease is an example of it. Watson 
Jones and Roberts state, “If it be accepted that 
Ktimmell’s disease of the spine . . . can occur in the 
absence of any fracture, it is to the hyperemic 
decalcification of contusion of the vertebræ that the 
condition must be ascribed.” King goes further and 
seems to believe that Kiimmell’s disease can occur in 
the absence of any fracture and is of the nature of a 
post-traumatic hyperwmic rarefaction. 


THE RADIOGRAPHIC DIAGNOSIS 


It must be obvious that in order to establish a 
diagnosis of Kitimmell’s disease in the case of a patient 
with kyphosis there must be available one skiagram 
taken soon after the injury showing an apparently 
normal vertebra and another at a later date showing 
collapse of the vertebra. It is essential to have a 
lateral view of the vertebra, anterior and posterior 
views being of little value in detection of any 
abnormality in the body of a vertebra. Also the 
skiagram must be good enough not only to show the 
outline of the body but also to show, at least to some 
extent, the internal architecture of the bone. 

Without such a skiagram it is quite impossible to 
say whether at the time of the original injury to the 
spine there was a fissured fracture of a vertebral 
body without displacement or whether no actual 
damage was done to the bone. The latter must 
be the case in order to establish the diagnosis of 
Kiimmell’s disease. 

A search for a case of Kiimmell’s disease in which 
there is a satisfactory lateral skiagram immediately 
after the accident is not very fruitful. Kiimmell’s 
first papers were published before the days of X rays. 
In some of his later papers there are reproduced two 
skiagrams, one showing an antero-posterior view of 
æa man’s spine taken some time after the accident, and 
a later view showing some collapse of a vertebra. 


MR. J. P. HOSFORD : KUMMELL’S DISEASE 


[FEB. 1, 1936 


The first antero-posterior view, however, although 
it is a good skiagram, is quite useless as negativing 
any injury to the body. Of the comparatively few 
cases he quotes, this is the only one of which any 
skiagrams are produced. 


In Schultz’s extensive review of the condition with 
reports of 21 cases no skiagrams are reproduced. 

Baker in the eight cases he quoted did not see any 
skiagrams taken immediately after the accident nor was he 
able to get reports on them. 

Blaine described ten cases but none of them were radio- 
graphed in the early stages. 

Cardis, Walker, and Olver, in 1928, quoted 14 cases in 
their excellent paper on Kiimmell’s disease, but in only 
one was any reference made to an early skiagram before 
collapse of a vertebra, and this was not reproduced. 

In 1931 Rigler reported one case, that of a woman aged 
55, who had a severe injury and was in bed for seven weeks 
with pain and weakness in the back. About a fortnight 
after getting up a skiagram showed no apparent 
abnormalities of the seventh or ninth dorsal vertebre, 
but nine months later a second skiagram showed that they 
were compressed. This may have been a case of Kimmell’s 
disease without any initial fracture, but during seven weeks 
in bed the vertebre had time to begin to consolidate if 
there was a fracture, and two weeks out of bed is little time 
for compression to begin to show itself distinctly. 

King reported six cases. One of these is an important 
case because there was the opportunity for an autopsy 
and a very detailed examination was carried out. It 
was the case of a woman of 57 who had a “ severe fall,” 
and later developed a kyphosis and paraplegia. It is 
most unfortunate that no skiagrams were obtained at 
the time of the fall. No early skiagrams are reproduced 
in any of his six cases. 


From a careful examination of the literature I 
have been unable to find a case of Kimmell’s disease 
in which a good lateral skiagram taken after the initial 
injury shows a normal vertebra. The following case 
may be quoted :— 


In 1929 a labourer, aged 55, fell twenty feet off a ladder 
and was admitted to St. Bartholomew’s Hospital. He 
had sustained a laceration of his scalp and a fractured 
clavicle, and complained of pain in the lower dorsal region. 
No deformity was present. Skiagrams were taken twice 
but showed no abnormality. He walked out of hospital 
three weeks later. After a further week a slight angular 
deformity was visible in the lower dorsal region and a 
skiagram showed a compression fracture of the ninth 
dorsal vertebra (Figure on Plate). 


This is not quoted as a case of Kimmell’s disease 
but as one of a fracture of the body of the vertebra 
which was missed at the first examination; it is, 
however, an exact parallel to many cases reported 
as Kiimmell’s disease in that (1) skiagrams taken 
immediately after the accident showed no deformity 
(but they were not really satisfactory views); (2) 
there was a latent period; and (3) compression and 
deformity were seen at a later date. One cannot 
but believe, however, that this is anything other than 
a case of compression fracture of a vertebra which 
was not recognised by the clinician or the radiologist ; 
and there seems no reason to invoke any other 
pathology than that of fracture, nor to give it any 
other name. 


DOES THE DISEASE EXIST ? 


In 1928 Cardis,. Walker, and Olver described 
Kiimmell’s disease as still struggling for recognition. 
There surely must be some doubt about the real 
existence of any condition which, over thirty years 
after its first description, is not fully recognised. 
There seems no real reason to believe that Kimmell’s 
disease is anything other than a. fracture of a 


THE LANCET] 


vertebral body. At the time of the original injury 
there are presumably one or usually more fissures 
through the bone. There may be little or no 
compression at the time: even if there is some 
compression it is likely to disappear when the patient 
lies flat in bed and so might not easily be recognised 
in a skiagram even if the latter were obtained. If 
at this stage the true state of affairs is recognised 
and a fracture of the body of a vertebra is diagnosed, 
appropriate treatment is carried out, the spine being 
immobilised in the fully extended position; no 
compression of bone is allowed to take place and the 
bone consolidates in its normal shape and position 
and the case is looked upon as a satisfactory result 
of a fracture of a vertebral body. On the other hand 
if the possibility of a fracture of a vertebra is over- 
looked for any reason and a kyphosis appears at a 
later date, no proper treatment having been carried 
out, it has been customary to refer to it as Kiimmell’s 
` disease, and to discuss a variety of pathological 
changes which may have brought it about. 

If we look in other parts of the body for the same 
changes following a fracture which has been over- 
looked and not properly immobilised, we see similar 
absorption and loss of bone substance. Typical 
situations where these changes are seen when efficient 
fixation has not been employed are in fractures of 
the neck of the femur, and in the common fracture 
of the carpal scaphoid. In this connexion it is of 
particular interest to find that King, a strong advocate 
of the theory that Kiimmell’s disease is due to a 
post-traumatic hyperemic rarefaction, says: ‘The 
usual finding then even in the cases in which there is 
fracture, is an active hyperemia.” 


It seems inconsistent and confusing therefore to 
make an exception of the vertebral bodies and give 
a special name to an overlooked fracture in this 
situation when no such deception is carried out in the 
case of other bones. Kiimmell must be given every 
credit for his observations and for drawing attention 
to the delayed collapse of a vertebra after an injury 
rather than for his explanation of this delayed collapse. 


Thus it would seem to be advisable to teach 
not that there is a condition known as Ktmmell’s 
disease of somewhat obscure pathology but that: 
(1) Compression fractures of the bodies of the vertebrae 
are easily overlooked owing to their relatively mild 
symptoms and absence of signs. (2) In all cases of 
pain in the spine following an injury skiagrams of the 
vertebre should be taken and if the lateral view 
is not clear it should be repeated. (3) If the skiagrams 
show no fracture and the pain persists when the 
patient has got up, another lateral skiagram should 
be taken and the closest clinical observation kept for 
the onset of any kyphosis. (4) Treatment in an 
ambulatory plaster jacket should be instituted at 
the earliest sign of any injury to a vertebral body. 


REFERENCES 

Baker, R. H.: Surg., Gyn., and Obst., 1920, xxxi., 359. 
Blaine, E. S.: Radiology, 1930, xv., 551. 
Cardis, Walker, and Olver: Brit. Jour. 1928, xv., 616. 
Henle, A.: Arch. f. kliu. Chir. . 1896, lii 
gone W., and Roberts, R. E.: Brit. “Jour. Surg., 1933, xxi., 
King, E. S. J.: 

London, 1935. 
Kümımell, H. Aerztl. Sachverst. Zeitung, 1895, i., 6. 

5 a Deut. med. Woch., 1895, xxi., 1380. 

ee »,: Arch. f. rae Chir., 1921, exviii., 878. 

es »»: Monats. f. Unfall., 1928, A 65. 

s3 ” : Arch. f. Osten: 1928, xxyi., 4 
Ludloff, K.: 15 Kong. der Deut. Orthopiid. cais Manse 

1920, p. 183. 
Rigler, L. G.: Amer. Jour. Roent., 1931, xxv., 749. 
Schultz J.: Bruns’ Beitr. z. klin. Chir., 1900, xxvii., 363 


Verneuil: Bull. do l'Acad. de Médecine de Paris, 
xxvili., 496. 


Surg., 


Localized Rarefying Conditions of Bone, 


"1892, 


MR. J. C. ROSS: LIPIODOL IN SURGERY OF BILIARY PASSAGES 


[FEB. 1, 1936 251 


THE USE OF 
LIPIODOL IN SURGERY OF THE 
BILIARY PASSAGES 


By J. Cossie Ross, Ch.M. Liverp., F.R.C.S. Eng. 


HONORARY ASSISTANT SURGEON, LIVERPOOL ROYAL INFIRMARY 5; 
SURGEON, SMITHDOWN-ROAD MUNICIPAL HOSPITAL ; 
DEMONSTRATOR OF OPERATIVE SURGERY, 
UNIVERSITY OF LIVERPOOL 


(WITH ILLUSTRATIONS ON PLATE) 


WHILE the use of lipiodol in the post-operative 
management of cases involving the biliary ducts is 
by no means new, general application of the method 
is unusual. Gabriel! in 1930 described a case 
where a biliary fistula was demonstrated by X rays 
after the injection of. lipiodol, and Ginsburg and 
Benjamin? reported a series of cases in the same 
year. 

During the course of operations on the gall- bladder 
it is sometimes a surgical necessity to explore the 
common bile-duct when the latter is dilated and 
when the presence of stones is suspected. Often it 
is possible to suture the common bile-duct with 
safety after incision and exploration; in these 
cases a drainage-tube is desirable, secured to the 
suture line by a single stitch. Usually the suture 
line remains watertight, and no bile is discharged 
through the precautionary tube. There are occa- 
sions, however, when the local pathology of the 
ducts demands drainage by a catheter, especially 
where numerous stones have been removed from the 
ducts and where infection of the latter is present. 

In my own series, consisting of 110 operations for 
cholecystitis, the common bile-duct was explored 
27 times with 4 post-operative deaths. The pro- 
portion of cases with stones in the gall-bladder or 
ducts represented 80 per cent., whereas in a previous 
investigation of 153 cases, 87 per cent. had the com- 
bined pathology of inflammation and stones. Out 
of the 27 explorations of the common bile-duct, 
stones were found in the ducts and removed in 16 
instances (see Table). 


Operations on the biliary tract (over 80 per cont: sad 


stones in addition to cholecystitis) 110 
Cholecystectomy .. si se oe ee zi 82 
Cholecystostomy .. a èa ia sio a 17 
Exploration of biliary ducts— Cases 

(a) Through stump of cystic ducts ; be 3 

(b) Exploration and immediate suture 6 | 

(c) Exploration and subsequent drainage by 27 

catbeter ia 

(d) Generalised inflammatory sclerosis of the 

ucts ; 
Stones present in biliary ducts .. ‘ 23 si 16 
Number of lipiodol injections carried out e ie 14 
INDICATIONS 


In 3 of the 27 cases in which exploration of the 
ducts was necessary, it was carried out through the 
stump of the cystic duct. In another case a generalised 
inflammatory sclerosis of the ducts was found a 
year after cholecystectomy had been performed ; 
in this case no drainage was instituted. In 6 cases 
the bile-duct was sutured after exploration, but in 
17 a catheter was stitched into the duct for various 
reasons, usually where numerous stones had been 
removed or where infection was present. 

In a few of the latter cases it was not certain at 
the time of the operation whether the ampulla of 
Vater was patent, owing to the necessity of conclud- 
ing the operation rapidly in view of the poor condition 


a+: = a ee A: 


252 


THE LANCET] 


or advanced age of the patient. In an elderly 
patient with jaundice due to a stone in the common 
bile-duct the operation may be necessarily a hurried 
and inadequate one, and the time required for com- 
plete exploration of the ampulla not available with- 
out undue risk. To quote the late Mr. Frank Jeans, 
‘better a live problem than a dead certainty.” 
Moreover, even with available time to pass a bougie, 
or to pass a rubber catheter and subsequently to 
pump saline through it into the duodenum, it is 
possible to miss a small stone, especially where there 
is much thickening in the vicinity of the ampulla, 
and where chronic pancreatitis is a prominent com- 
plication. Kehr admitted missing stones in the biliary 
ducts in 2°5 per cent. of 1105 operations, and Deaver 
reported that second operations constituted 4 per 
cent. of 1189 explorations of the biliary passages.‘ 
It is in the post-operative management of such cases 
as these that this method appears to be of value. 
Lipiodol is especially useful in what might well be 
called ‘‘second-hand’”’ operations on the biliary 
tract. These cases are notoriously dangerous and 
ditficult, and four examples are included among the 
present series. In connexion with these second-hand 
cases, the incision of choice appears to me to be a 
Kocher when a paramedian has been used on the 
previous occasion. A Kocher incision ensures that 
the operative field lies between the adhesions caused 
by the previous operation and the liver, and fre- 
quently the general peritoneal cavity is completely 
excluded, a useful feature when biliary drainage is 
‘contemplated. 

Many tests have been used at various times for 
determining the patency of the common bile-duct. 
Among the better known tests are the following :— 

1. The examination of the stools for bile-pigment. 

2. The introduction of an Einhorn tube into the duo- 
denum and the injection through the tube of magnesium 
sulphate solution. No bile is obtained through the tube 
when the common bile-duct is completely blocked. 

3. The disappearance of jaundice. 

4. The van den Bergh test. 

5. If a T-tube has been introduced into the common 
bile-duct for drainage purposes, jaundice will occur when 
the outer extremity of the tube is clamped if there is not 
free entry of bile into the duodenum. 


The most commonly used test is that mentioned 
first, but the following obvious fallacy suggests itself. 
If the fæces are normal in colour, bile is entering the 
duodenum without hitch; but where it is necessary 
to drain the common bile-duct for several days, all 
the bile may be discharged through the drainage- 
tube in spite of the fact that the ampulla of Vater is 
patent. Thus, this time-honoured test is not of great 
value where drainage of the common bile-duct is 
taking place. In fact, none of these tests are reliable 
criteria as there may be a partial suppression of bile 
giving light-coloured stools with a patent duct. 

Finally, injection of lipiodol will not only indicate 
whether the block is partial or complete, but will 
demonstrate the site, and will exclude that due to 
spasm of the muscle of Oddi. If the lipiodol is held 
up in the common hepatic duct or supraduodenal 
part of the common duct, it is suggested that the 
usual cause is fibrous stricture, while ampullary 
blockage is commonly due to a stone if muscular 
spasm is excluded. Although the very definite advan- 
tages of the T-tube must be freely admitted, I 
have never succeeded in overcoming a prejudice 
due to the split in the common duct necessarily 
produced when finally withdrawing the tube, and 
due to the bulky T junction. This may or may not 
predispose to stricture formation, but I feel safer 


MR. J. C. ROSS: LIPIODOL IN SURGERY OF BILIARY PASSAGES 


[FEB. 1, 1936 


with a soft rubber catheter which can be introduced 
through a small incision in the duct, can be removed 
without causing any further damage, and has in my 
experience provided excellent drainage. Further, 
although in previous papers the injection of lipiodol 
has been carried out through a T-tube, equally good 
results can be obtained through a soft catheter. 

Although it is the usual custom in this country, 
and my own practice, to remove this catheter ten 
days to two weeks after the operation, Overholt 5 
is strongly of opinion that it should not be removed 
before the patency of the biliary tract has been 
demonstrated by lipiodol. His statement that a tube 
in situ is easier to deal with than a biliary fistula 
appears at first sight to require some consideration ; 
but a recent case has convinced me that a tube is 
certainly safer than a fistula. In this case drainage 
of the common duct had been carried out by another 
surgeon 14 days previously. On the 10th day the 
tube was removed, and on the 11th the fistula super- 
ficially closed, and pain and discomfort were experi- 
enced in the right upper quadrant of the abdomen. 
On the 14th day general “ bile’’ peritonitis suddenly 
supervened, and at operation large quantities of bile 
were evacuated from the peritoneal cavity. What 
had happened was that bile had collected in the 
region of Morison’s pouch, owing to ampullary block 
and to premature closing of the biliary fistula. 

A further argument in support of Overholt’s view 
is furnished by Pribram’s method (described below) 
for the solution of ampullary stones by ether. 


TECHNIQUE OF INJECTION 


About ten days after the operation, 10—20 c.cm. 
of warmed lipiodol are slowly injected into the tube 
draining the common bile-duct. Before doing so, 
any bile in the tube is aspirated, and care is taken to 
use no force in injecting the opaque liquid. Imme- 
diate radiography will show the lipiodol in the duo- 
denum if the duct is patent; it is remarkable with 
what rapidity the lipiodol passes into the duodenum, 
and it is almost impossible to outline the ducts in 
such a case. For this reason lipiodol cannot be relied 
upon to demonstrate a residual stone which is not 
causing obstruction. The non-opaque stone may be 
outlined by adsorbed hpiodol, but the latter passes 
on so quickly into the duodenum that no indication 
may be given. 

The radiogram, however, may reveal the lipiodol 
filing the common bile and common hepatic ducts 
and stopping short at the ampulla. This hold-up 
may be due to spasm of the ampullary sphincter or 
to an impacted stone. In the former case, a second 
radiogram taken three-quarters of an hour after the 
hypodermic administration of atropine may reveal 
that the lipiodol has passed into the duodenum. If 
the opaque fluid has entered the duodenum either 
before or after the administration of atropine, the 
tube draining the common bile-duct may be with- 
drawn with safety on the tenth day after the opera- 
tion with the confident expectation that recovery will 
take place without either the supervention of jaundice 
or of persistent biliary fistula. If, on the other hand, 
the hpiodol is persistently held up at the ampulla, a 
stone in that situation is very probable. 


VARIOUS CONSIDERATIONS 
The sphincter of Oddi.—There is considerable 
divergence of opinion as to the effectiveness of this 
sphincter. Pribram ® states with conviction that 
sphincteric spasm occurs frequently and may pro- 
duce characteristic symptoms. This view is supported 
by Kretchner,? who reproduces an interesting radio- 


THE LANCET] 


gram in which the lipiodol is shown filling the common 
bile and hepatic ducts and also outlining the lower 
end of the duct of Wirsung. This observation seems 
to throw some light on the pathology of acute hemor- 
rhagic pancreatitis. On the other hand, as pre- 
viously mentioned, all observers have commented 
on the rapidity with which the opaque fluid enters 
the duodenum in the great majority of cases. 

Biliary dyssynergia or spastic dyskinesia.—While 
this condition of abnormal tonus of the ampullary 
sphincter may be deduced by the use of the duodenal 
tube, it can only be positively demonstrated by 
injection of lipiodol. There is steadily increasing 
clinical and physiological evidence not only of 
the effectiveness of the sphincter but also of the 
occasional presence of biliary dyssynergia. 

Reference may be made especially to the recent 
work of Russell Best and Frederick Hicken.* These 
authors compare lesions of the ampullary sphincter 
with cardiospasm, pylorospasm, &c., and bring for- 
ward much radiological evidence that biliary dys- 
synergia may produce a definite mechanical block 
to the passage of bile into the duodenum. It is further 
claimed that the subsequent dilatation of the biliary 
ducts may produce attacks of biliary colic, and that 
the condition may be independent of cholangitis, the 
presence of stones, strictures, duodenitis, or pan- 
creatitis. This view offers a reasonable explanation 
of the occurrence of biliary colic and of the so-called 
“hepatic neuralgia,” and accounts for the per- 
sistence of gall-bladder symptoms in some few 
individuals after removal of the gall-bladder. These 
post-operative symptoms have usually been attributed 
in the past to congestion Or infection of the ducts, or 
to the elusive “‘ missed stone.” When a definite 
diagnosis of biliary dyssynergia has been made by 
injection of lipiodol, the post-operative régime should 
include substances which relax the choledochal 
sphincter such as atropine, magnesium sulphate, or 
fats. It is interesting to contemplate the possibility 
of biliary dyssynergia, occurring as a primary con- 
dition, causing stagnation of bile and predisposing to 
the precipitation of stones, 

Additional applications.—The method, may also 
be applied where cholecystostomy has been per- 
formed, the opaque fluid filling the gall-bladder and 
the ducts provided the cystic duct is patent. Simi- 
larly, where the gall-bladder has been drained in a 
case of acute pancreatitis it is helpful as well as 
instructive to demonstrate or exclude sphincteric 
spasm. 

Possible dangers of the method.—Tenney and Patter- 
son ® have recorded a case where pyrexia, jaundice, 
and abdominal pain were produced by the injection 
of bismuth paste under pressure into a biliary fistula. 
The explanation here seems to be the simple one of 
a thick paste blocking both fistulous tract and com- 
mon bile-duct, especially as the symptoms subsided 
subsequently. It is obvious that bismuth paste is 
highly unsuitable for this diagnostic measure. 

Mallet-Guy, Beaupére, and Armanet,!® who record 
the onset of similar symptoms some hours after 
injection of lipiodol, are inclined to blame the viscidity 
of lipiodol blocking the common bile-duct and pan- 
creatic ‘ducts, and the production of “pancreatic 
œædeməa.” In the latter case, however, there were 
several anomalous features. For instance, the jaun- 
dice was of painless onset following a course of neo- 
salvarsan, and no stone or obstruction of the ducts 
was found at operation. Moreover, two further 
injections of lipiodol were given after the original 
20 c.cm. in an attempt to outline the biliary tract. 


MR. J. C. ROSS: LIPIODOL IN SURGERY OF BILIARY PASSAGES 


[FEE. 1; 1936 253 


In my opinion it is a great mistake to aim at outlining 
the ducts. If there is no obstruction the opaque 
solution passes into the duodenum with great rapidity, 
and little more than a minute residue is to be seen 
in the ducts. For this reason it is difficult to demon- 
strate with certainty a stone not producing a com- 
plete block. Occasionally, such a non-opaque stone 
is shown in the radiogram as a clear area outlined by 
lipiodol. Again, it is difficult to assess the value of 
outlining the biliary tract in cases of obstruction. 
It is sufficient for practical purposes to test the 
patency or otherwise of the biliary system, and this 
appears to be a safe procedure. I have carried out 
the diagnostic injection of lipiodol in 14 cases with- 
out the production of symptoms or other effects in 
any instance. 

Ether solution of stones impacted at the ampulla.— 
When a stone has been demonstrated at the ampulla 
by lipiodol, Pribram advises the daily injection of a 
few cubic centimetres of ether into the tube draining 
the common duct for several days. He has shown 
that ether disintegrates certain gall-stones by dis- 
solving the cholesterol nuclei, thus reducing the 
stones to a pultaceous mass. The latter passes readily 
through the ampulla into the duodenum. The appli- 
cation of this method to the treatment of biliary 
fistule is obvious. A fine rubber tube is introduced 
through the fistula down to the obstruction, and the 
subsequent daily injections of ether may obviate a 
difficult and dangerous operation in cases where the 
obstructing agent is a stone. 

I have not had an opportunity of using ether as 
a solvent of gall-stones, for in the cases recorded 
below the lipiodol passed into the duodenum either 
before or after the administration of atropine; 
but from Pribram’s recorded cases this method 
seems to deserve extended trial. 


CASE REPORTS 


CasE 1.—This was a woman, aged 67, who had had an 
operation for cholecystectomy. performed some years 
previously. Operation was necessitated by repeated 
attacks of severe biliary colic associated with jaundice. 
The jaundice varied in intensity but never completely 
cleared. Her general condition was poor, and there was 
some jaundice at the time of operation. In view of the 
two latter facts, and of her age, the operation was neces- 
sarily a hurried one performed under gas-oxygen anæs- 
thesia. Many adhesions had to be separated before the 
common bile-duct could be exposed and incised. Several 
faceted stones were removed from the common bile- 
duct, but her condition did not permit of more than a 
hasty palpation of the ampulla of Vater. A catheter was 
inserted into the common bile-duct and drained bile for 
nine days after the operation. Lipiodol (10 c.cm.) passed 
easily through the common bile-duct into the duodenum 
(Fig. I. on Plate), so the tube was removed on the ninth 
day. She was discharged from hospital three weeks after 
the operation and has not had either jaundice or biliary 
colic from that date. 


CasE 2.—This was a male, aged 20, who was admitted 
to hospital with severe biliary colic which settled down, 
but was succeeded by jaundice. At the operation a 
strawberry gall-bladder with thick pink walls was removed 
and the common bile-duct exposed. When the common 
bile-duct was opened a collection of “ bile mud” was 
evacuated. The subsequent bile was normal in appear- 
ance and consistency. The ducts appeared to be sub- 
acutely inflamed, and a row of elastic glands were found 
in the right edge of the gastrohepatic omentum imme- 
diately behind “the common bile-duct. These glands 
appeared to be secondary to the straw berry gall-bladder, 
and subsequent microscopic examination confirmed that 
their origin was inflammatory. Several of the larger 
glands were excised in order to avoid extrinsic pressure 
on the duct. It was found possible to pass a 7/10 bougie 
through the common bile-duct into the duodenum with 


i 


954 THE LANCET] . CLINICAL AND LABORATORY NOTES [FEB. 1, 1936 


ease. A catheter was inserted into the common bile-duct 
and the operation concluded. A few days later radio- 
graphy revealed the lpiodolin the duodenum (Fig. II). 
This patient was discharged from hospital three weeks 
after operation, his Jaundice having completely cleared 
and his wound healed. 


Case 3.—This was a female, aged 48, who had had two 
previous operations elsewhere, one of which consisted of 
cholecystectomy, incision of the common bile-duct, and 
removal of stones from the hepatic and common bile- 
ducts. A subsequent operation was performed for inci- 
sional hernia. She was admitted to hospital suffering 
from severe biliary colic, and a history of two recent 
mild attacks of jaundice. The abdomen was opened 
through a Kocher’s incision, and the common hepatic 
duct exposed after a prolonged and arduous separation 
of adhesions. The common bile-duct and the duodenum 
were welded together by dense inflammatory adhesions 
that defied separation. The common hepatic duct was 
opened and several stones removed from it and the com- 
mon bile-duct. A probe passed into the duodenum, but 
the probe could not be identified in the dense inflam- 
matory mass just above the first part of the duodenum. 
A drainage-tube was inserted into the common hepatic 
duct and the operation concluded. Although it was 
possible to pass the probe into the duodenum, it was not 
possible to exclude completely stone or stones at the lower 
end of the common bile-duct, so that it was very satis- 
factory, a few days later, to obtain a clear radiographic 
picture of the common bile-duct and to see that the lipiodol 
had passed without hitch into the duodenum (Fig. III). 
The patient subsequently had an uninterrupted con- 
valescence. 


Case 4.—This was a female, aged 62, who had had two 
previous operations—one for cholecystectomy and another 
for a perforated gastric ulcer. Her general condition was 
poor and there was definite evidence of myocardial 
degeneration. Operation was necessitated by repeated 
attacks of severe pain. The abdomen was opened through 
a Kocher incision and the common bile-duct exposed. 
The adhesions were especially dense as the previous per- 
forated gastric ulcer added its contribution of adhesions 
to those due to the cholecystectomy. The common bile- 
duct was opened, stones removed, and a catheter inserted 
into the duct which was approximately one inch in 
diameter. A 9/12 bougie passed easily into the duodenum ; 
the operation was concluded. After the operation her 
condition was never satisfactory, but the patency of the 
common bile-duct and ampulla of Vater were demon- 
strated by the rapid passage of lipiodol into the duodenum 
(Fig. IV.). Unfortunately, however, her condition became 
steadily worse, and death occurred one month after the 
operation. A post-mortem was not obtainable, but all 
clinical evidence went to suggest the cause of death to be 
myocardial failure rather than any biliary upset. There 
was no suppression of bile at any stage of her illness. 


Case 5.—This woman, aged 48, came into hospital with 
a history of three attacks of severo abdominal pain and 
vomiting, said to have been associated with the doubtful 
appearance of jaundice on one occasion. One of these 
attacks had occurred a few days before her admission to 
hospital. When examined there was protective spasm 
and tenderness over the whole of the upper abdomen, 
especially over the gall-bladder. Radiography of the latter 
revealed two opaque gall-stones in the gall-bladder, which: 
did not fill or excrete dye. The gall-bladder was exposed 
by a Kocher’s incision, and chronic cholecystitis and 
cholelithiasis were found, in conjunction with subacute 
pancreatitis. The pancreas was swollon, oedematous, and 
inflamed, and there were small areas of recent fat necrosis. 
Obviously, the attack from which she had suffered several 
days before admission to hospital had been that of an 
acute or subacute pancreatitis. The gall-bladder was 
opened, the stones removed, and a cholecystostomy per- 
formed. It was decided not to drain the pancreas as 
there did not appear to be any indication to do so, especi- 
ally as the condition was obviously subsiding. 

This patient’s convalescence was smooth, and a radio- 
gram of a subsequent injection of lipiodol through the 
tube draining the gall-bladder revealed the opaque fluid 
in the duodenum (Fig. V.). 


SUMMARY AND CONCLUSIONS 


l. Operations on the biliary passages often present 
difficulties, especially where the post-operative manage- 
ment is complicated by doubts as to the patency of 
the ducts. 2. The usual clinical tests for deter- 
mining the patency of the ducts, especially the 
presence of bile-pigment in the fæces, are often 
fallacious. 3. The injection of lipiodol into the 
common bile-duct presents no difficulty, is not 
dangerous in itself, and yields valuable information. 
4, The lipiodol method determines the prognosis with 
accuracy. Further, it indicates the advisability or 
otherwise of removal of the tube draining the common 
bile-duct, and the possible application of additional 
measures. 5. The condition of biliary dyssynergia 
affords a reasonable explanation for post-operative 
symptoms in patients where cholecystectomy has 
been carried out. The diagnosis of this condition can 
only be made positively by means of the lipiodol 
injection, and when such a diagnosis has been made, 
post-operative treatment should be directed towards 
promoting relaxation of the ampullary sphincter. 
6. Some typical examples are described in which the 
lipiodol method has proved of value. 


I am indebted to Dr. P. H. Whitaker whose welcome 
help has been of the greatest assistance to me from the 
radiological aspect. 

REFERENCES 
1. Gabriel, W. B.: THE LANCET, 1939, i., 1014. 
2. Gine ue. Bas and Benjamin, E. W.: Ann. of Surg., 1930, 
xci., 233. 
3. Ross, J. C.: Brit. Med. Jour., 1932. i., 1026. 
4. Short, A. R.: Index to Prognosis, Bristol, 1932. 
5. Overholt, R. H.: Surg., Gyn., and Obst., 1931, lii., 92. 
6. Pribram, B. O.: Ibid., 1935, 1x., 55. 
7. Kretchmar, A. H.: Amer. Jour. Surg., 1933, xxi., 383. 
8. Best, B. R., and Hicken, N. F.: Surg., Gyn., and Obst., 
December, 1935, p., 721. 
9. Tenney and Patterson: Jour. Amer. Med. Assoc., 1922, 
l lxxviii., 171. 
10. PACT Beaupère, and Armanct: Lyon méd., 1927, 
exl., 215. 


BEDSIDE RADIOGRAPHY FOR A FRACTURE 
By W. B. R. MoxNtTEII, M.A. Camb., F.R.C.S. Edin. 


‘ (WITII ILLUSTRATIONS ON PLATE) 


AN agricultural labourer of 75 presented himself 
at my house recently suffering from a cold in the 
head incapacitating him from work. This was two 
years after he had fractured his femur and a few days 
after I had been reading about the need for fracture 
clinics in this country. It seems to me in retrospect 
that this man’s sound functional recovery and ability 
to do full work illustrates first the value of detail in 
treatment, and secondly the value of radiography 
in bed without disturbance. These should be avail- 
able whether the patient is treated at home, in 
hospital, or in a fracture clinic. 


At the age of 73 this man fell heavily from a haycart. 
Shortly after admission to the Butterfield Hospital, 
Bourne, X ray examination (Fig. I. on Plate) showed a 
comminuted fracture of the left femur, involving shaft, 
neck, and both trochanters. By means of strapping along 
the length of thigh and leg traction was applied, with the 
log rested in a Thomas splint and abducted and flexed at 
the hip-joint. A subsequent radiogram, taken without 
moving the patient, showed satisfactory abduction, 
protraction, and alignment, but with small trochanter 
displacement, due undoubtedly to pull by the psoas 
(Fig. II.). It then seemed best that the abduction and 
flexion should be maintained without further protraction, 


THE LANCET] 


A rigid iron frame was made to extend from lower ribs 
to calf, having riveted to it at right angles a half hoop 
to embrace thorax and cross strips at mid-thigh and calf ; 
and having the longitudinal strip bent, at the level of the 
hip-joint, outwards through 30° to maintain abduction and 
upward through 40° to maintain flexion. This was 
incorporated in a plaster-of-Paris case extending from the 
lower ribs and enclosing the foot on the left side, and to 
the knee on the right. X ray examination then showed 
satisfactory disposition of the fragments (Fig. III.). 
After two months the left knee was liberated, the metal 
support having been sawn through at that level, and the 
plaster case removed from knee downwards. After three 
months weight bearing was permitted while still wearing 
the plaster case. Four months after the accident the 
patient was discharged from hospital wearing a walking 
calliper. This he discarded (contrary to instructions) 
after a few weeks, for he complained that it interfered 
with digging! Fig. IV. shows the state of affairs seven 
months after the injury. 

It is now two years since the accident, and for more than 
twelve months he has been doing full work including potato 
digging. There is a good range of movement at the hip, 
though some limitation of abduction, and no measurable 
shortening. The man himself admits no disability. 


‘The successful result emphasises once more the 
fact that stereotyped methods of treatment are 
inadvisable. On the positive side it points to the 
extreme value of intercurrent radiography, without 
disturbance of limb or patient, as a means of making 
the treatment suit the patient. 

Bourne, Lincs. 


A METHOD OF TYING IN A CATHETER 
By G. B. Davis, M.R.C.S. Eng. 


HOUSE SURGEON TO THE UROLOGICAL DEPARTMENT AT KING'S 
COLLEGE HOSPITAL, LONDON 


Many methods have been devised for keeping a 
catheter securely in place, ranging from simple but 
primitive devices to elaborate ‘‘ machines.” Pro- 
bably the method most commonly used now, in 
hospital and private practice, is the system of tapes 
tied to the catheter, the four ends being held to-the 
penis by an encircling band of strapping. Even this 
has disadvantages. (1) It takes time to put on neatly. 
One is apt to get “tied up” with the seemingly 
innumerable ends of 
tapes and strapping, 
and often when it is 
completed all the tapes 


The tapes, 
being close to the penis, 
become very dirty from urine and pus tracking round 
the catheter. (3) With the slight and unavoidable 
tension on the catheter, the tapes become taut, and 
cut into the penis as they converge on the catheter. 
This occurs especially as they cross the corona, and I 
have often seen ulcers where tapes, hardened by 
dried urine and pus, have cut into the glans. This 
is, perhaps, the greatest objection to the method. 
(4) If the catheter has to be changed, or removed 
temporarily (e.g., for cystoscopy), the whole apparatus 
must be removed and a fresh one applied. 

These objections may appear trivial but in practice 
are very real. The appearance of things after a 
catheter has been kept tied in for a week in a patient 
with infected urine or urethritis is enough to make 
one most dissatisfied with the tape method. 

The following method aims at meeting these dis- 


CLINICAL AND LABORATORY NOTES 


are not 
bide eater 
taut. (2). 


[FEB. 1,1936 255 


advantages, and, if not entirely overcoming them, at 
least mitigating them. Its essential feature is the 
use of something more rigid than tapes. A material 
which was soft, stiff, and at the same time pliable 
seemed indicated, and for this purpose pipe-cleaners 
have proved the ideal thing. They cost ld. per packet 
of 12, and four are necessary for each case, the 
“extra thick ”? variety being the best. 

After the catheter has been passed, four pipe- 
cleaners are strapped with 1 inch Elastoplast strap- 
ping round the circumference of the penis, as near 
the base as possible. The four ends are then brought 
to the catheter and fixed there with a small strip 
of elastoplast, in such a way that each pipe-cleaner 
has a definite bow, and stands well away from the 
glans penis. The ends at the base of the penis are 
then bent back or cut off. It is important to apply 
the band of strapping loosely round the penis to 
avoid constriction and cdema, and to press it well 
on to the skin. The whole procedure takes under a 
minute, with practice, and has proved quite satis- 
factory. 

Unlike the tapes, pipe-cleaners have the necessary 
rigidity to ‘“‘stand away’ from the penis and not 
press on the corona. Because they can be made to 
stand away, too, they are not soiled so soon by 
urine or pus. Being soft, they do not cut into the 
skin, and are quite comfortable to the patient. If 
the catheter has to be removed temporarily, the 
strapping holding the ends on the catheter is removed, 
leaving the pipe-cleaners in place, ready to be strapped 
again to the new catheter. The method is essentially 
simple, clean, and very easy to apply. By his kind 
permission, it has been used on the last 30 cases 
under the care of Mr. John Everidge. 


AN UNUSUAL CAUSE OF INTERNAL 
HEMORRHAGE | 


By EMLYN E. Lewis, F.R.C.S. Eng. 


RESIDENT SURGICAL OFFICER, QUEEN’S HOSPITAL, BIRMINGHAM 


EARLY in August, 1935, a man 77 years of age 
was admitted to the Queen’s Hospital having col- 
lapsed in the street. He was suspected of having a 
perforated ulcer. He had been unwell for a few days, 
having shortness of breath. There was no indiges- 
tion. The collapse was ushered in by giddiness and 
by slight upper abdominal pain which by the time 
of examination had become severe and generalised. 
His pulse was rapid and thready, his temperature 
subnormal, and his skin cold and clammy. He was 
tender and rigid over the whole abdomen but parti- 
cularly in the epigastrium ; there was no diminution 
of liver dullness, and he had much pain in the right 
shoulder. 

A diagnosis of mesenteric thrombosis was ade: 
morphia gr. 4 was given, and rectal saline adminis- 
tered. The patient’s condition improved and in two 
hours the abdomen was opened under gas-and- 
oxygen anesthesia. The peritoneal cavity contained 
a great quantity of blood. The spleen was intact, 
and the stomach was delivered with abnormal ease 
owing to the lesser omentum having been torn away 
from the lesser curvature. The torn omentum was 
widely infiltrated with blood-clot and expanded to 
a thickness of about 2 inches. No actual bleeding- 
point could be seen, and there was no evidence of 
fresh hemorrhage. The man’s condition being grave, 


(Continued at foot of next page) 


256 


THE LANCET] 


MEDICAL SOCIETIES 


[FEB. 1, 1936 


ROYAL SOCIETY OF MEDICINE 


SECTION OF EPIDEMIOLOGY 


AT a meeting of this section on Jan. 24th, with 
Surgeon-Captain S. F. DUDLEY, the president, in the 
chair, a discussion took place on the 


Use and Abuse of the Swab in Combating 
Diphtheria 


Dr. Hl. J. Parisu, of the Wellcome Research 
Laboratories, Beckenham, began by saying that if 
immunisation were universal and timely the subject 
would be unimportant, but that there was still much 
diversity of opinion and practice. The responsibility 
for the diagnosis of diphtheria rested entirely with 
the clinician. In typical cases the swab should have 
only a confirmatory value, but where, clinically, the 
presumption was against diphtheria, it might help 
him to decide. Good technique was essential at the 
bedside as well as in the laboratory, and swab-taking 
should not be delegated to a student or nurse. An 
antiseptic gargle should not have been used for some 
time before using the swab, and with only a small 
nidus of infection care must be taken to rub the 
actual lesion and to avoid contamination with saliva. 
In a difficult case the bacteriologist should be given 
adequate data, and he, in turn, should issue his report 
without delay. He felt that antitoxin should be given 
whenever a swab was taken, as many lives were still 
being lost through failure to give serum early enough. 
The swab should be of greater value to the clinician 
and the medical officer of health as an administrative 
measure rather than as a diagnostic aid. Doubtful 
cases should not be notified until there had been a 
report on the swab. If negative, another swab should 
be taken, and if this was also negative the patient 
could safely be nursed at home, even in the presence 
of Schick-positive children: Vincent’s angina or 
streptococcal sore-throat might, however, require 
hospital care. Caiger and O’Brien had reported that 
in 41 per cent. of 529 patients admitted as cases of 
diphtheria, and Dr. E. H. R. Harries that in 33°6 per 
cent. of 2099, a revision of the diagnosis was necessary. 
An ‘‘observation certificate °” for admission to 
hospital would save much expense and a rebuff to 
the practitioner when his diagnosis was revised, but 
for this the L.C.C. system of isolation cubicles would 
be essential. Sometimes the membrane of a transient 
true diphtheria in almost immune persons might clear 
before admission to hospital and these might soon 
be discharged. It was often necessary to swab 
contacts in order to acquire early information about 
the spread of infection, and it was important to swab 
the nose as well as the throat, for there might be a 
positive result in one when the other was negative. 


—_— 


(Continued from previous page) 


after evacuation of the blood, the abdomen was 
hurriedly closed. It was suspected that the left 
gastric artery had ruptured, possibly through an 
aneurysm. Three days later the patient died, and 
post-mortem examination showed syphilitic aortitis, 
aneurysmal dilatation at the origin of the coliac 
artery, and rupture into the lesser omentum of an 
aneurysm about an inch in length situated on the 
left gastric artery. Evarts Graham in his “‘ General 
Surgery ” (Chicago, 1931) records almost a similar 
case treated successfully by Green-Powers. 


In many outbreaks the real menace was the profuse 
carrier, but though those with few bacilli probably 
helped greatly in natural mass immunisation, the 
sparse carrier of one day might be a profuse and 
dangerous one on the next. The introduction of 
tellurite media had materially increased the propor- 
tion of positive reports and this increased the 
clinician’s responsibility in interpreting them. It 
was of supreme importance to make virulence tests 
in convalescents and carriers, for they often harboured 
non-virulent forms. 

In research the swab was invaluable in discovering 
the presence of diphtheria in Schick-negative reactors, 
the invasiveness of Corynebacterium diphtheric gravis, 
the carrier rate and the effect upon it of artificial 
immunisation, and the origin of natural antitoxin. 
Certain strains of the gravis type seemed to be more 
invasive than the strains met with a few years ago, 
and were responsible for most of the diphtheria in 
Schick-negative reactors. The degree of protection 
shown by a negative Schick test might occasionally 
be inadequate to prevent infection by virulent 
strains, and it should be the aim of the practitioner 
to confer as high a degree of protection as possible. 
With the increasing prevalence of the gravis organism 
in various parts of England not only had there been 
an increase in the number of cases reported in Schick- 
negative reactors, but sometimes also in the number 
of carriers associated with those cases. A high 
carrier rate in an immunised population might be due 
either to the immunisation itself or to a more virulent 
and invasive strain, but there was no doubt that 
mass immunisation very greatly reduced the incidence 
of diphtheria. 

The clinician must realise that the newer knowledge 
had complicated the work of the bacteriologist and 
this might explain some of the negative reports in 
undoubted clinical diphtheria. Some modification of 
laboratory technique was therefore desirable, and 
Dr. Parish suggested as a method, first, the examina- 
tion of the direct smear, chiefly to exclude Vincent’s 
angina, and then inoculation of a Léffler slope and 
of McLeod’s chocolate tellurite medium, on a plate 
or, more conveniently, in a McCartney’s screw-capped 
bottle. This enabled a report to be made in from 
24-48 hours, but was difficult to carry out in a small 
laboratory. It tended, however, to shorten the 
bacillus and make microscopical recognition difficult. 
A simpler alternative was to give a preliminary 
report in 18 hours from a Löffler slope and, later, a 
full report after a thick subculture of the easily made 
Horgon and Marshall’s blood tellurite medium and 
after fermentation and virulent tests. The great 
advantage of the tellurite medium over Lé6ffler’s 
was that it produced an increase of 10-25 per cent. 
in the positive results. It also differentiated the 
Klebs bacillus from Hofmann’s and the gravis type 
from the others, and by inhibiting the growth 
of other organisms it allowed the colonies to be 
picked out. 

The swab saved precious time in making a diagnosis 
and though improvements in technique had added to 
the cost the full laboratory examination was not 
necessary in the ordinary typical case. He had 
himself found the serum-treated swab most valuable 
for accelerating the report. He had described it in 
a letter to Tire LANCET,! and had shown that an 
accurate report could be made in two hours in 80 per 
cent. of clinical diphtheria and in four hours in 


—— 


1THE LANCET, 1985, i., 400. « 


| THE LANCET] 


95 per cent., contrasting with 83 per cent. after the 
18 hours necessary by Léffler’s method. The value 
of the swab was highest in administration and research 
as it was desirable to have the largest possible number 
of isolations. 
sistent carriers to decide if they were to be released 
from strict isolation before they became bacterio- 
logically negative. This step should only be taken 
after a thorough overhaul of the upper respiratory 
passages by a competent specialist. Swabbing must 
not be used as a primary or even chief means of 
diagnosis, for diphtheria was a disease, not a mere 
bacteriological finding. It was also necessary to 
differentiate clinical diphtheria from the mere 
presence of the bacilli in the throat. Finally, he urged 
that every hospital should have its own bacteriological 
laboratory and that there should be closer coöperation 
between clinician and bacteriologist, but the onus 
in regard to early diagnosis and treatment rested with 
the physician. 

Dr. C. O. STALLYBRASS (Liverpool), from the point 
of view of public health and hospital administration, 
discussed the value of the swab for diagnosing diph- 
theria before admission, in the isolation hospital, 
and in carriers and ‘‘ missed’? cases. He assumed 
that the swab was supplementary to artificial 
immunisation. Of 200 consecutive cases admitted 
to Liverpool hospitals as diphtheria, the diagnosis 
was confirmed in 175 : the average age was 10 years ; 
the average delay in calling medical aid was 36 hours, 
with a further 16 hours before the first dose of anti- 
toxin was given; the mortality was 8 per cent. 
Swabs were much more often taken from adults 
than from children, and the delay in sending for the 
doctor was much greater in fatal cases. The condi- 
tion of the patient, judged by the dose of serum 
on admission, was much graver in the fatal cases 
and in those who had not been swabbed outside, 
whose mortality was little more than half the average 
of the series (4:8 as against 8). The main causes of 
death were a severe type of infection and failure to 
realise the gravity of the infection in young children 
(by doctors as well as by parents). He urged the use 
of the swab in all doubtful cases, especially in children 
under 7 yearsofage. He advocated the more frequent 
swabbing of the nose. If a positive swab taken 
outside the hospital was not necessarily proof of 
diphtheria, still less did a negative swab show its 
absence. Swabs negative to diphtheria often showed 
Vincent’s angina and swabbing was invaluable in 
the differential diagnosis. 

In hospital the use of the swab had been radically 
changed by the division into “gravis,” “ inter- 
mediate,” and ‘‘mitis’? types. In Liverpool a 
case notified as diphtheria was seen on admission 
by a resident medical officer. Clinical diphtheria 
was sent to a general ward, doubtful cases to a bed- 
isolation ward or cubicle. A swab was at once taken 
and a Schick test carried out, followed, if necessary, 
by a dose of serum after four to six hours. The 
cultures if positive were tested for virulence, and if 
negative a second culture was made a few days later. 
Of 145 gravis only 1 and of 116 intermediate 
strains only 4 were non-virulent, but of 121 mitis 
strains 43 were non-virulent. The proportion of the 
gravis type in various cities was found from the 
literature to vary greatly. 

With an outbreak of diphtheria in a children’s 
ward, a kind of standstill order should at once be put 
into operation. The children could be separated 
into four groups: (a) Schick-positive, swab-positive ; 
these should be isolated and receive a dose of serum. 


ROYAL SOCIETY OF MEDICINE: EPIDEMIOLOGY 


It was often very difficult with per-' 


[FEB. 1, 19386 257 


(b) Schick-negative, swab-positive; carriers who should 
be isolated until a virulence test was done. (e) Schick- 
positive, swab-negative; these should be left in 
the ward and immunised. (d) Schick-negative and 
swab-negative; these remained in the ward and 
needed no further treatment. After this the stand- 
still order could be relaxed. 

The abuse of the swab lay mainly in allowing the 
bacteriological finding to warp the judgment, causing 
clinical diphtheria to be called something else, or 
a mere carrier an active case. This, however, 
still left open the question of what constituted clinical 
diphtheria. 

Dr. J. D. ROLLESTON agreed with both the previous 
speakers that there was a need for collaboration 
between physician and bacteriologist, and that the 
onus in diagnosis rested primarily on the physician. 
There was still too often delay in giving antitoxin 
or in sending patients to a fever hospital, because 
a swab had not been received or was negative. 
Malignant diphtheria might simulate quinsy or 
mumps, and a swab might. be negative because the 
bacilli were too deep in the mucous membrane, and 
it only became positive when the membrane began 
to separate. The danger of a wrong diagnosis was 


‘Shown when 58 per cent. died of 40 patients with 


malignant diphtheria which had been incised, com- 
pared with 3-4 per cent. of other cases of equal severity. 
The direct smear helped to diagnose Vincent’s angina 
and to show the prevalence of other organisms, 
but it should be limited to acute faucial diphtheria. 
A negative swab might be due to the struggling of the 
child, to applying it too soon after meals, to a recent 
use of antiseptic, or to the inexperience of the. 
examiner. In the skin, diphtheria might simulate 
eczema, herpes, different forms of suppuration, and 
in wounds, in a number of which diphtheritic paralysis 
resulted. Obstinate whitlows would disappear after 
a small dose of diphtheria antitoxin. He was sceptical 
of the practical value of terminal swabbing before the 
patient was discharged from hospital; a negative 
swab was no guarantee that the patient was free 
from infection, and the return rate was no higher 
in hospitals which had given up this practice. It 
had, however, a certain forensic value. 


The CHAIRMAN referred to a psychological abuse 
of the swab. If there were no such measure as 
swabbing, the practitioner would probably treat all 
his cases of diphtheria with antitoxin at once. He 
had found a 25 per cent. increase in the number of 
positive swabs by examining at 48 hours as well as | 
at 24 hours, and he thought terminal swabbing would 
be much more valuable if the criterion of freedom 
were seven consecutive negative swabs in a week. 
He pleaded for more simultaneous Schick and swab 
tests, and more information was needed about 
isolation of carriers. 

Dr. G. BOUSFIELD said that in poor districts the 
practitioner much opposed giving antitoxin to a 
patient unless he could prove to the relatives that it 
was necessary. If a case looked like diphtheria it 
should be treated as such by the doctor, or he should 
send the patient to an appropriate place. After 
having done 15,000 primary Schick tests, he had 
noticed that they were becoming less strongly 
positive. Care was needed before treating all the 
less profuse carriers, as that might upset Nature’s 
balance and interfere with the process of natural 
immunisation. 

Dr. E. A. UNDERWOOD objected to the text-book 
statement that antitoxin should be given whenever 
a swab was taken. It was also a questionable policy 


259 THE LANCET] 


to have doubtful cases removed to a fever hospital 
for observation. 

Dr. E. W. GooDALt did not think it necessary to 
indulge in universal swabbing, and remarked that 
advocates of this did not include the staffs of fever 
hospitals. He had not met cases in which diph- 
theritic whitlows had caused other cases of diphtheria. 

Dr. R. A. O’BRIEN thought every effort should be 
made to shorten the period in making a report on the 
swab. 

Dr. CLARK TROTTER said it was difficult to get the 
practitioner to understand what he ought to do in 
cases of diphtheria. On the appearance of one case 
in a household the family doctor might swab all the 
other embers and all who had been in immediate 
contact, just because he felt he was expected to do 
it. To eliminate mixed infections, Dr. Trotter said 
he was in the habit of giving every case of scarlet 
fever a prophylactic dose of diphtheria antitoxin ; 
this greatly improved the scarlet fever cases and pre- 
vented any possible spread of diphtheria. 


SECTION OF DISEASE IN CHILDREN 


AT a meeting of this section held on Jan. 24th, 
with Sir LANCELOT BARRINGTON-WARD, the presi- 
dent, in the chair, a paper on 


Metabolism, General Nutrition, and Growth 
in Infancy and Childhood 


was read by Dr. E. P. Pourtron. Ile said that the 
work he had done with Mr. T. W. Adams possibly 
provided a new way of studying these problems, 
and he was bringing it before the section in the hope 
of getting assistance. He had had occasion to recal- 
culate the metabolism results of Benedict and Car- 
penter from oxygen-consumption and respiratory 
quotient, and had found that in children these results 
differed from those obtained by calorimetry. Assump- 
tions from the respiratory quotient were misleading, 
and he felt that carbon dioxide output should be 
regarded more truly as a measure of metabolism. 
By plotting the logarithin of the carbon dioxide 
against the logarithm of body-weight he found 
a linear increase up to 18 months, a flattening 
from 18 months to 4 years, and then a linear 
increase again. That is, as the child passed 
from 18 months to 4 years, the carbon dioxide 
output remained constant while the body-weight 
increased. A possible explanation was that when 
the child started walking more actively he lost 
fat, and metabolism continued thereafter at a 
slower rate. If this were so, there should be an 
alteration in the relationship of height to weight at 
this period, the gain in height increasing as com- 
pared with the gain in weight. Dr. Poulton demon- 
strated further graphs in which the logarithm of 
height and the logarithm of weight of children from 
birth to adult age were considered. There were 
inflexions in the curve when the body-weight reached 
10 kg. (22 Ib.) between the ages 10 months and 
2 years, and again when the body-weight was about 
18 kg. (39:5 lb.) at age 4-5 years. A third inflexion 
occurred at 15 years when body-weight was from 
50 to 55 kg. (110 to 120 lb.). The slowing of the 
weight increase between 1 and 4 years without a 
proportional slowing in height increase could be 
explained by loss of fat, and the fact that meta- 
bolism remained about constant at this period, 
despite increase in weight, was regarded as due to 
the disappearance of luxus consumption associated 
with the fat of babyhood. | 

The relation of height to weight represented 


ROYAL SOCIETY OF MEDICINE: DISEASE IN CHILDREN 


(FEB. 1, 1936 


general nutrition, and could be used with advantage 
to compare the general nutrition in different types 
of children and in different strata of society. An 
important question was whether nutrition was con- 
stant in different social strata. Baldwin had collected 
measurements in the United States which incidentally 
showed the change in relationship of height to weight 
at 5-6 years and again at 15} years. The old figures 
of Roberts on public-school children and those of 
artisans showed what was generally agreed, that 
height and weight bore the same relationship to 
each other in all classes, so that this relationship 
could be roughly called an index of growth. There 
inust, however, be a third factor, time, entering into 
it. It was usual to correlate time or age with weight, 
but when age and height are correlated there was 
a much closer agreement with the growth curves. 
Dr. Poulton showed charts to illustrate this point, 
taking measurements of boys from an Oxford pre- 
paratory school from 8 to 134 years and older boys 
from Epsom College. It was interesting that Roberts's 
figures from the eighties, of height and age of boys, 
at public schools, naval and military colleges, and 
universities, and medical students, fell below what 
is regarded as ideal to-day. Fleming and Martin’s 
statistics from Wales, including some elementary 
school-children, showed lower curves, while Green- 
wood’s from elementary schools all over the country 
were lower still. Elderton’s figures for Glasgow 
children taken by districts were all graded according 
to the social status. So in comparing the different 
classes of the community of varying social strata, 
while the height-weight curves were constant, the 
lower classes were less tall for their age, and prac- 
tically speaking the social status could be graded by 
this property. 

Prof. LEONARD FINDLAY was glad that Dr. Poulton 
had shown the fallacy of the height-weight index; 
these two were measurements of two totally different 
things—the height of growth and the weight of 
nutrition. There was a real difficulty with regard to 
standards ; comparison of private patients with, 
say, Baldwin’s measurements showed the former as 
sometimes as much as two or three years above the 
latter. Rate of growth of height and of weight 
varied much in different social classes. Another 
interesting point was the focusing of attention on 
the first eighteen months of life. In a study under- 
taken with Prof. Noel Paton, he had found that 
the rate of growth was strikingly greater during this 
period, and he thought that in questions of under- 
nutrition this was the period on which to concentrate 
if valuable time was not to be lost. | 

Dr. ALAN MONCRIEFF emphasised again the import- 
ance of considering the carbon dioxide output in 
estimating the metabolism in young children. The 
oxygen-consumption alone could be very fallacious. 
Secondly, he complained of the lack of proper growth 
standards for this country. Some years ago he had 
collected data from several foreign countries, and 
had found considerable variations. Yet we were 
content to accept as a standard figures from the 
mixed population of America. We could not begin 
to argue about malnutrition or undernutrition until 
we had standards for English children. He hoped 
that the promised and long-awaited anthropometric 
survey would shortly appear. 


Dr. POULTON, in reply, pointed out that the height- 
weight relationship was only fallacious in so far as 
it was constant whatever class was studied. Brodie’s 
figures for animals showed a difference between 
those fed improperly and those on adequate diets, 


THE LANCET]. 


ROYAL SOCIETY OF MEDICINE : UROLOGY 


[FEB. 1, 19386 259. 


dition was liable to persist in association with sub- 


and he concluded that in this country all children iti i ist i are . 


got enough calories, and though a child could gorge 
himself on bread and gain weight, he would not grow 
taller. Possibly the difference in height in the dif- 
ferent social strata resulted from lack of vitamins, 
and what was needed was more vitamin A, and per- 
haps D, rather than more calories. Dealing with 
the relation of height to weight, the height-age 
curve was straight, the weight-age curve flattened 
out, and height should be taken for measurement 
of growth. He wanted to stress the importance 
of weighing children naked. There was a real need 
for reliable observations on children from a statistical 
point of view. 


SECTION OF UROLOGY 


AT a meeting of this section held on Jan. 23rd, 
Mr. E. W. RIcHES being in the chair, a paper was 
read by Dr. J. Leon Jona, of Melbourne, on 


The Kidney Pelvis 


its normal and pathological physiology, illustrated 
by cinematography and pyelograms. In a pre- 
liminary anatomical survey Dr. Jona pointed out 
that the segmental character of the embryonic kidney 
was preserved in the adult calyces. These, together 
with the infundibulum of the pelvis and the ureter, 
were enclosed by layers of smooth muscle which 
were found, on pyeloscopy, to contract rhythmically 
in a manner which the speaker compared with the 
systole and diastole of the heart muscle. If the 
pelvis were filled with radio-opaque fluid through a 
ureteric catheter and observed on the fluorescent 
screen this action could be followed. The calyces 
contracted in regular order from above downwards, 
each contraction lasting from 1 to 3 seconds and 


being followed by a resting period of similar duration. 


The infundibulum contracted in a similar fashion 
and forced the urine down into the ureter. Regurgi- 
tation into the calyces was prevented by a kind of 
“snap” action of the proximal part of the infun- 
dibular recess. The cinematograph which followed at 
this point had been prepared by an artist to whom 
the speaker had demonstrated the sequence of events 
in the living subject. The film showed very clearly, 
by a synthetic series of diagrams, the rhythmic 
contractions already described. 

Aberrations in the regularity of this mechanism 
were found in a variety of pathological states such 
as atony, spasm of the whole kidney pelvis, spasm of 
the ureter at one point, or atony of the ureter. Pyelo- 
grams illustrating these different conditions were 
demonstrated. Spasm was frequently reflex in 
origin and might be due to disease of the gall-bladder 
or appendix, inflamed lymph glands, or to an aberrant 
renal artery. Dr. Jona had even seen spasm of the 
left ureter in a patient with gail-stones. Atony and 
dilatation could occur in the absence of obstruction 
and might be due to the action of the sex hormones. 
Antiperistaltic waves were frequently associated 
with spasm of the ureter at one point; they were 
also observed in the ureters in apparently normal 
subjects when the bladder was distended and mic- 
turition prevented. Such antiperistaltic waves were 
an obvious mechanism in the production of pyelitis 
should the bladder be infected. The use of pyelo- 
scopy might assist in the early diagnosis of renal 
tumours when the only clinical symptom was hema- 
turia. In pregnancy the ureters were often enlarged 
by as much as two-thirds of their normal size, and 
this was often accompanied by elongation and kinking 
of the upper or free part of the ureter. Such a con- 


involution of the uterus. Mr. Harold Burrows’s 
observations on the effects of cstrogenic substances 
upon the musculature of the ureters were, said Dr. 
Jona, highly significant. 

Dr. Jona demonstrated a graphic method of inves- 
tigating pelvic pressure and contractility. In this 
the ureteric catheter is connected with a tambour 
and a record of the pressure is obtained on a revolving 
drum. With this apparatus he made a short record, 
using manual pressure on a rubber bulb in imitation 
of the conditions which would obtain in practice. 
Tracings in normal subjects, he said, showed a regular 
undulating curve corresponding with the rhythmic 
systole and diastole of the pelvis. A change from 
the horizontal to the sitting posture caused an 
appreciable increase in the intrapelvic pressure, as 
did also an increase of intra-abdominal pressure— 
for example, in deep. inspiration. This graphic 
method of investigating the muscular activity of the 
urinary tract was of considerable service in distin- 
guishing between cases of hydropelvis where the 
muscle would contract and those cases where atony 
prevailed. In the latter the addition of 10 c.cm. of 
fluid simply added to the distension without pro- 
ducing an appreciable rise in pressure. In such cases 
nephrectomy might be advisable, but it should always 
be borne in mind that if an obstructive cause could 
be found and removed a great degree of improve- 
ment was to be expected in the contractility of the 
pelvic musculature. The combination of pyeloscopy 
with graphic records of intra pelvic pressure was of 
considerable service in estimating the effects of drugs 
upon this part of the urinary tract. Thus, in one 
case, in which a tracing was demonstrated, a single 
dose of pituitrin had been effective in restoring a 
normal rhythm where dysfunction had previously 
prevailed. Both atropine and a small dose of hista- 
mine would cause a moderate rise of pressure. Acri- 
flavine and mercurochrome had a similar effect which 
the speaker attributed to their action upon the muscle 
rather than to any antiseptic effect. One effect of 
aspirin was to lengthen diastole. 

The observations described had all been made in 
women. Dr. Jona gave no account of his work on . 
animals apart from a single experiment in which he 
demonstrated the deleterious effect of using too 
great a pressure upon the renal pelvis. In this the 
radio-opaque fluid had penetrated into the inferior 
vena cava and its branches. 


DISCUSSION 


Mr. YATES BELL said that in a series of 12 cases 
of renal pain he had found hypertonus of the pelvis 
in the majority. In one case, a girl of 12 who had 
suffered from intractable pyelitis for a period of 
from 4 to 5 years, an intravenous pyelogram was 
normal apart from the form of the calyces, which 
were small and globular. Pyeloscopy showed no 
contractions, but these were initiated by injecting 
0.5 c.cm. pituitrin and, after a course of treatment 
with this drug, the patient’s condition returned to 
normal. 

Dr. N. S. Fr1nz1 considered that the modern fluores- 
cent screen and improved X ray apparatus had 
been of enormous assistance in obtaining effective 
pyeloscopy. He thought that intravenous Uro- 
selectan had superseded retrograde pyelography too 
extensively but there were indications that the 
pendulum was swinging back. 


Dr. G. E. VILVANDRE suggested that the effects of 
pyeloscopy might be imitated by taking plates at 


260 THE LANCET] 


more frequent intervals in the course of a pyelogram. 
Ordinarily exposures were made at intervals of from 
10 to 15 minutes; if plates were taken at intervals 
of one minute a record might be obtained of the con- 
tractions described by Dr. Jona. He also suggested 
that kinking of the ureter was fairly common and 
not by any means confined to pregnant subjects. 

Mr. A. W. CUBITT discussed the bearing of intra- 
vesical pressure upon ascending infection of the 
urinary tract with special reference to cases in which 
prostatectomy had been performed. In such cases 
drainage of the bladder led to the conversion of a 
positive pressure into a negative one. He thought 
this might facilitate an ascending infection, and for 
this reason advocated complete closure of the bladder. 
He also described the relief of pain effected by 
atropine in a case of vesical stone. 


Dr. JONA, in reply, remarked that cases such as 
Mr. Yates Bell had described were undoubtedly 
forthcoming if they were looked for. His only 
objection to Dr. Vilvandré’s suggestion was based 
upon expense, which would be considerable. To 
Mr. Cubitt he expressed doubt as to whether the 
pelvis of the kidney would stand a negative pressure. 


MEDICAL SOCIETY OF LONDON 


Prof. Q. E. Gask, the president, took the chair at 
a meeting of this society held at 11, Chandos-street 
on Jan. 27th, when Mr. V. ZACHARY COPE opened a 


discussion On Acute Appendicitis 


Even after the fifty years which had elapsed, he said, 
since Fitz’s famous paper of 1886, the mortality 
from acute appendicitis was still considerable and 
did not show diminution. The main problems 
had always been to decide the best time to operate 
and how much ought to be done at the operation. 
J. B. Murphy of Chicago, than whom no one had 
done more to put the surgery of appendicitis on a 
sound footing and who had had an operative mortality 
of about 4 per cent., which would be considered good 
to-day, had emphasised the great importance of 
operating on all cases early and before perforation 
of the appendix. He had called this the first stage of 
the disease, applying the term “‘ second stage ” to that 
period, for about three days after perforation, when 
the inflammatory process was increasing and spread- 
ing. The operation, he had written, must then be a 
limited one: simple opening of abscess and relief 
of pus tension in the affected area, with the removal 
of the appendix if it were accessible and easily 
amputated. There should be the least possible 
separation of agglutinations. When the patient 
was apparently overwhelmed with intoxication, a 
simple incision was made and pus tension relieved 
with a large drainage-tube. In the third stage, the 
stage of subsidence of the acute symptoms, he had 
generally operated and let out pus. He had therefore 
operated promptly in nearly all cases. Where, 
however, the surroundings or low state of the patient 
and the absence of a competent surgeon contra- 
indicated an immediate operation, he had recom- 
mended Ochsner’s treatment, with the warning 
that it required a great deal of judgment. Ochsner 
had aimed at changing a dangerous acute into a 
relatively harmless condition by inhibiting peristalsis 
and giving the peritoneum an opportunity to remove 
the infection by absorption or circumscription. He 
had not sought to avoid operation but had chosen 
the most favourable time for it. He had not only 
operated at once on every case in which he had thought 


MEDICAL SOCIETY OF LONDON 


[FEB. 1, 1936. 


the appendix was still unperforated, but had often 
operated promptly upon appendicular peritonitis. 
For the past thirty years the majority of surgeons 
had followed the teaching of Murphy. During the 
last few years, however, a number of the younger 
surgeons had questioned the wisdom of prompt 
operation at all stages. They regarded cases in 
which symptoms had been present for fifty hours as 
suitable for delayed treatment ; they put the patient 
in the high Fowler position, allowed no purgatives 
and gave no morphine. They allowed only water 
by mouth. They did not recommend delay in young 
children or where the diagnosis was uncertain, and 
they regarded as additional indicationsfor operation the 
previous administration of a strong purgative, super- 
ficial hyperesthesia, and obvious general peritonitis. 


IMMEDIATE AND DELAYED OPERATION | 


The advantages of the so-called immediate opera- 
tion were that the exact pathological condition was 
ascertained, the infective focus was usually removed, 
the infective field was drained where necessary, and 
the patients and relatives were saved a trying delay. 
Its disadvantages in cases with perforation of the 
appendix were said to be the danger of spreading the 
infection, the greater frequency of intestinal obstruction 
and ileus, and the frequency of secondary abscesses, 
fecal fistule, and incisional hernia. The advantage 
of the Ochsner method was said to be that operation 
was undertaken when the infection was localised and 
the risk minimal. Its drawbacks were that if, the 
infection did not become limited the patient might 
be in a worse state than before; extra work and 
strain were thrown on all concerned ; treatment must 
be carried out on the threshold of the theatre by the 
surgeon himself; and delay with mistaken diagnosis 
might be fatal. There was a great deal of truth 
in these criticisms, but they were of varying weight. 

Mr. Cope said he was doubtful whether statistics 
could solve the problem of which was the better 
method, and he thought there was need of a thorough 
investigation into the whole question of appendicitis 
mortality by a responsible and impartial body. 
From his clinical experience, in spite of the comi- 
parative and average success of prompt operation, 
he had from time to time had cases in which delay 
had seemed to be the better plan. He still always 
advised immediate operation, not only for the unper- 
forated appendix but also for perforative appendicitis 
with diffuse peritonitis, so long as the patient was 
not too toxic and was reacting well to the inflamma- 
tion. The cases which he decided upon their merits 
were those with a definite and circumscribed lump and 
those with advanced peritonitis. If he thought the 
lump represented a subsiding inflammation with 
perhaps a small, ill-defined abscess, he sometimes 
tried the starvation treatment of Ochsner. If he 
thought there was a well-defined abscess, he usually 
opened it. With advanced peritonitis and a toxic 
and dehydrated patient it was better to wait a few 
hours and sometimes a day or two while the patient 
was hydrated and detoxicated by intravenous and 
rectal saline, It would be a retrograde step to teach 
that delay was the usual correct treatment. Delay 
should not be practised except by experienced 
surgeons. 

Mr. Cope described his own technique and, in 
conclusion, recommended that whenever possible an 
experienced surgeon should be in charge of any case 
of appendicitis, : 

EXPECTANT TREATMENT 

Mr. R. J. MCNEILL Love said that in appendicitis 

that had become limited to the right ihac fossa or 


THE LANCET] 


pelvis immediate operation might be extremely 
difficult. Although a practised surgeon could remove 
the appendix with the minimum of disturbance, 
many cases fell into the hands of the less experienced, 
whose operative results were buried in the records of 
their hospitals. The main points of expectant treat- 
ment were the four “F’s”:. Fowlers position, 
fomentation, the four-hourly chart, and fluids by 
the mouth in minimal quantities. He had never felt 
very happy about fluids by mouth, but preferred 
intravenous infusion for four or five days. If 
expectant treatment was adopted for the localised 
condition, the disease followed one of three courses. 
In about 65 per cent. of cases the infection subsided 
and swelling disappeared, and three months later 
the appendix was removed at a clean operation with 
negligible mortality. In 25 per cent. of cases an 
abscess formed, showing that infection had become 
limited and resistance increased. Expectant treat- 
ment could be still carried on, but it was wise to 
drain the abscess. In 10 per cent. of cases expectant 
treatment must be abandoned because of increase of 
pain, tenderness, rigidity, and fever. The surgeon 
was then faced with the necessity of operating on a 
more toxic patient. Expectant treatment had been 
criticised on the ground, among others, that it was 
impossible to gauge the condition of the appendix. 
Once localisation had occurred, the surgeon knew 
something much more important: the condition of 
the surrounding peritoneum, omentum, and bowel, 
which were all acting as a wall to the inflammation. 
Discharging wounds and fecal fistulae were more 
common after the immediate operation. In suitable 
cases the mortality following expectant treatment 
was about 3 per cent. less than that obtained from 
immediate operation by experienced surgeons. The 
clean operation three or four months after the acute 
condition had subsided could be performed safely 
by a surgeon of less experience. 
THE STATISTICAL ASPECT 

Mr. H. C. W. NUTTALL, speaking of the statistical 
aspect, said that with a mortality of 2-53 per cent. 
he considered that he still had something in hand. 
Two points of view had to be distinguished: that of 
the full-time surgeon and that of the general prac- 
titioner who did a certain amount of surgery. The 
latter might easily be taught to operate carefully ; 
it was more difficult to teach him to watch the 
patient. House surgeons must be taught never to 
attempt to remove the appendix if there were any 
diticulty. Hyperzsthesia was of very little value in 
diagnosis, as it was present in 50 per cent. of cases. 
The most difficult cases were those in which the 
condition had been established for some time and the 
surgeon could not tell where the infection had started 
and where to make the incision. Mr, Nuttall would 
still advise operation if the appendix region were 
incriminated. Some patients suffered severely from 
thirst unless they were given water by the mouth ; 
to do so made little difference to the abdomen if the 
drainage were adequate. In the vast majority of 
straightforward cases he did not drain, but he always 
drained for the slightest amount of hemorrhage, for 
a blood-clot in an infected abdomen was very serious. 
He did not regard the diminution of mortality- 
rate by 3 or 4 per cent. by the expectant treatment 
as good enough; the immediate operation gave 
better results in the end over a large series of cases. 

Mr. HuGH WBITELOCKE stated that at the Radcliffe 
Infirmary, Oxford, the staff delayed operation only 
in two or three cases a year, vet the figures had 
improved for two reasons: the introduction of 
continuous intravenous drip in severe toxic cases, 


MEDICAL SOCIETY OF LONDON 


[FEB. 1, 1936 261 


and the careful suction of local peritonitis, particularly 
from the pelvis. He had rarely drained by a stab 
incision over the pubes. By inserting a tube drain 
to the base of the pouch of Douglas and by with- 
drawing it about half an inch every day with a slight 
rotation, almost any pelvic abscess could be satis- 
factorily drained through a lateral gridiron incision. 
Mr. JULIAN TAYLOR adduced as a reason for the 
low mortality at University College Hospital that 
the honorary staff dealt with practically all appendix 
cases. If the surgeon were experienced, it did not 
matter which principle he followed. The general 


_presumption of the exponents of delayed operation 


that patients died from the dissemination of infection 
from an abscess was quite wrong ; this was the rarest 
possible occurrence. 

Mr. G. H. Corr said that some drainage statistics 
which he and a colleague had compiled and shown 
to a professor of statistics had illustrated the danger 
of any but a lateral incision. The mortality from 
an appendix abscess was approximately 3 per cent., 
but from spreading peritonitis it rose to 80 per cent. 
at about the tenth day. When the appendix and 
the more local inflammation had been removed and 
the operator saw clear lymph pouring into the local 
focus, he should leave a tube in for a short time ; 
otherwise the risk was less if no drain were used. The 
difficulty lay in deciding what and what not to leave. 

Mr. W. E. TANNER remarked that in some cases 
where the appendix was bound down to the back of the 
abdominal wall and the cecal end was healthy he had 
divided the cecal end, invaginated the cecum, 
pulled out the mucosa of the appendix, and inserted 
a drain; the patient was saved a second operation. 
When a very old patient had an appendix of this 
type a transfusion of 200 c.cm. of blood would promote 
local suppuration and the patient would get better. 
This was far superior to giving vast quantities of 
fluid intravenously. 

Sir JAMES WALTON also considered that the 
important factor was not so much the method as the 
man who carried it out. The important thing was 
the teaching which the surgeon was to give to students. 
Every general practitioner was likely to regard himself 
as a skilled surgeon for the purpose of deciding on 
delay. The enormous improvement in results had 
been due to the fact that practitioners were learning 
to send cases up for early treatment. When an — 
abscess was localised and well defined the surgeon 
should always operate, and the only question was 
whether the appendix should be removed. There 
were three factors: what the patient would stand, 
how diflicult the appendix was to get out, and how 
quickly the individual surgeon could get it out. 

Mr. J. E. H. ROBERTS agreed that a new body of 
statistics should be obtained from hospital surgeons. 
A form would have to be filled up when each case 
was seen and the treatment was planned, and the 
material would have to be submitted to a professional 
statistician. A clear exudate in the peritoneum did 
not necessarily mean general peritonitis but might 
be due to infection passing through the walls of an 
unruptured abscess. He could not believe that when 
there was a general infection of the peritoneum 
and the source of infection continued, it was not 
advisable to remove the rest of the appendix. 

Prof. J. PATERSON Ross considered that the main 
argument for delayed treatment arose when the 
abscess was diffuse in the peritoneal cavity. Even 
with a diffuse peritonitis he removed the appendix, 
just as he would remove a rusty nail from an infected 
knee-joint. After that, the Ochsner treatment was 
the right one. 7 


262. THE LANCET] 


Gefass erweiternde Stoffe der Gewebe 


By J. H. Gappoum, Professor of Pharmacology at 
University College, London. With an introduction 
by H. H. DALE, Director of the National Institute 
for Medical Research, London. Leipzig: Georg 
Thieme. 1936. Pp. 200. R.M.18. 


A LARGE number of pharmacologically active 
substances can be isolated from living tissues. Some 
of these, for instance the hormones, adrenaline, 
and pituitrin, are obtained from highly specialised 
cells and bring about an increase in vascular tone. 
Others may be prepared from a large variety of tissues 
and give rise to vasodilatation when injected into 
animals ; it is with these substances that this mono- 
graph deals. Sir Henry Dale discusses their general 
nature and significance in an introductory chapter. 
Three are chemically well-defined substances of 
known constitution 
and adenosine. The evidence is in favour of the view 
that histamine and acetylcholine, at least, exist 
in the cells in an inactive combination and are 
released when the cells are stimulated or damaged ; 
after their release they tend to produce local rather 
than general effects. A short historical review is 
given, and it is interesting that these substances 
were well known chemically before their physiological 
‘significance was realised. Prof. Gaddum_ begins 
with a very useful section outlining the methods 
generally available for the study of vasodilators 
present in tissue fluids and extracts. Histamine, 
acetylcholine, and adenosine compounds are fully 
dealt with in separate chapters. A very useful 
section follows in which substances of unknown 
constitution present in extracts of various organs 
are discussed, such as the ‘‘heart hormone” of 
Haberlandt, Kraut and Frey’s ‘kallikrein,’ and 
Gley and Kisthinios’s ‘“‘angioxyl.’’ The evidence 
for the separate identity of these various substances 
is examined critically, and the information provided 
will be of particular interest to clinicians who are 
offered preparations containing such substances 
as their active principles. These earlier sections are 
likely to be used mainly for reference purposes ; 
the later ones have a more general interest. 

In recent years evidence has rapidly accumulated 
showing that the action of many nerves is brought 
about through the liberation of chemical substances 
at their endings, a conception which though not 
new had previously been based on scanty experimental 
data. Convincing evidence in favour of this view 
is given and the whole subject is fully reviewed. 
Sir Henry Dale has coined the term ‘“ cholinergic ” 
for nerves in which acetylcholine or some closely 
related substance is the transmitter, and there is 
now evidence to show that probably all pre-ganglionic 
autonomic fibres and all post-ganglionie para- 
sympathetic fibres are cholinergic, as are the motor 
nerves to striped muscle. ‘‘ Adrenergic nerves,” 
that is to say, nerves which act as if adrenaline or 
some related substance were produced when they are 
stimulated, are also dealt with in this section, although 
strictly they do not come under the general title of 
the monograph. In the final chapter recent additions 
to our knowledge of several topics of general interest 
are outlined, including local chemical mechanisms 
regulating the circulation, anaphylaxis, and traumatic 
shock. 

An excellent bibliography is provided and a good 


index. The book is indispensable to those working 


REVIEWS AND NOTICES OF BOOKS 


namely, histamine, acetylcholine, 


(FEB. 1, 1936 


on pharmacological or physiological problems, and 
contains much information of value to the physician 
(who can read German) interested in the fundamental 
bases of medicine. | 


Essentials of Cardiography 


By H. B. RussELL, M.D., M.R.C.P. Lond., Medical 
Officer in Charge of the Cardiographic Depart- 
ments at St. Thomas’s and the Royal Masonic 
Hospitals. London: J. and A. Churchill Ltd. 
1936. Pp. 82. 7s. 6d. 


Tuis small book contains the essentials of electro- 
cardiography and of radiological examination of the 
heart (orthodiagraphy) presented in an elementary 
form for the use of students. 

In the first section, the different types of normal 
and pathological electrocardiogram are portrayed 
and simply yet clearly described. With a few 
exceptions the illustrative records are quite good, 
but the deflections are unlabelled which is a serious 
defect in a book intended for students. The second 
section of the book, dealing with radiology, is 
elementary but not very accurate. Some of the 
illustrative orthodiagrams are crude and the inter- 
pretation given is in several instances open to question. 
The anatomical diagrams might have been better, and 
that of the first oblique position is incorrectly labelled. 
Enlargement of the left auricle is not described, 
though it is mentioned as affecting the left heart 
border. The value and importance of radiological 
examination of the heart exceeds that of electro- 
cardiography to-day, and some account of the method 
is required by students. If this section of the book 
were improved and slightly expanded, it would fulfil 
this requirement. 


Principles of Bacteriology 


Sixth edition. By ARTHUR E. EISENBERG, A.B., 
M.D., Director of Laboratories, Sydenham Hospital, 
New York; Member, New York Pathological 
Society, New York; and MABEL F. HUNTLY, 
R.N., M.A., Director of Nursing, Wesson Memorial 
Hospital, Springfield, Massachusetts. With annota- 
tions and a section on Microbic Variations by F. E. 
CoLieN, M.S., Ph.D., Professor of Bacteriology, 
Vocational School, Milwaukee, Wisconsin. London: 
Henry Kimpton. 1935. Pp. 378. 12s. 


THIS is an American work designed as an introduc- 
tion to Bacteriology for Nurses. In this country 
it would be considered unsuitable for such a purpose 
as it is against our educational rule to demand so 
much in the way of theoretical knowledge from 
nurses, most of whom have had but scanty general 
scientific training to serve as a foundation. This 
book is not likely to arouse enthusiasm for the 
American system of instruction. We find, for 
example, descriptions of such uncommon diseases as 
coccidial granuloma and sprue (said to be due to 
monilia !), but the treatment of such interesting and 
important subjects as diphtheria or streptococcal 
disease is quite inadequate. What can a nurse 
profit by reading a few paragraphs on such highly 
uncertain subjects as local immunity, Rosenow’s 
elective localisation or bacteriophage, not to speak 
of the side-chain theory, bacterial variation, or the 
technique of tle Wassermann reaction? An unfor- 
tunate feature of the book is the form in which many 
of the questions are put; a statement has “T” 


THE LANCET] 


and ‘“‘ F” written in front of it with the instruction 
to circle the ‘‘T”’ if the statement is true, the “F ” 
if it is false. Here are a few examples. ‘The 
gonococcus is a streptococcus,” “Dr. W. H. Park 
is the head of the New York Board of Health 
Laboratories,” “Drs. George F. and Gladys H. 
Dick found the cause of pneumonia to be a strepto- 
coccus.” We know that nurses often have to do their 
reading when they are too tired for any mental 
effort, but this is surely going too far in “ spoon- 
feeding.” It might even dawn on the tired reader 
that if she answers sufficient questions and uses the 
throw of a coin to make her decisions she will be 
practically certain to score a comfortable 50 per 
cent. It is fair to say that as the book has reached 
a sixth edition it cannot have failed in the purpose 
for which it was intended. 


Modern Sociologists 
l. PARETO. By FRanz BorKENAvU. London: 
Chapman and Hall. 1936. Pp. 219. 6s. 
2. TYLOR. By R. R. Marett, M.A., D.Sc., LL.D., 
Rector of Exeter College, Oxford. Same 
publishers. 1936. Pp. 220. 6s. 


THESE two volumes owe their production to 
recognition by the publishers of a growing interest 
in social science, and the result is the issue of a series 
of sociological studies under the general editorship 
of Prof. Morris Ginsberg, professor of sociology in the 
University of London, and Mr. Alexander Farquharson, 
general secretary of the Institute of Sociology of 
London. The books are not intended to serve only 
as students’ text-books, but the selection of both 
authors and subjects has been made with a view to 
supplying a systematic introduction for any intelligent 
reader to the best of modern thinking about the 
- social world in which we live and work. 

1. Pareto, born in 1848, was of aristocratic Italian 
descent, but his father was for some years a refugee 
in France and the son began his education in Paris. 
The father was a Mazzinist but the son showed marked 
antagonism towards the family tradition. Pareto 
became an engineer and while quite young obtained 
a considerable position in his calling, but he was 
never able to make his opinions fit with his career. 
He was caught between a government which was 
not renouncing economic State intervention and 
the revolutionary Socialist party. His attacks on 
economic protection developed into attacks on the 
government, and his situation became impossible. 
Being a comparatively rich man he retired from public 
life, and by a fortunate accident secured a chair 
at the University of Lausanne, whence came a series of 
writings whose bitterness was due to his position 
between two incompatible attitudes, but whose teach- 
ing was none the less valuable. Pareto died when 
Fascism had been only a year in existence so that, 
although in many directions his views might have 
coincided with Fascism, there is hardly evidence 
strong enough to justify the claim of the Fascists 
that Pareto was their chief precursor. Dr. Borkenau’s 
closely explanatory description of Pareto’s teaching 
will be welcomed by students of sociology. 

2. Edward Tylor was a Quaker and was taken away 
from school too young to make it likely that he would 
develop into a scholar in the narrow sense of the 
word. In the widest sense he became a pre-eminent 
scholar, for admittedly his studies in anthropology 
made him the most learned man of his day over the 
vast field implied, though evidence forthcoming 
during the 20 years since he died would have 
extended his outlook and might have modified some 


REVIEWS AND NOTICES OF BOOKS 


[FEB. 1, 1936 263 


of his theories. His studies originated in a happy 
and accidental meeting in Cuba with the famous 
ethnologist Henry Christy. They travelled through 
Mexico together and Tylor’s first book, ‘“‘ Anahuac,” 
records their experiences. In 1860 he showed himself 
the learned anthropologist that he already was, in a 
volume entitled the ‘‘ Early History of Mankind,” pub- 
lished in 1865; here he proved the width and import- 
ance of his studies, and when in 1871 the classic work 
“ Primitive Culture ’’ appeared he became celebrated, 


gaining election as an F.R.S. while still under 30, and 


shortly afterwards the D.C.L. Oxf. Prof. .Marett’s 
exposition of Tylor’s work makes good and valuable 
reading. Such chapters as those on Society and on 
Material Culture show how great a man Tylor was 
and the important directions in which he was a 
pioneer, and the chapter setting out the connexion 
of religion and animism explains a direction of 
Tylor’s researches with which his name is especially 
associated. This is a really useful little book. 


A Doctor’s Odyssey | 
A Sentimental Record of Le Roy Crummer: 
Physician, Author, Bibliophile, Artist in Living, 
1872-1934. By A. GAYLORD Braman. London: 
Humphrey Milford, Oxford University Press. 1935. 
Pp. 340. lls. 6d. 


Trus is an intimate picture of a man who had 
a large number of medical friends and connexions 
and deserved his position and popularity. Physician, 
book-collector and virtuoso, traveller, artistic critic, 
and gourmet, he touched life at many angles and 
always received and communicated impressions. 
The author describes the biography as “‘ a sentimental 
record” and plays Boswell to his Johnson with 
admiration and without criticism. The chapter 
describing in detail the collection of books which 
Dr. Crummer made includes interesting notes on 
his activities as a collector and repeats his amusing 
little estimates of characteristics of both the shop 
and the shopkeeper at the various marts which he 
visited. The Crummer collection is now in the 
possession of the University of Michigan and will 
there remain a memorial of a very interesting 
personality. 


Quarterly Journal of Medicine 

THE January issue contains the following papers :— 

Erythrocyte Sedimentation-rate in Diseases of the 
Heart, by PauL Woop (see p. 271). 

Observations on the Treatment of Myasthenia Gravis:— 
A. M. Cooke and R. PassMorkE give the results of the use 
of various therapeutic measures on myasthenia gravis in 
a girl of 13 years. They found that glycine, acetylcholine, 
and Parathormone produced no clinical improvement, 
whereas Prostigmin by injection led to complete relief of 
symptoms for four hours, while eserine and ephedrine by 
the mouth gave a lesser but much more prolonged improve- 
ment. They also studied the creatine and creatinine 
metabolism in this patient and formed the opinion that 
the biochemical lesion is not an inability to form creatine 
from its precursors but rather an inability to metabolize 
creatine properly. 

Glycogen Disease (von Gierke’s Disease) by R. W. B. 
Ers and W. W. Paynre.—This paper is illustrated by a 
detailed account of seven cases. The familial incidence of 
many of them is demonstrated and it is suggested that 
the condition may possibly be inherited as a Mendelian 
recessive character. 

Two Cases of Muscular Degeneration Occurring in Late 
Adult Life.—S. Nevn reviews the recorded cases of late 
progressive muscular dystrophy. Pathological and bio- 
chemical examinations of the affected muscles obtained 
at biopsy were made on these two cases, and changes 
were demonstrated differing at least in degree from those 
characteristic of progressive muscular dystrophy. 


264 THE LANCET] 


REVIEWS AND NOTICES OF BOOKS 


[FEB. 1, 1936 


Achrestic Anemia.—M. C. G. IsrAets and J. F. 
WILKINSON give an account of a group of cases of megalo- 
cytic anemia which do not fit into the categories so far 
described; closely resembling pernicious anxmia, but 
differing from it, especially in course, prognosis, and treat- 
ment. This class of anemias they term “ achrestic ” 
because they seem to represent a failure to utilise the anti- 
anemic principle. The distinguishing characteristics are 
shown to be a megalocytic anemia, the presence of free 
HCl in the gastric juice, failure to respond properly to 
anti-anemia therapy, megaloblastic hyperplasia of the 
bone-marrow, and a prolonged course, eventually fatal. 

Leucocytosis in Typed Lobar Pneumonia.—JoHn 
FLEMING reports observations on the leucocyts count in 
pneumonia on a series of cases in which the special type 
of pneumococcus concerned has been determined. He is 
able to show that during the first three days of illness 
a leucocytosis of over 20,000 is characteristic of most 
cases of Type I. lobar pneumonia, while a leucocytosis 
of less than 20,000 is usually found in Type II. pneu- 
monia; further, that the leucocyte count is of prognostic 
value when the type of organism, the age of the patient, 
and the duration of the illness are all considered. 

Gargovlism.—R. W. B. Erus, W. SHELDON, and N. B. 
Capon describe a syndrome characterised by bone changes, 
a peculiar facies, congenital clouding of the corneal, 
abdominal distension with enlargement of the liver, 
spleen, and mental deficiency. They report in detail 
seven cases personally observed, and review ten cases 
from the literature. 


British Journal of Surgery 


THE January issue (Vol. XXIII., No. 91) contains 
the following papers :— 

Spondylitis Ankylopoietica, by F. CAMPBELL GOLDING 
(London). An account of the radiological findings in 
91 cases. Early joint and muscle pains occurred in the 
majority; the opinion was reached that  sacro-iliac 
disease antedated by several years the spinal changes. 

An Improved Technique for the Introduction of Radium 
Needles in the Treatment of Carcinoma of the Breast, 
by R. Brooxe (Chichester). The radium needles are 
contained in hollow trocars passed through the breast 
substance and fixed at each end in a rigid frame. 

Further Observations on the Disturbance of Metabolism 
Caused by Injury, with particular reference to the dietary 
requirements of fracture cases, by D. P. CUTHBERTSON 
(Glasgow). A diet rich in first-class protein and of high 
caloric value appeared largely to mitigate the drain on 
the body nitrogen. 

Csophagectomy for Carcinoma of the Thoracic Œso- 
phagus, by E. S. J. Kina (Melbourne). Report of a 
successful operation by the transpleural route; pre- 
liminary gastrostomy and artificial pneumothorax had 
been performed. 

Gastric Diverticula, with report of a case before and 
after operation, by G. A. Ewart and G. R. MATHER 
CoRDINER (London). Clinically there is no characteristic 
picture, and the operation is diflicult. The X ray diagnosis 
is discussed in detail. 

A Method of Treating Fractures of the Lower Limb: 
Use of a Combined Counterpoise and Traction System with 
a Thomas Leg Splint and Hinged Knee-piece Attachment, 
by A. LEWER ALLEN (Johannesburg). The splint is so 
suspended that it is used as a finely balanced, first-class 
lever, the site of fracture and the fulcrum coinciding. 

Renal Rickets and Dwarfism: A Pituitary Disease, 
by Bruce Cnown (Winnipeg). In two cases described the 
association of dwarfism, polyuria, and urinary tract 
dilatation suggest a pituitary-diencephalic lesion. Such 
a lesion was found in the second case. The nephritis is 
regarded as secondary to an abnormal mincral metabolism. 

Isolated Dislocation of the Base of the Fifth Metacarpal, 
by Norman RoBerts and C. THURSTAN HOLLAND 
(Liverpool). Forward and inward dislocation (three 
cases reported) is easily reducible by traction, but requires 
prolonged extension. Outward dislocation into the palm 
(one case) may require open operation. 

Rupture of the Long Head of the Biceps Brachialis, 
with notes on four cases, by H. A. H. Harris (Chelms- 
ford). Two cases were successfully treated by suture of the 
long head of the biceps to the coracoid process of the scapula. 


Progressive Post-operative Cutaneous Gangrene, by 
H. T. Cox (Manchester). A case is reported which showed 
extensive sloughing and a definite zone of black gangrene. 
Histologically the process was limited to the true skin. 
Operation was successful. 

Intravenous Pyelography in a Series of Cases after 
Transplantation of the Ureters, by G. Grey TURNER 
(London) and J. H. Sarnt (Newcastle). Investigation 
in six cases showed satisfactory renal function in five; 
in one only was there impairment on both sides, and that 
was partial. The action of the whole colon as a urinary 
reservoir was demonstrated. 

A Gridiron Access to the Biliary Apparatus, by C. 
JENNINGS MARSHALL (London). An external rectus 
incision is carried down to the posterior layer of the 
rectus sheath and through the posterior lamina of the 
internal oblique aponeurosis. The transversalis is divided 
by transverse incision. 

Mucoid Carcinoma of the Cæcum in a Boy of 13 Years, 
by Rosertson F. Oev (Edinburgh). The diagnosis 
at operation was tuberculosis of the cecum. Death 
occurred by generalised metastasis. 

Anterior Dislocation of the Hip, by J. A. MACFARLANE 
(Toronto). Open operation was required in a case of 
suprapubic dislocation, although attempts at manipulative 
reduction were made immediately after the accident. 

Calcified Cyst of the Pericardium, by A. Dickson 
Wricut (London). A hematoma, caused by a blow with 
a hockey-ball, became encapsuled and calcified. Successful 
removal is reported. 

A Chloride-secreting Papilloma of the Gall-bladder. 
A Tumour of Heterotopic Intestinal Epithelium: with 
a critical review of papilloma of the gall-bladder, by 
A. B. Kerr and A. C. LENDRUM (Glasgow). Chole- 
cystostomy was followed by such excessive chloride 
loss as to prove fatal. 

The Treatment of Acute Mammary Abscess by Incision 
and by Aspiration, by R. J. V. BATTLE and G. N. BarLey 
(London). A method is described of treatment by repeated 
aspiration and washing out with Dakin’s solution. The 
indications for this method and for incision are discussed 
in five types of breast abscess. 

The Influence of (Estrogenic Compounds in Causing 
Hernia and Descent of the Testis in Mice, by Haro tp 
Burrows (London). (Œstrone has been found to inhibit 
or prevent descent of the testis. Scrotal herniw are 
induced by every potent cestrogenic compound, but only 
in the presence of a mature or nearly mature testis. 

An Exporimental Method of Providing a Collateral 
Circulation to the Heart, by LAURENCE O’SHAUGHNESSY 
(London). A pedicled omental graft has been applied 
to the surface of the heart, the experiments being carried 
out in 14 cats and 2 dogs. 


There is an account of a visit to the surgical clinic 
of the St. Vincent’s Hospital, Melbourne ; and also 
reports on cases of special interest and rarity. 


AN INTERESTING AMALGAMATION.—A notice appears 
in the current Riforma Medica announcing an 
amalgamation for subscription purposes of the three 
Italian medical journals, Jl Policlinico, La Riforma 
Medica, and La Minerva Medica. The communica- 
tion points out that such a conjunction offers to the 
medical profession the opportunity of keeping in 
touch with all professional activities in much more 
convenient circumstances through the medium of 
the three great magazines. The combined subscrip- 
tion to the three journals is 150 Lire in Italy, and the 
subscription can be sent to the managers of any of 
the three papers; it can be made in two sums of 
75 Lire each, the first of which is due now, the second 
instalment falling due on June 30th. Subscribers 
to the three periodicals will not only receive the 
journals at this reduced price, but will be allowed 
a discount of 10 per cent. on all the publications 
of the journalistic group P.R.M. It is suggested 
that by placing the subscribers in a position to estimate 
the progress of medical literature in a very convenient 
manner they will reap advantage, while the Journals 
will be able to realise through the union a valuable 
conjunction of work and influence and stability. 


THE LANCET] 


THE LANCET 


LONDON : SATURDAY, FEBRUARY 1, 1936 


PHYSICAL STANDARDS IN INDUSTRY 


In his opening address on Jan. 24th to the 
newly formed Association of Industrial Medical 
Officers Sir Davin Munro remarked how difficult 
it had been since the war to obtain systematic 
data about the physical condition and state of 
health of any large groups. The report by National 
Service medical boards upon the physical examina- 
tion of 2} million men of military age in 1918 had 
given rise to alarm at the time, but statistical 
criticism had since shown that except for youths 
of 18 the examinees could not be regarded as a 
representative sample of the nation’s manhood. 
But that census did show a mass of remediable 
defects among those of an age to start on an 
industrial career ; and recent rejections of recruits 
for the Army and Air Force told the same story. 
At the head of the causes for rejection stood such. 
items as loss and decay of teeth, deformities of 
feet, defects of vision and hearing—in particular 
middle-ear disease—and heart trouble, many of 
them remediable defects. Prof. E. P. CaTHcart’s 
investigation for the Industrial Health Research 
Board included measurements of height, weight, 
and strength in men representative of every section 
of the working community, but it had not been 
found possible to correlate these measurements 
with the disabilities causing rejection, although 
again there was no question of the magnitude of 
the remediable defects. Bearing all this in mind, 
Sir Davip went on to suggest that medical officers 
in whole-time employment with industrial firms 
were probably better placed than any other 
scientific men or administrators for getting infor- 
mation about physical fitness or unfitness. What 
he would like to see was some system of setting 
out essential data of physique and disabilities 
found on entry and of recording them on some 
kind of agreed form, so that the data collected 
would be comparable firm by firm. It should 
also, he hoped, be possible to keep a-record of the 
numbers rejected and of the causes of rejection, 
which would throw light on the known gaps in our 
existing health services. He would also like to see 
the data of physical states at entry and causes for 
rejection, followed by a comparison of those who 
are successful in industry, entered on these 
standards, with an unsuccessful group. If a 
medical record of sickness could be kept for 
every one of the personnel followed up, it would 
surely throw much more light than we have at 
present on the causes, incidence, and prevalence 
of occupationa] disease ; and here again the entries 
should be on an agreed form comparable between 
one firm and another, for the key to advance in 
knowledge of occupational disabilities is accurate 
diagnosis. What he was suggesting was in fact a 


PHYSICAL STANDARDS IN INDUSTRY 


~ 


[FEB. 1, 19386 265. 


piece of combined research in which the Research 
Board could assist. The first step towards such 
collaboration would be for medical officers to send 
to the Board such records as they now keep ; with 
the aid of expert medical statisticians it should then 
be possible to see what can be made of existing 
systems and what is required for coérdinating 
further information. Sir. Davip Munro touched 
on the difficulty, well known to the Research 
Board, that operatives are shy of medical examina- 
tions. These objections on the part of the worker 
(to quote the introduction to one of the Board’s 
annual reports) are easy enough to understand and 
are due partly to the spectre of unemployment 
which is always before his eyes and partly to there 
being many things about medica] examinations, 
as he has experienced them, which offend his sense 
of fair play. To both of these factors is due a 
suspicion that, if the slightest physical defect is 
shown in the examination, it will be recorded 
against his name, and should the management 
have anything against him it will serve as an 
excuse to get rid of him; for he must know that 


‘physical unfitness is often an excuse for dismissal. 


Sir DAvip was hopeful that the Association would 
be able to collect the information without exciting 
prejudice. What.he had in mind was strictly a 
piece of research. There was no intention of 
making an official collection of sickness statistics 
in rivalry with those of the Ministry of Health 
and the General Register Office. 


RADIOLOGY IN RELATION TO OBSTETRICS 


ALTHOUGH in the past few years, as the result 
of improvements in apparatus and the develop- 
ment of new techniques, the place of radiography 
in the study of the pregnant woman has been 
generally realised in continental countries and 
in America, obstetricians in this country have 
not availed themselves of radiographic facilities 
to. the same extent. At combined sections of the 
Royal Society of Medicine, where the subject was 
discussed last week, Prof. FLETCHER SHAw divided 
the blame between the obstetrician and the radio- 
logist ; while the one had been slow in utilising 
radiological methods, the other had been slow in 
developing the technique. It would now appear 
that the obstetrician is at last becoming cognisant 
of the great help he may receive from X ray 
examination of his patients; introducing the 
discussion Prof. D. Dovuaat said that in every 
maternity hospital it was essential to have a 
radiological department equipped and staffed for 
diagnosis and research. It is to be hoped that this 
standard will now be generally accepted, sight 
not being lost of the fact that X ray examina- 
tion is supplementary to but does not supplant 
thorough clinical examination. Further, in order 
that the utmost may be obtained from his work, 
the radiologist should be in full possession of 
clinical data about the patient, since in all radio- 
logical investigations it is by correlation of the 
clinical and radiological evidence that the ultimate 
diagnosis is reached. In addition, if antenatal 
radiography is to advance, the radiologist should 


266 THE LANCET] 


AN ELOQUENT GOOD-BYE 


[FEB. 1, 1936 


be informed of all pertinent events subsequent to 
his examination ; from a consideration of these 
he will learn what modification in technique 
may be required to get even better results. In 
the early months of pregnancy a positive diagnosis 
may be established by radiography at the sixteenth 
week; by this time the vertebral bodies and the 
vertex of the skull are ossified sufficiently to cast 
characteristic shadows. It is perhaps not too 
much to hope that further refinement in technique 
may demonstrate foetal parts as early as the twelfth 
week. The Aschheim-Zondek test is positive much 
earlier than this, but the demonstration of foetal 
parts is incontestable. 

Radiographic pelvimetry has proved its value ; 
with radiograms taken under standard conditions 
it is possible by a simple calculation to determine 
the diameters of the pelvis. Measurements should 
be made as early as possible before the uterine 
contents obscure the definition. At the same 
time as the pelvic diameters are ascertained it will 
be possible to exclude deformities of the pelvic 
inlet, whether due to congenital abnormalities, 
skeletal dystrophies, or local bone disease. The 
information thus gained may lead the obstetrician 
to anticipate difficulties which might be encountered 
when labour commences. As gestation advances 
radiography is of help in determining multiple 
foetuses, in recognising abnormalities of the foetus, 
and in estimating the maturity of the foetus 
more accurately than can be done by calculation 
from the date of the last menstrual period. 
Towards term the position and presentation can 
be shown on the film, information that is not 
always certain even when the clinical examination 
has been made under general anesthesia. About 
the value of cephalometry or the mensuration of 
the foetal head there is more difference of opinion ; 
during labour it is the bony pelvis which is rigid, 
whereas the foetal head is capable of alteration in 
its diameters. But Dr. L. N. REEcE is confident 
that cephalometry may be used to fix the last 
moment at which the head will pass through the 
birth canal. In the diagnosis of placenta previa 
two radiographic methods are available. In the 
first the amniotic fluid is rendered radio-opaque 
by the injection of a medium like Uroselectan B 
when the placental site will be shown as a defect 
in the shadow of the amniotic fluid ; this method, 
known as amniography, is not free from the risk 
of inducing premature labour and foetal death. 
In the second method the bladder is filled with a 
solution of sodium iodide, when a central or 
marginal placenta previa is revealed by an altera- 
tion in the position of the shadow of the foetal 
head in relation to the superior outline of the 
bladder. In the diagnosis of pyelitis of pregnancy 
help may be had from intravenous urography 
in assessing the excretory power of the kidneys 
and the degree of enlargement of the renal pelves, 
their calyces, and the ureters ; when the diagnosis 
has been made serial urograms may be used as a 
guide to treatment. Over and: above all this, 
should the pregnant woman present signs or 
symptoms of intrathoracic mischief the radio- 
logist should be called in. 


It has been argued that antenatal radiography 
is unnecessary since the majority of labours 
terminate normally, but as Prof. DoUGAL remarked 
at the R.S.M. discussion this argument would 
apply just as much to clinical pelvimetry. And 
surely the early recognition of abnormalities, 
maternal and feetal, will do something towards 
reducing mortality? The demonstration of 
multiple fostuses will prepare the mother for 
unexpected additions to her household, while the 
demonstration of foetal abnormalities will prepare 
the obstetrician for difficulties in the conduct of 
the labour and may in some instances lead to the 
induction of premature labour. Reckoned in 
terms of money, X ray examination looks expensive 
in comparison with other methods of investigation ; 
but its routine use would soon bring down the cost 
considerably, and complications avoided should 
be entered on the credit side. 


AN ELOQUENT GOOD-BYE 


A FEW days ago Lord HORDER marked the end 
of his term as physician to St. Bartholomew’s 
Hospital by addressing his colleagues at the 
hospital and the students in a farewell address. 
The address, with which the issue of THe LANCET 
opened last week, is an able review of the situation of 
clinical medicine, in which the author traces in wise 
and witty terms the main reasons for its present 
position, and closes by pointing shrewdly to a 
place where the clinical training of students might 
well be and could easily be bettered. 

The orator testified to being a personal witness 
in his own time of three great advances in the 
science and art of clinical medicine which have 
rendered the doctor of greater service to the 
patient. That he would mention two of these 
advances would be immediately guessed, for it is 
plain how immeasurably, whether in the field 
of the internal physician or in that of the surgeon, 
precision of diagnosis and treatment has been 
gained through radiology; and equally plain 
is it that the correlation of laboratory methods 
with ward work has brought about similar 
enlightenment to the physician of the day that 
was denied to an older generation. But to the 
wisdom and skill of that older generation Lord 
HORDER paid tribute when he pointed out that, 
although deprived of the opportunities for more 
accurate knowledge enjoyed by their successors, 
they were able to meet difficult situations often 
in an astonishingly pertinent manner through 
cultivated powers of observation. Consultation 
of obituary notices of our forefathers will show 
how often they had impressed their contemporaries 
by their apparently intuitive knowledge ; appar- 
ently they guessed, for it might happen that the 
surmise turned out to be correct when its author 
could not supply hard-and-fast reasons, but really 
they were deducing their view from things detected 
by their sharpened senses, though unrevealed to 
those less fortunately endowed. The other factor 
to which Lord Horprr attributed the main 
progress in clinical medicine is relevant here. It 
is the increased frequency of and greater thorough- 
ness In post-mortem examinations. “ The clinician,” 


THE LANCET] 


|. .WHAT’S HIS NAME? 


A 


[FEB. 1,1936 267 


he says, “ began to think morbid-anatomically.”’ 
That is exactly what the old observer was doing, 
though he had not the same chances which his 
modern example enjoys of ascertaining in the 
dead-house whether his solution of the cross-tissue 
lights had been correct. It is clear from older 
medical literature that great importance was 
attached by many physicians to the lessons of 
post-mortem pathology, but the facilities for 
learning the lessons of the post-mortem room were 
even in times comparatively recent very scanty at 
many institutions. It is a notable advance in 
clinical medicine that the better opportunities 
should be more generally utilised. 


Particular attention may be drawn to Lord 
HoRDER’s suggestion that in one place the medical 
education of the senior student could be definitely 
improved to the saving of his time, and the advance 
of his appreciation of clinical work. His actual 
words are : 


The fundus oculi and the membrana tympani are 
normal anatomical structures, yet few clinical clerks 
have ever seen them before they enter the wards 
and, largely as the result of this fact, some have not 
seen them clearly even when they leave. We could 
profitably exchange the time spent over theories of 
colour vision and the intimate structure of the organ 
of Corti for these important matters: The blood-cells 
are a part of normal histology, but they have rarely 
been counted, or, if they have, it has only been 
during the demonstration of the Thoma-Zeiss 
pipette. The contours of the abdomen, the reflexes 


and tendon-jerks, the normal gait, the surface 
markings of the lungs, the deposits that may occur 


‘in urine apart from disease, the flora of the fæces 


in health . . . is it really economical that the time 
of the clinicians—and of the senior clinicians— 
should be taken up in teaching about these things ? 


Similar observations have been made by the 


orator himself and by others in the recent dis- 


cussions of the medical curriculum. And in the 
many places in which practical reform has lately 
taken place no doubt the criticism has been met, 
but it is a point which all teachers in all schools 
might well remember. While abstaining almost 
wholly from reference to himself in his eloquent 
farewell words, Lord HORDER, we may be certain, 
is here alluding to a situation in medical training, 
the effect of which he has often felt personally. 
To a great teacher nothing is more baulking than 
to find that the lessons which he is striving to 
convey are rendered of little use to his audience 
by their lack of fundamental knowledge, and all 
the members of hospital staffs will remember: to 
have been hampered in their educational work in 
this manner. Also many a man, looking back on 
his career as a student, will wish that he had 
been made to lay down as part of his regular 
routine that foundation for work which later he 
was compelled to construct, as best he could, 
beneath an erection already to some extent 
elaborated. Lord Horprr’s words are very 
timely. 


ANNOTATIONS 


WHAT'S HIS NAME ? 


Ir is in keeping with current tendencies in medical 
psychology that disorders of memory are chiefly 
regarded from the standpoint of emotional inter- 
ference. Where a memory has been lost or falsely 


recalled, it is in such mechanisms as repression that 
we are apt to seek the explanation, unless con- 
cussion or some other crude damage is to blame. 
Engrams and biological memory do not preoccupy 
us as they did the readers of Semon, although the 
ancestral memory of Jung and the organic mneme 
of Rignano are not far removed from Semon’s con- 
ceptions. Among non-medical psychologists to-day 
there are some who have studied the development 
of memory in young children; but there are few, 
medical or otherwise, who have investigated how 
this function behaves during the later life of a normal 
person. To read psycho-analysts, one might suppose 
that a man would have every experience from the 
cradle to the analytic hour available to memory, 
if only the appropriate conditions for its recall could 
be analytically brought about ; to read the psychia- 
trists, one might suppose that between the extremes 
of arterio-sclerotic or senile dementia on the one 
hand, and the boasted mental vigour of a Cornaro 
on the other, there is no change in the powers of 
memory that one may look for among men who 
had reached or passed middle life, no failure that 
comports with the slow physical changes that betoken 
age without presaging decay. Yet we all know, in 
ourselves or our intimates, how insensibly the recalling 
of names and dates becomes less prompt and casy 
as the fifties pass into the sixties. It has been pointed 
out that such a falling-off may be compatible with 


continuously productive mental work within an 
accustomed sphere, though unexpected demands 
upon the memory, or emotional disturbance, will be 
likely to accentuate the affection. It is perhaps 
significant that some elderly writers on these topics 
have said that the function of memory is in a certain 
regard inversely proportional to intelligence ; people 
with exceptionally good memories produce nothing 
new because they do not “work over,” and uncon- 
sciously modify, their material as less gifted people 
do. Hence, thought Kraepelin, the few hours of 
sleep that these fellows of prodigious memory usually 
require; they do not have to use sleep for working 
over their memories, as the rest of us must. Forel 
declared that forgetting is one of the conditions of 
intelligence. Against these partial views may be 
set the words of Pascal, a man as phenomenal in 
memory as in intelligence, who wrote (Pensées, 
Article XXV., 14): “La mémoire est nécessaire 
pour tous les opérations de ľesprit.” Certain it is, 
that to be unable to recall at need is a provoking 
experience to those who have been accustomed to 
find their memories loyal and prompt. The order 
of these lapses is unclear. , Although for the grosser 
defections, Ribot’s law of regression may suflice, the 
much commoner elusiveness of names must be 
brought under some other rule. Bleuler,! unrepentant 
apostle of associationism, would have it that sub- 
stantives go first, and especially concrete ones, 
because in them the word is less important than in 
the case of verbs and conjunctions and other indica- 
tions of a relationship ; for the mental representation 
of the concept “Jackson ”? or *“‘ table °? the word is 


1 Bleuler, P. E.: 
Springer. 1932. 


Naturgeschichte der Seele. Perlin : J ulius 


268 THE LANCET] 


scarcely necessary, the image of the object sufficing, 
whereas in the case of abstract images the word 
supplies the simplest and clearest component which 
can easily release definite associations or can itself 
be stirred readily from without into activity. Bleuler’s 
treatment of the matter raises issues that can scarcely 
be studied without regard to the verbal and nominal 
losses in aphasia—and to begin to discuss aphasia 
is to open the floodgates, if not to plunge into the 
bottomless whirlpool. . 


ROUTINE EXAMINATION OF MILK FOR 
TUBERCLE BACILLI 


WHEN milk is to be tested by guinea-pig inoculation 
for the presence of tubercle bacilli the technique 
adopted must depend on a compromise between 
accuracy and expense. A single guinea-pig is liable 
to die prematurely, and if there are very few bacilli 
in the milk they may not produce lesions in every 
animal. An attempt has therefore been made by 
Mattick and White! to estimate the increase in 
efficiency obtained by inoculating two guinea-pigs 
per sample in place of one. Their findings are based 
on examination of 4775 samples, of which approxi- 
mately 3100 were bulk samples while the rest came 
from individual cows. From the results it is calculated 
that if 1000 bulk samples were tested by inoculation 
of a single guinea-pig 84 reinvestigations would be 
needed because of premature death whilst 62 positive 
samples would be falsely reported as negative. If 
two guinea-pigs were used instead of one, only seven 
reinvestigations would be needed because of the 
premature death of both animals, and only four false 
negative results would be returned. These figures 
make very clear the advantage of using two experi- 
mental animals for every sample. Another question 
concerns the actual technique. In the present 
investigation the deposit from 75c.cm. of milk, 
centrifuged for 20 minutes at 3000 r.p.m., was 
emulsified in 5 c.cm. of saline and divided between 
two guinea-pigs. It may be asked why the test 
should not be made more sensitive by inoculating 
each animal with all the deposit from 75 c.cm. of 
milk; this would not add much to the expense 
of the test though it would of course increase the 
labour of centrifugation. Mattick and White do 
not comment on this point, but there are two obvious 
objections to the use of large quantities of milk. 
First, by doubling the strength of the inoculum, 
the amount of extraneous matter, other than tubercle 
bacilli, is doubled and the chance of intercurrent 
infection thus increased ; for the observations recorded 
show that the amount of dirt in the inoculum influences 
the probability of premature death. Secondly, the 
problem of transit of samples may make it difficult 
or even impossible to obtain large quantities of milk. 
Against these objections must be weighed the undeni- 
able advantage of increasing the concentration of 
tubercle bacilli by doubling the volume of milk 
tested. In the present experiments each pair of 
guinea-pigs was kept in a single cage and out of the 
9550 which were inoculated about 10 per cent. died 
prematurely. This figure, which agrees with those 
given by other workers, might well be lowered if 
only one animal was kept in each cage, but the 
extra attention and accommodation required might 
neutralise the economy. 

It is noteworthy that in Mattick and White’s 
inquiry only 13 per cent. of samples taken from cows 
suspected, on clinical grounds, of suffering from 


a a T. R., and White, P. 


: Med. Oficer, Dec. 28th, 
1935, p. 26 


RECURRENT PAROTID SWELLING 


[FEB. 1, 1936 


tuberculous mastitis proved to be excreting tubercle 
bacilli in the milk. Superficially this figure reflects 
upon the value of the routine clinical examination 
of udders for suspicion of tuberculosis. But it must 
be remembered that tuberculosis is only one of 
several common causes of chronic mastitis and the 
symptoms of tuberculous mastitis are by no means 
characteristic. In all cases of doubt a sample must 
be sent in for laboratory examination and this 
may well account for the low proportion of peo 
returns, 


RECURRENT .PAROTID SWELLING 


Mocu attention has lately been paid to recurrent 
swelling of the parotid gland, partly in the hope of 
elucidating its pathology and partly to show that it 
differs from epidemic parotitis. The newer methods 
of investigation, such as sialography, and the examina- 
tion of catheter specimens of parotid saliva, have 
thrown some light on the condition, but the various 
investigators have naturally tended to emphasise 
different aspects of the problem, and „their data 
are not always comparable. 

The diagnosis is used to cover all cases of periodical 
or recurrent enlargements of the parotid, irrespective 
of the frequency or duration of the attacks or the 
underlying lesion. In 19 such cases studied by 
Payne,! no fewer than 16 of the patients were women, 
the average age at onset being 29, and the average 
duration of symptoms nine years. As a whole, 
the group showed nervous instability, and there were 
wide variations in their attacks. Characteristic 
changes were found in the saliva, which was always 
infected (most commonly. with Streptococcus viridans) 
and sialography demonstrated equally characteristic 
changes in the ducts, strongly resembling those 
of bronchiectasis. Similar cases have been recorded 
by Pyrah,? and more recently Pearson? has 
described a series of 17 cases, 13 of them in 
children under twelve. This series differs from those 
previously described not only in age-incidence, 
but also in the preponderance of males and the 
rapidity of appearance and disappearance of the 
swelling in many of the children. Pearson divides 
his cases into non-infected and infected, but it is not 
clear whether bacteriological culture of the saliva 
was carried out in all of them. Sialography in both 
groups showed changes like those recorded by Payne. 
In a large proportion of the cases there were associated 
symptoms attributable to allergy (e.g., asthma, hay- 
fever, or urticaria), and the saliva of one patient 
during the attacks contained plugs packed with 
eosinophils. In this connexion the report of Meyer ' 
of a familial history is interesting ; his patient, the 
mother, and the great grandmother had all suffered 
from recurrent parotid enlargement. 

From the practical point of view, two facts are 
especially important. The first is that many of the 
cases are diagnosed and treated as mumps, or as 
recurrent mumps, though it is doubtful whether 
there is ever a second attack of mumps. Secondly, 
it is noteworthy that gross suppuration is rare, 
although the local condition may be disconcerting, 
and the immediate prognosis is therefore good. 
The separation of these cases from recurrent swelling 
of the parotid due to calculi should not be difticult, 
but swellings of the same kind have been recorded in 
toxic conditions such as lead-poisoning or in associa- 
tion with the use of iodine or mercury. Similarly, 


1! Payne, R. T. : THE LANCET, 1933, i., 348. 
? Pyrah, L. N. : Brit. Jour. Sure., 1933, xx. , 508. 
* Pearson, R. S. B. : Arch. Dis. Childhood, October, 1935, p. 363. 
‘Meyer, H. Ss. : Jour. of Pædiat., 1934, iv., 248. 


THE LANCET] 


they should be readily differentiated from the 
occupational enlargements of the parotids seen in 
glass-blowers and players of wind instruments and 
occasionally in malingerers, for in these the swellings 
are pneumatoceles, For the rest it must be admitted 
that no uniform explanation is applicable to the 
groups of cases now being considered. The rapid 
development of the parotid -swellings in early life 
and their frequent association with allergic symptoms 
are striking features, as is also the observation that 
in adults they are associated with emotional instability. 
As seen on X ray examination the changes in the 
ducts are alike in children and adults. Whether the 
primary obstruction is allergic, spasmodic, or catarrhal 
is uncertain, but once it has developed, it is followed 
by dilatation and sooner or later by infection. In 
childhood it may be found that the attacks cease with 
the elimination of certain articles of food from the 
diet, with the clearing-up of buccal infection or with 
simple massage of the parotid gland. In adults 
the same methods may be successful, but where 
organic changes are more advanced, slitting and 
dilatation of the duct, auriculo-temporal avulsion, 
and X ray treatment may all give better results. 


PHYSIOLOGICAL CHANGES DURING PUBERTY 


ALTHOUGH much statistical information is available 
concerning growth in the years of puberty, it is mostly 
based on the study of large groups of children at 
different age-periods. Thus it has been shown that 
about two years before puberty begins there is a 
slowing in vertical growth, followed by a rapid 
increase during several subsequent years, girls being 
taller than boys. The maximum increase in weight 
occurs slightly later than the maximum increase in 
height. Of the signs of puberty in girls, breast 
development is usually the first, and it is followed 
by rounding of the hips and the appearance of pubic 
and axillary hair, in that order. As a rule menstrua- 
tion is the last, or almost the last, sign, becoming 
established when breast development is nearly 
complete. 

Thinking in terms of the individual rather than the 
age-group Dr. Gustav Nylin ! has made an intensive 
study of 12 girls in the four years during which 
the onset of puberty might be expected. They were 
inmates of the State Institute for the Blind at 
Tomleboda, and were most of them suffering from 
congenital eye defects, but they were chosen because 
their physical and psychical status was otherwise 
as nearly as possible normal. Conditions of examina- 
tion were standardised. In all but one subject the 
maximum growth in height was found to correspond 
with the commencement of puberty, though the 
age at which this occurred varied considerably 
(from 9-8 years to 14 years, with an average of 11-8). 
The duration of this maximum height increase varied 
from 471 to 884 days, and in most cases breast develop- 
ment was complete when growth ceased. As breast 
development was found to be the first sign of puberty, 
there therefore appeared to be a close relationship 
between breast development and height increase. 
The thyroid also seemed to increase in size during 
the same period, but as the means of measuring its 
growth were not accurate, little emphasis can be 
laid on this impression. Nylin also found that the 
height-increase declined when menstruation began. 
The arteriovenous oxygen difference under standard 
conditions proved singularly constant during growth, 
from which he: concludes that the blood flow is a 


1 Physiology of the Circulation during Fuberty. Acta Med. 
Scand., Suppi. lxix., 1935, p. 77. 


THE WILLIAM HARVEY MEMORIAL 


[reB. 1, 1936 269 


direct function of standard metabolism, since the 
latter was observed to increase considerably during 
the period of maximum growth. The pulse-rate 
fell throughout the period of study, and showed 
no signs of rising with the onset of puberty; but 
there was a rise in both systolic and diastolic blood 
pressure during the period of development. The 
vital capacity also increased during development, 
though its increase became manifest later than the 
other functional changes. 


THE WILLIAM HARVEY MEMORIAL 


WE wish to impress earnestly upon our readers the 
situation of the Harvey Memorial Fund instituted 
some time hack with the object of rebuilding the fallen 
tower of Hempstead Church, Essex. Our readers 
have been kept informed of this movement and 
must sincerely 
hope with us 
that it will 
soon come to 
a satisfactory 
conclusion, for 
the delay has 
been regretted 
by many, 
though strenu- 
ous efforts have 
so far failed to 
abbreviate it. 
The present 
position is 
that the work 
of restoration, 
which so far 
has been ex- | 
ceedingly well 
carried out, 
has ‘proceeded, 
and about two- 
thirds of the 
structure has 
been restored ; 
but the fund 
is now exhausted and progress has ceased. 
The last third of the work, which includes 
the rehanging of the bells, remains to be dealt with, 
and a sum of approximately £2000 is yet required 
for the termination of the undertaking. Lord Horder 
has become chairman of the committee in the place 
of the late Sir John Rose Bradford, and all donations 
should be made payable to the Harvey Memorial 
Fund and sent to Dr. G. de Bee Turtle, Royal 
College of Physicians, Pall Mall East, London, S.W.1. 


AN ANTISTREPTOCOCCAL AGENT 


INTEREST has lately been aroused by the claims of 
German workers to have synthesised a chemothera- 
peutic compound efficient against streptococcal 
infections. This substance, which has been named 
Prontosil, when given either subcutaneously or by 
the mouth, protected mice against a lethal dose of 
streptococci injected into the peritoneal cavity. 
Whereas in untreated animals there were enormous 
numbers of cocci in the peritoneal exudate, in those 
treated with prontosil the organisms were few and 
mainly undergoing phagocytosis. The drug has no 
appreciable bactericidal action in vitro, and the 
mechanism by which it acts in the body was there- 
fore obscure. At a discussion in London last autumn 1 


1 THE LANCET, 1935, i., 840. 


270 THE LANCET] 
it emerged that English workers had been able to 
confirm the original claims only in part; a longer 
survival in experimentally treated mice was com- 
mon, but ultimate recovery, so far from being the 
rule, was rather the exception. This difference was 
apparently attributable to the properties of the 
streptococci used, those in the favourable German 
experiments being derived directly from human 
sources, whereas in England the strains employed 
had been submitted to repeated mouse passage, 
with a consequent increase in virulence for mice. 
The still more recent findings of C. Levaditi and 
A. Vaisman,? who used non-passaged strains, 
indicate a striking therapeutic effect, but one to 
which there were exceptions in every series of animals ; 
with whatever dosage, either of the drug or of culture, 
100 per cent. survival was never obtained. These 
investigators also report experiments designed to 
ascertain how the drug acts. On the possibly inade- 
quate ground that reticulo-endothelial “ blockage ”’ 
does not interfere with the therapeutic action of 
prontosil, they conclude that its effect is not secured 
by any sort of stimulation of the defence mechanism. 
On the other hand, they have come to the conclusion 
that it acts by preventing capsule-formation, and so 
rendering the streptococcus susceptible to phago- 
cytosis. This plausible idea is supported only by 
the observation that the drug is ineffective when 
the inoculum consists of (capsulated) streptococci 
derived directly from the peritoneal cavity of another 
mouse. The hypothesis may very well be true, but 
it perhaps requires verification by other means. 
Meanwhile the therapeutic utility of this drug needs 
to be studied further in the clinical field, though the 
temptation to its indiscriminate employment should 
be resisted. Levaditi and Vaisman have shown by 
experiment that prontosil is without influence on a 
number of other bacterial and virus infections, and 
the original clinical results reported from Germany 
indicate that it is of value only in infection by Strepto- 
coccus pyogenes. Its use should evidently be restricted 
to cases of this infection. 


RECONSTITUTION OF DURHAM UNIVERSITY 


TE Commissioners appointed under the University 
of Durham Act, 1935, have drawn up a first draft of 
statutes for the reconstitution of Durham University. 
Under the new constitution the Newcastle College 
of Medicine and Armstrong College will cease to 
exist as separate corporations and be merged in 
University College, Newcastle-upon-Tyne. The coun- 
cil of University College will consist of the principal, 
the dean of medicine, six and twelve members to be 
appointed in the first instance by the existing councils 
of the College of Medicine and of Armstrong College 
respectively, six members to be appointed by the 
academic board of University College, four members 
by the Newcastle City Council, two members by the 
Northumberland County Council, two members by 
the house committee of the Royal Victoria Infirmary, 
one member by the committee of management of 
Newcastle-upon-Tyne Dental Hospital, two members 
representative of other associated hospitals, and, if 
the council so determine, two codpted members. 
None of the members appointed by the existing 
council of the College of Medicine shall be full-time 
teachers and not more than two shall be part-time 
teachers in University College. The council will 
appoint a dean of medicine for a period not exceeding 
five years who shall be responsible—under the 
authority of the council, the academic board, and the 


* Presse méd., Dec. 25th, 1935, p. 2095. 


RECONSTITUTION OF DURHAM UNIVERSITY 


[FEB. I], 1936 


principal—for guiding the organisation and develop- 
ment of medical education and research and for main- 
taining close relations between University College 
and the associated hospitals. All matters relating 
to the organisation of medical education and research 
shall be referred in the first instance to a medical 
studies committee of the academic board. As soon 
as possible after the appointed day a temporary 
Newcastle council will be formed which will forthwith 
appoint a dean of medicine who shall thereupon 
become a member of the temporary council in place 
of the existing dean of the board of the faculty of 
medicine. As soon as this appointment has been 
made the temporary council will provisionally deter- 
mine, without any report from the academic board, 
what holders of academic posts shall be members of 
this board. The Commissioners are ready to receive 
and consider any representations made to them 
before April Ist, 1936. Such representations should 
be sent to the secretary to the Commissioners, 3, 
Sanctuary Buildings, Great Smith-street, London, 
S.W.1. : 
ACTION OF AMYL NITRITE 


TuE inhalation of amyl nitrite as a treatment 
for angina pectoris was introduced by Lauder 
Brunton in 1867. He tried it because he knew 
that venesection diminished the severity of the 
attacks of pain and it seemed to him that amyl 
nitrite, a drug already known to diminish vascular 
tension, should act similarly. The striking relief 
which it afforded was related by him to the fall of 
blood pressure produced by the drug with conse- 
quent relief to the heart. This, the most apparent 
explanation, received almost universal assent and is 
still held by some clinicians. It is only of recent 
years that the view has been attacked as inadequate, 
but the cumulative evidence against it as a complete 
explanation is now considerable. 

Five years ago Lewis,! investigating a series of 
cases of angina pectoris associated with high blood 
pressure, found that amyl nitrite would often give 
relief without conspicuous change in the blood 
pressure, and concluded that the effects of the drug 
were not to be ascribed to simple lowering of the 
pressure but were ‘‘in part, if not in chief part, due 
to dilatation of the coronary vessels.” Studies on 
the relationship of blood-pressure changes to the 
disappearance of pain in angina of effort after the 
inhalation of amyl nitrite have led to similar con- 
clusions.? That amyl nitrite dilates the coronary 
vessels in animals is certain ; but the fall in systemic 
blood pressure tends to reduce the flow of blood 
and this effect might well lead to a reduction in the 
total blood-flow through the coronary arteries. 
Actual measurements in the intact animal have 
given conflicting results, although the balance of 
evidence is in favour of an increase in the total 
blood-flow. The importance of further evidence in 
man is therefore apparent. 

It is now widely believed that alterations in the 
electrocardiogram similar to those seen in coronary 
thrombosis may occur when there is a relative 
ischemia of the cardiac muscle. Nitroglycerin has 
been shown by Scherf and Schnabel ® to prevent, or 
diminish the degree of, this alteration in attacks 
of angina pectoris, and Evans and Hoyle* have 


demonstrated improvement in abnormal electro- 


cardiograms after amyl nitrite. Nagl’ has recently 


1 Lewis, T.: Heart, 1931, xv., 305. 

*Wayne, ©. J., and Laplace, L. B.: Clin. Sci., 1933, i., 103. 
3 scherf, D., and Schnabel, P.: Klin. Woch., 1934, ii., 1397. 
€ Ivans, W., and Hoyle, C.: THE LANCET, 1933, i., 1109. 
è Nagl, F.: Wien. klin. Woch., 1935, xlviii., 1543. 


THE LANCET] 


RED CELL SEDIMENTATION IN HEART DISEASE 


[FEB. 1, 1936 271 


eee 


recorded simultaneously the effect of amyl nitrite 
on the electrocardiogram, arterial and venous blood 
pressures, and heart-rate of normal persons, Altera- 
tions in the T wave of the electrocardiogram were 
brought about which are interpreted as due to a 
temporary relative cardiac ischemia. It is believed 
that this can be accounted for by the rise in ‘the 
heart-rate which increases the work of the heart at 
the same time as the coronary flow is reduced by the 
fall in blood pressure. Nagl suggests, therefore, that 
amyl nitrite should not be used in cases of angina 
pectoris with a tendency to tachycardia. It is 
known that its inhalation may rarely increase the 
severity of anginal pain ê or even induce an attack,? 
and changes such as Nagl describes may well be the 
cause. But in practice it is impossible to foretell 
which patients will respond well and which badly to 
amyl nitrite and actual trial in an attack is the only 
test. It is worth noting that patients who suffer 
from the relatively mild pain of angina of effort usually 
prefer to take nitroglycerin, while amyl nitrite is 
best reserved for the long-lasting ‘‘ spontaneous ” 
attacks in which it gives the spectacular relief on 
which its reputation rests. 


ETTORE MARCHIAFAVA 


THE death of Prof. Marchiafava in Rome has been 
overshadowed by war, but the passing of so great a 
figure in international medicine should not be for- 
gotten because he had outlived his contemporaries. 
Ettore Marchiafava was born in Rome on Jan. 3rd, 
1847, and he died there on Oct. 25th, 1935. He took 
his degree in medicine in 1871, was nominated next 
vear assistant in the 
university department 
of pathological anatomy, 
and succeeded to the 
chair in 1883 when 
Tommasi-Crudeli was 
transferred to the chair 
of hygiene. During his 
40 years as professor of 
‘pathological anatomy 
Marchiafava made many 
important contributions 
to medical knowledge. 
This was a time of 
renaissance in Italian 
medicine, in which he 
bore a distinguished part. 
He was a great teacher ; 
his lectures on patho- 
logical anatomy made the dead live again to 
his hearers as he recalled the history, the symptoms 
and physical signs, and summed up their relation 
to post-mortem findings. But outside Italy 
Marchiafava’s fame is based upon his observations 
on malaria. As early as 1879 he maintained 
that melanin was derived from the destruction of 
the hæmoglobin of the red corpuscles, and he 
went on to interpret correctly the early stages of 
development of the malarial parasite. With Celli 
he demonstrated the development of the parasite 
in the red corpuscle, the amcboid movement, and 
the production of melanin. In 1889 he and Bignami 
discovered the parasite of «stivo-autumnal or sub- 
tertian fever, and in 1892 they described the character 
of the pernicious forms. He was also able to dif- 
ferentiate the quartan from the benign tertian 
parasite. Marchiafava’s interest in pathology never 


* Wood, F. C., and Wolferth, C. C.: Arch. Internal Med., 
1931, xlvii., 339. 


ceased, and in his ninth decade he was still to be 
found at work in the Institute of Pathological 
Anatomy. 


RED CELL SEDIMENTATION IN HEART DISEASE 


THE value of the erythrocyte sedimentation-rate 
as an indication of active disease has been demon- 
strated in rheumatic carditis, and also in syphilitic 
aortitis, thyrotoxicosis, and hypertensive heart 
disease. In the January issue of the Quarterly 
Journal of Medicine Paul Wood gives the results of 
sedimentation tests done on 164 cases of all types of 
heart disease and heart failure, excluding cases with 
any form of intercurrent infection or with a secondary 
anemia as shown by a red cell count of under 4 million 
or a hemoglobin under 70 per cent. As controls 
he has used 19 patients with cardiac neuroses. He 
finds that congestive heart failure retards the 
sedimentation-rate regardless of the cardiac patho- 
logy and therefore masks evidence of active disease. 
Increased sedimentation-rates are found in active 
rheumatic heart disease, myocardial infarction, and 
syphilitic aortitis; the result in this last condition 
may help in the distinction between an aortic 
valvular disease due to syphilis, rheumatism, or 
athero-sclerosis. Again, the sedimentation-rate may 
enable one to distinguish between coronary thrombosis, 
angina of rest, and angina of effort, since in cases of 
coronary thrombosis the rate is not immediately 
increased, but after a day or two increases steadily 
to a maximum, till about the end of the third week, 
after which it slowly returns to normal. Angina 
of effort, on the other hand, shows a normal 
sedimentation-rate, and angina of rest, in the 
absence of syphilitic aortitis, gives a slightly to 
moderately increased rate which does not change 
materially from week to week. 


THE ENDOCRINE ORGANS AND INSANITY 


“ We believe that it cannot be successfully denied that 
the corpus of present day psychiatric literature conveys, 
and is intended to convey, the idea that the endocrine 
pattern is a significant and important causal factor in the 
etiology of those abnormalities of behavior that are 
collectively subsumed under the term ‘insanity.’ But 
where is there precise proof, in the truly scientific sense, 
that this is so?” 


HaAvInG put this question to themselves, and 
finding no satisfactory answer, Raymond Pearl, 
Marjorie Gooch, and Walter Freeman set about the 
task of seeing whether a statistical study of the weights 
of the endocrine organs in a group of the insane would 
provide any information from which conclusions 
could be drawn. Their study,! most carefully and 
laboriously carried out, deals with. 1307 insane 
persons dying in hospital and examined post mortem 
by Freeman. Each individual was placed, according 
to the preponderance of clinical evidence, into one 
of four broad groups—namely, cycloids, paranoids, 
schizoids, and epileptoids. This material, as the 
authors point out, has serious limitations; it 
relates wholly to a mentally diseased population, 
and standards of comparison from normal persons 
can be taken only from the very heterogeneous 
materials available in the literature. Secondly, 
the progress of the patient to death may well have 
changed the biologically normal weight relations of 
the parts. Imperfect as the data are, they should, 
however, be capable of revealing any pronounced 
differences between what the authors term the 
endocrine pattern of the psychiatric disease types. 


1 Human Biology, 1955, vii., 350 and 555. 


272 THE LANCET] 


In fact the analysis shows no striking or orderly 
difference in the weights of the various organs in the 
four groups. If, for instance, aberrations of thyroid 
structure and function are significant factors in the 
etiology of different types of psychoses, this fact is 
not reflected in any definite manner in the weight of 
the organ, so far as the present data indicate. 
the other hand, the quantitative pattern of the 
endocrine system as a whole, as indicated by organ 
weights, does appear to differ between the insane 
and the most reliable “norms” that the authors 
have been able to discover. This difference concerns 
not so much the total mass of all the endocrine organs 
taken together as a whole, in proportion to body 
size, but the pattern of the system—the proportionate 
quantitative contribution of the several organs to the 
total. Judging by this comparison, the insane 
are deficient relatively in thyroid tissue but over- 
supplied relatively with parathyroid, thymic, and 
adrenal tissue. They show only a generally small 
and probably insignificant relative excess of pituitary 
and pineal tissue and a small relative deficiency of 
testicular or ovarian tissue. 


The authors with becoming caution conclude, 
therefore, from their elaborate study that the pattern 
of the endocrine system as a whole may really differ 
significantly between the mentally diseased and the 
not-mentally diseased, but to prove this will require 
more evidence, and evidence of a different character, 
than they have been able to present. Until that 
evidence is available they suggest that vague 
generalisations about the importance of the endocrine 
glands in Insanity are premature. 


A CAUSE OF ULCERATIVE COLITIS ? 


CnRONIC ulcerative colitis is sometimes regarded 
as a sequel to bacillary dysentery and sometimes 
improves under treatment with antidysenteric serum. 
Bargen attributes it to a specific diplo-streptococcus ; 
others have put forward the claims of certain 
anaerobic bacteria. None of its “‘ causes, however, 
has yet been generally accepted and attention must 
therefore be paid to the evidence put forward by 
Dack and his fellow-workers?} in Chicago. Believing 
that no satisfactory growth of a delicate and deep- 
seated organism is likely to be obtained in ordinary 
cultures of feeces—or indeed from scrapings of ulcers 
seen directly with proctoscope or sigmoidoscope 
where the contents of the upper bowel are continually 
pouring over the ulecrated area—they have investi- 
gated 3 cases of chronic ulcerative colitis in which 
symptoms and radiographic and proctoscopic examina- 
tions were characteristic of the severe form of the 
disease, and in which the affected colon had been 
completely isolated following an end ileostomy. 
Numerous observations of these cases led to the 
recovery from the colon of Gram-negative -pleo- 
morphic non-sporulating rods extremely sensitive 
to oxygen and difficult to subculture. The same 
organism was isolated by appropriate methods from 
the non-isolated colou in 7 out of 12 additional cases 
of non-specific chronic uleerative colitis and = in 
2 cases of specific (ameehic) ulcerative colitis, Com- 
plement-fixing antibodies were found in the serum 
of 14 out of 16 cases of typical chronic ulcerative 
colitis, but in only 3 of 16 control patients. In 
several cases complete fixation was obtained with a 
serum dilution of 1 in 10. The organism in question 
seems to resemble very closely the bovine Bacillus 


1 Dack, G. M., Dragstedt, L. R., and Heinz, T. E.: 


Jour. 
Amer. Med. Assoc., Jan. 4th, 1936, p. 7. 


A CAUSE OF ULCERATIVE COLITIS ? 


On 


[FEB. 1, 1936 


necrophor»s which produces severe septic processes 
in a number of domestic animals. This organism 
may invade any tissue and produces various necrotic 
foci—e.g., calf-diphtheria, necrotic ulcers of the 
intestine in hog-cholera, metastatic necrosis of liver 
and lungs of cattle and swine, and necrotic stomatitis 
of calves, lambs, and pigs. 


MILK BY FOUR DIFFERENT NAMES 


From April Ist of this year there will be four 
grades of milk instead of the five on sale at present. 
The draft Milk (Special Designations) Order, 1936, 
does not employ exactly the nomenclature forecast 
in our leading article of July 6th last, but the scheme 
is substantially the same, with its advantages and 
disadvantages. In future there will be two grades 
of fresh milk, called Tuberculin-tested and Accredited ; 
also two grades which have been treated by heat, 
called Pasteurised and Certified (Pasteurised). The 
last-mentioned is tuberculin-tested milk which has 
been pasteurised, and it will therefore be the cleanest 
and safest of the four grades, having a bacterial 
content of not more than 30,000 bacteria per c.cm. 
(compared with 100,000 in pasteurised). The present 
top grade, Certified, which is bottled on the farm 
and contains no more than 30,000 organisms, is 
abolished. Tuberculin-tested and accredited milks 
will closely resemble the present Grade A (T.T.) 
and Grade A respectively ; but after the end of this 
year the requirement that they shall contain no 
more than 200,000 bacteria per c.cm. before delivery 
to the consumer will be replaced by a methylene-blue 
reduction test. Everyone will be glad that the 
name ‘“‘Grade A” should give way to a more non- 
committal description, and it is an advantage that 
the ‘‘ accredited ” herds should be inspected quarterly 
instead of every six months. But whatever its name, 
this type of milk cannot—as we said in July—be 
recommended by the medical profession for con- 
sumption in the raw state. 

Under the new Order the Ministry of Health will 
no longer grant licences to producers of tuberculin- 
tested milks. All the licences will henceforward be 
issued by local authorities, 


OwING to the death of King GEORGE it has been 
decided not to hold the Hunterian festival dinner 
of the Royal College of Surgeons on Feb. 14th, but 
the Hunterian oration will be delivered at 4 P.M. on 
that day by Mr. C. II. Fagge as arranged. The ball 
of the St. George's Hospital medical school on 
Feb. 19th has been cancelled, and the dinner of the 
Royal Society of Medicine on the same day has been 
postponed. Prof. Edward Mellanby’s lecture, on 
Jan. 31st to the Royal Institution, on Recent Advances 
in the Treatment of Disease has also been post- 
poned. 


INDEX TO “THE LANCET,” Yor. II., 1935 


Tur Index and Title-page to Vol. II., 1935, 
which was completed with the issue of Dec. 28th, 
is now ready. A copy will be sent gratis to sub- 
scribers on receipt of a post card addressed to the 
Manager of TuE LANCET, 7, Adam-street, Adelphi, 
W.C.2. Subscribers who have not already indicated 
their desire to receive Indexes regularly as published 
should do so now. k 


THE LANCET] 


[FEB. 1, 1936 273 


PROGNOSIS 


A Series of Signed Articles contributed by invitation 


LXXXVI.—PROGNOSIS IN ASTHMA 


It is generally held that asthma does not appear 
unless there is a hereditary predisposition, and as 
this predisposition is inherent and permanent it is 
impossible to speak of a cure for asthma. On the 
other hand, we have reason to believe from the study 
of pedigrees and from the results of skin tests on 
apparently normal individuals that the asthmatic 
tendency may remain latent throughout life, and 
we know that many patients lose their asthma for 
long periods of time. 

Little is known about the factors which detone 
the latency or manifestation of asthma. Some 
physicians of experience do not share the prevalent 
enthusiasm over modern methods of treatment, and 
believe that we are no better able to control the 
disease than were physicians of a generətion ago, 
though we are better equipped than they to relieve 
its symptoms. Asthma is a variable illness, and 
while we must often sympathise with the patient in 
his relapses, we can also congratulate him on his 
remissions. It is understandable that these remis- 
sions should be attributed to the treatment, rather 
than to that waywardness of the disease which we 
consider responsible for the relapses, and every 
therapeutic novelty is for a time regarded as a cure 
for asthma—vaccines, endocrines, allergens, X rays 
and irradiation, ketogenic diet, gold, liver, artificial 
fever, and sympathectomy. Attacks of asthma, like 
attacks of peptic ulceration or acute rheumatism, 
tend to recover spontaneously, and of patients 
seeking medical advice for asthma some 50 per cent. 
may be expected to improve without specific treat- 
ment. With few exceptions no treatment precludes 
the likelihood of relapse in a few months or years, 
and though it is possible to distinguish those who 
are likely to do well from those who are likely to do 
badly, it is rarely wise to predict complete cessation 
of the paroxysms. For all this, I believe that the 
outlook for the asthmatic~ patient to-day is better 
than it was thirty years ago. 

In what follows I shall assume the orthodox treat- 
ment of asthma. The paroxysms are relieved by 
antispasmodics such as adrenaline and ephedrine. 
Between the attacks attention is paid to the hygiene 
of life, the avoidance of overloading of the stomach 
or colon, the minimisation of contact with animal 
and vegetable dusts. Psychological stimuli are 
removed and respiratory exercises are carried out 
regularly. Septic foci and nasal abnormalities are 
treated with the utmost conservatism. When 
there is bronchitis an autogenous vaccine from the 
sputum is used, and if the patient is clearly sensitive 
to common inhalants such as pollen or orris root the 
attempt is made to desensitise him. 

The questions that arise in prognosis are (a) risk 
of death in a paroxysm ; (b) prospect of immediate 
improvement; (c) prospect of permanent recovery ; 
(d) effect of the disease on the general health and 
duration of life. 


Death in or following a Paroxysm.—It is sometimes 
suggested that asthma is more annoying than dan- 
gerous, and that it has little influence on the duration of 
life. Itis true that death during a paroxysm is unusual. 
It is nevertheless not so unusual as is taught, and 
whenever a patient passes into the status asthmaticus 
or has persistent dyspnea for more than one or 


two days the risk of sudden death should be seriously 
considered, Experience of a large clinic at which 
several hundred patients are in regular attendance 
suggests that one or two of these patients may be 
expected to die of asthma every year. Death may 
result from the immediate effects of the paroxysm, 
from heart failure, or from pneumonia. I believe 
that pneumonia is usually initiated by patchy or 
more massive collapse of the lungs induced by exces- 
sive secretion of mucus and bronchospasm, and it 
may be followed by pleurisy and empyema. A rarer 
sequel of the paroxysm is spontaneous pneumothorax, 
which is usually more alarming than dangerous. 
I have also seen cerebral hemorrhage in a young 
woman. 

Prospects of Immediate Improvement.—With modern 
treatment about 20 per cent. of patients are com- 
pletely relieved of their asthma for some years; 
between 15 and 20 per cent. are absolutely resistant 
to treatment, while the remainder are more or less 
improved though still subject to attacks. In other 
words, between 66 and 75 per cent. of cases are signi- 
ficantly improved. Failure to improve may be due 
to incomplete investigation and treatment, or to 
ignorance and lack of coöperation on the part of the 
patient. The patient may know the cause of his 
asthma but is unable to avoid it and desensitisation 
proves unsuccessful. The ability to spend one’s 
childhood at a public school on the south coast 
rather than in an overcrowded tenement in Hoxton, 
to winter in Switzerland, or to undergo a long and 
expensive course of desensitisation, is naturally an 
important element in prognosis. Favourable features 
are early age of the patient, brief duration of the 
asthma, and infrequent attacks. The popular belief 
that children ‘grow out” of asthma probably 
exaggerates the frequency of spontaneous recovery 
and should not be allowed to encourage neglect of 
treatment. A seasonal incidence and sensitisation 
to a single inhalant such as pollen, to which the 
patient can be specifically desensitised, are of good 
prognostic omen. Allergic complications such as 
hay-fever, rhinorrhea, eczema, and migraine are of 
no moment, and, indeed, in so far as they stress the 
importance of protein hypersensitiveness, are of good 


augury. Nasal disease, respiratory complications 
(such as bronchitis, emphysema, and pulmonary 


fibrosis), and hyperpiesia mitigate strongly against 
lasting improvement. The chronic nasal patient, 
shorn of turbinates, wheezing and whistling through 
his antrostomies, is as big a bugbear to the physician 
as is the chronic abdominal patient, and he is as 
little amenable to treatment. As already indicated, 
the chances of improvement are inversely propor- 
tional to the age, and while the duration of the 
asthma is less significant than the age of the patient, 
it is unusual for a patient who has had asthma for 
more than 20 years to gain real freedom from the 
disease. 

The Prospect of Permanent Recovery.—What happens 
to patients who are for a time completely relieved of 
their asthma ? Unfortunately many of them relapse, 
and within five years nearly half of them are having 
asthma again. It is probable that the longer the 
remission the smaller the likelihood of relapse, but 
it is quite common for patients to relapse after being 
free for ten or more years. Remissions of this kind 
occur most frequently between the ages of 15 and 30, 


274 THE LANCET] 


and it is not unusual for adults coming for treatment 
to give a history of asthma in childhood which dis- 
appeared at puberty and has only reappeared after 
many years. In such cases it is usually a new and 
different stimulus which is evoking the asthma—in 
Rackemann’s simile the gun remains loaded and a 
new trigger is firing the attack. Once more improve- 
ment should follow appropriate treatment, an improve- 
ment which in chastened mood we shall now describe 
as relief rather than cure. 

Effect of Disease on General Health and Duration 
of Life-—The risk to life is greater in patients over 40, 
more especially when the asthma did not develop 
till adult life; in those whose attacks are frequent 
and difficult to relieve by symptomatic remedies ; 
and in cases accompanied by atheroma, hyperpiesia, 
or emphysema. The family history is more often 
negative and protein hypersensitiveness is more 
often absent in fatal cases than in the average asth- 
matic. On the other hand, extreme protein hyper- 
sensitiveness is not unduly dangerous except in so 
far as acute anaphylaxis may result from the paren- 
teral introduction of the protein in skin testing or in 
attempted desensitisation. In patients under 40 
with mild and occasional asthma the mortality is 
probably not more than 25 per cent. above the 
standard figures. In patients over 40 with frequent 
and severe paroxysms the mortality is two or three 


MENTAL HEALTH CONFERENCE 


[FEB. 1, 1936 


times the standard value, the excess of deaths being 
due to heart disease and pneumonia. 

Apart from respiratory and cardiovascular com- 
plications asthmatics are a healthy race, perhaps 
less liable than their fellows to infectious illnesses. 
They are bad subjects for operation or for acute 
respiratory disease, but have the compensation that 
an operation or a febrile illness is often followed by 
a relatively long period of freedom from asthma. 
The distress induced by a hearty meal induces many 
of them to maintain their nutrition at a subnormal 
level, but this doubtless has its advantages as well 
asits drawbacks. They are intelligent and courageous, 
and while psychological factors play an important 
part in their illness it is unwise to regard an asthmatic 
as neurotic in the derogatory sense or he will confute 
you by dying in an attack. If the physician cannot 
cure the malady the patient can nevertheless learn 
to manage it and live with it, and he should be 
encouraged to live as full a life as possible. 
Occupations which entail arduous physical exertion 
or exposure to dust are unsuitable, but with 
these exceptions the asthmatic should be encouraged 
to look forward to a career on an equal footing 
with his fellows. 


L. J. Witts, M.D., F.R.C.P., 


Professor of Medicine in the University of London at 
St. Bartholomew’s Hospital Medical Scho¢t. 


SPECIAL ARTICLES 


MENTAL HEALTH 


TROUBLES OF ADULTS AND CITILDREN 


a 


THE fourth biennial conference of the National 
Council for Mental Hygiene was held at the Central 
Hall, Westminster, from Jan. 23rd to 25th. At the 
opening session the chair was taken by Mr. W. F. 
Roch, vice-president, and a discussion on Mental 
Hygiene and International Relations was opened by 
Lord ALLEN OF HURTWOOD, who said he believed 
that the psychological factor would increasingly 
determine the question of war or peace. Almost for 
the first time in history the exercise of imaginative 
will-power could now give the victory to peace, 
notwithstanding the causes of war that still remained. 
There was now no physical reason why anyone in 
any part of the world should be hungry, ill-clad, or 
ill-housed, or why nations should fight for their 
livelihood. There was now a mechanism, in the 
League of Nations, whereby men could make effective 
over the world of nature that mastery which science 
had placed in their hands. Men’s minds, however, 
seemed to be still inadequate and the problem was 
one deserving the consideration of those interested 
in mental hygiene. Mental adjustment and control 
were essential to counterbalance the accumulated 
fund of tradition and behaviour which caused every 
nation to work off its unsocial passions on its neigh- 
bours. The evils of the Treaty of Versailles might 
have been due very largely to life in an ill-ventilated 
nursery ruled over by a tired nurse and visited by 
a preoccupied father and a too-loving mother. The 
citizen must cease to make his children in his own 
image. Dr, WILLIAM BROWN read the paper published 
on p. 290, and a brief discussion followed. 


At the first session on Friday morning the chair. 


was taken by Dr. Arthur MaeNalty, and the subject 
of discussion was the Organisation and Correlation 
of Mental ILealth Services in Local Areas, The 


opening speakers were Prof. R. M. F. Picken, Miss 
Evelyn Fox, and Dr. T. 8. Good. In the afternoon, 
under the chairmanship of Mrs. E. M. Hubback, 
Dr. Helen Boyle, Mrs. Neville Rolfe, and Mr. Claud 
Mullins opened a discussion on Problems of Marriage 
and the Establishment of Courts of Domestic 
Relations. Eloquent appeals were made by magis- 
trates and doctors alike for the establishment of 
special courts, imbued with the atmosphere of the 
consulting-room, to try to prevent the breaking-up of 
marriages which might be saved by modern psycho- 
logical methods and the application of sympathy and 
common sense, Several speakers also urged extension 
of the divorce law for cases where there was no 
possibility of successful treatment. 

In the evening the Bishop of Southwark took the 
chair, and a discussion on the Priest and the Doctor 
in the Treatment of Nervous and Mental Disorders 
was opened by Dr. H. CRICHTON-MILLER. Nervous 
and mental disorders, he said, did not arise from 
simple causes, and it was in the field of multiple 
causation that the codperation of priest and doctor 
was most often justified. It was essential to guard 
against the facile acceptance of a single explanation 
which, more than anything, led to partial and 
ineffective treatment. The adjustment of a per- 
sonality to, for example, a persistent neuralgic pain 
should be the concern both of doctor and priest. 
The three great sources of maladjustment were fear, 
guilt, and inferiority, and in each of these, and 
particularly in the second, the priest had a part to 
play. The problem for discussion was: “ How far 
does equanimity count in promoting and maintaining 
health, and what measure of equanimity can be 
secured by the representative of organised religion ~ ” 
Just as science was broader than the practice of 
medicine, so religion was broader than the function of 
the priest. 

Canon T. W. Pym expressed the difliculty of the 
priest who was certain that his penitent was nervously 
ill when the general practitioner called it overwork 


THE LANCET] 


or indigestion and dismissed the matter. The tempta- 
tion to unprofessional psychiatry was very great 
Even when the patient was put in the hands of the 
right doctor the priest’s business was by no means 
over. For the rebuilding of the religious section of 
the mind after the psycho-analytic breaking-down 
the religious expert was needed. Probably very 
much could be done by ministers of religion to 
prevent the onset of a nervous or mental disease if 
only the clergy could obtain some reliable instruction. 


Mr. Z. F. Waris regretted a tendency to water 
down Christian essentials in order to establish a 
respectable concordat with science, He outlined the 
contributions which the priest could make to psycho- 
therapy, emphasising his value in convalescence. 


On Saturday the subject of the three sessions was 
Education for Living 


In the morning the period before the age of eight 
was discussed, in the afternoon that from eight to 
fourteen, and in the evening that from fourteen 
onwards. The chair at the first session was taken 
by the Rev. A. W. Harrison. 


THE NURSERY 


Dr. R. G. GORDON outlined the problems of the 
infant, and the seeds that might be sown in the early 
months of life. The relationship of the child to the 
parents should be an equilateral triangle; divided 
loyalties were reflected in the growing child by a 
sense of bewilderment or an attempt to play off one 
parent against the other. Recent work had thrown 
a good deal of light on eidetic imagery: an imagery 
so vivid that it could not be distinguished from 
reality. About 50 per cent. of children experienced 
it, but it always faded soon after puberty. A child 
might be accused of lying when he was really merely 
describing such images, and if they were really 
alarming they might have a serious effect on the 
child’s development. Frightening experiences, whether 
real or imaginary, produced a feeling of insecurity 
in respect of his environment, while sexual experiences 
or images produced a sense of guilt or insecurity. 

Dr. MARIA MONTESSORI described the process of the 
child’s growth and said that all living creatures in 
the early stages went through sensitive periods. The 
young caterpillar found the tender shoots at the tip 
of the branch as the result of his extreme sensitivity 
to light, and lost that sensitivity as soon as he was 
capable of absorbing other nourishment. By means 
of temporary sensibility of this kind each charac- 
teristic was fixed and stabilised. The child’s purpose 
was totally different from that of the adult. He did 
not scrub a table to get it clean but to scrub until he 
had mastered scrubbing. The child who had been 
thwarted in one of his sensitive periods had lost for 
ever that particular chance of natural growth. Such 
thwarting might provoke violent reactions with no 
apparent cause. It was therefore essential to investi- 
gate the causes of naughtiness and capricious 
behaviour. The adult knew the child as he was in 
disease but had no knowledge of the healthy child 
because, like all other undiscovered forces of the 
universe, he was outside the adult's experience. 

Miss J. A. CALLARD (vice-chairman, Welsh com- 
mittee, National Union of Teachers) said there was 
no reason why the nursery and infant stages should 
not be regarded as a whole, and the primary con- 
sideration at this period was the incessant care for 
the physical well-being of the child, and regard for 
the cultivation of desirable habit and deportment. 
The more formal aspects of instruction would not be 


MENTAL HEALTH CONKBERENCE 


[FEB. 1, 1936 275 


emphasised, but continuous progress would be made 
in knowledge and expression by methods which 
invoked in aid of education the pleasurable activities 
natural to children. As a result of modern training, 
teachers were both qualified and anxious to undertake 
this work. There was a crying need for more and 
better provision. for the younger children of this 
country. The pre-school child had suffered hitherto 
an avoidable neglect. The open-air principle was 
particularly desirable for the younger children, and 
a garden was invaluable. Miss Callard pleaded for 
the use of the opportunities already available ; 
hundreds of classrooms in infant schools were 
unoccupied, and their adaptation would be less 
costly than building nursery schools. There was no 
reason for the creation of a gulf between schools 
for those under five and for those over five, and the 
amenities of a nursery school should be accessible 
after that age. Regular and nutritious meals were 
essential, as were also training in hygiene and cleanli- 
ness, and provision of bathing facilities and stretcher 
beds for the afternoon rest. There was a need for 
unification of administrative control. 


In the afternoon the chair was taken by Dr. 
J. A. Glover, and Dr. EMANUEL MILLER spoke on 


MOULDING THE MIND: EIGHT TO FOURTEEN 


He looked with suspicion, he said, on any efforts to 
mould the mind, for the phrase implied preconceived 
ideas as to shape and a ready-made design for living. 
The major conflicts of life were faced and dealt with 
in the first five years, neurosis and character formation 
being the resultants ; intelligence alone remained to 
develop. The ability to exercise curiosity, to make 
emotional contacts with schoolmates and teachers, 
depended on the degree of emotional freedom left 
after the years of early struggle. Before teachers 
set to work on the child between eight and fourteen 
they ought to be provided with such knowledge of his 
childhood as was put into the hands of physicians 
by the social worker of a child guidance clinic. It 
must be ascertained whether the child was tenderly 
mother-fixed or terrified by parental authority ; 
whether he had latent anxiety or an obsessional dis- 
position. The attempt to mould the mind must be 
made with knowledge of the material presented. The 
intellectual capacity and character must be studied 
and estimated. Special handling would be called 
for if there were lack of capacity to play in group 
games, inability to ask questions or excessive question- 
ing, lack of curiosity about manual operations, 
excessive ‘‘ goodness,” indifference and shyness in 
social contacts, attitudes of renunciation, or repeated 
physical incapacity with trivial physical signs or 
absence of organic disease. Moulding should be 
designed to remove anxiety or obsession by active 
treatment, to obviate frustration by love, to afford 
outlets for aggression in the play group, to condone 
vulgarity, to organise the “ gang spirit ” by suitable 
group activities, to accept sympathetically the 
tendency to inverted sex interests by preparing for 
heterosexual enlightenment at puberty, to correct 
physical anomalies before puberty, and to cultivate 
manual and artistic aptitudes. 


Miss M. WITHERS (headmistress, Dawson Junior 
Girls’ School, Barking) said that nowadays children 
were not educated for their work but for their leisure. 
If they were to get the most out of life every side 
of their nature must have an opportunity to develop ; 
there must be an inner harmony and balance not 
easily upset by the buffets of life. The school must 
see that each child was given ample opportunity for 


2 76 THE LANCET] 


MENTAL HEALTH CONFERENCE 


[FEB. 1, 1936 


self-expression. This, with the younger ones, came 
most naturally through painting, acting and rhythmic 
movement, but if these were to be continued success- 
fully with older girls there must be a carefully planned 
progressive scheme. The objects of education could 
be helpfully discussed with nine- to ten-year-olds. 
Cooperation between home and school was very 
important, as parents were apt to be concerned 
primarily with the means of securing a job. When 
the early forms of self-expression ceased to interest, 
some kind of craft work was most likely to appeal. 
Nature study and elementary science were always 
attractive, and children took infinite delight in 
growing plants, animals, and the vagaries of the 


weather. The humanities were the most important 
of all subjects. Literature gave immense pleasure to 
children. Children should leave school with the 


belief that they were entering on a great heritage 
and that the infinite resources of knowledge were 
only waiting to be explored. 


Miss F. HAWwTREY (principal, Avery Hill Training 
College) said that her students were taught to aim 
at directing activities rather than at moulding the 
mind. It was easier to change theory than practice. 
Modern theory was enlightened, but the average class 
still contained 40-60 children, wedged in heavy dual 
desks between high windows, and formative experi- 
ences were almost impossible to attain. The child 
owned nothing but his own copybook ; the figures he 
modelled must return to the common lump, and the 
well-thumbed text-books must go back to the school 
cupboard. Schoolrooms were dark and stuffy, and 
cold water alone ran into the small stained basins. 
The asphalt playground was as hideous as a prison 
yard. Moreover, there were still many teachers who 
had learned in a hard school and felt that they must 
teach in a hard school. Amidst these surroundings 
“ education for living’’ must be practised. One of 
the most serious and insidious threats to freedom 
arose from the scholarship examination. A little girl 
of 54 was said to have observed, “I shall have to 
get a move on; I have only 4} more years to get 
my scholarship.” Yet many thousands of teachers 
were now giving their lives to put the new theories 
into practice. Bare classrooms were filled with 
flowers. TFlower-beds were made in playgrounds with 
soil and manure brought in paper bags. Opportunities 
were found for music, dancing, dramatic work, and 
painting. The Iladow recommendations would not 
become effective until suitable schools were provided ; 
the reform of school buildings was an urgent question 
for education. Schools ought to be beautiful. Prof. 
Burt had said that the ideal school should be a 
wilderness playground with a shelter somewhere in it. 
Nowadays a child’s natural exclamation on seeing 
a pull was, “ Look, Mummy, it flies like an aeroplane ! ” 
The sum of one penny a day per child would be 
enough to ensure the future and enable the young 
“to draw good into themselves from all their 
surroundings.” 


THE FINISHED PRODUCT 


The evening discussion on the adolescent was 
conducted under the chairmanship of Mr. Basil 
Yeaxlee. Mr. R. E. ROPER said that the educational 
ladder at this age was supposed to lead to higher 
things, but the trouble about a ladder was that so 
few people could use it at one time. The post-war 
increase which had filled the schools was now swelling 
the ranks of young labour. Into this mad medley 
were thrown those who had completed secondary 
school or university courses, slaving for a certificate 
or degree which would give a better chance of 


employment. The anxiety and competition insepar- 
able from adult life to-day cast their shadows over 
the 8-14 group with a ruinous pre-selection from 
which infant schools were not wholly free. There 
Was an increase in young adult tuberculosis and a 
rise also in the number of those certified as mentally 
defective, and in suicides and attempted suicides. 
The present chaos could be reduced to some order 
by raising the school-leaving age, with maintenance 
where necessary, by extending continued education 
and by improving school premises. The size of the 
classes must be reduced and education must be 
thought of in terms of the individual. All examina- 
tions before the last year should be abolished, and 
even this one should be combined with records of 
school life as a whole. Above all, anxiety must be 
removed from education. ‘Finished’? too often 
meant ‘‘ done for” ; the educationist must see that 
it meant “ perfect, so far as age permitted. 


Miss G. Hanow (principal of the Society of Oxford 
Home-Students) declared that most of the girls who 
came to her from secondary schools were healthy 
minded and wholesome, but the exception always 
attracted the greater interest. There was no doubt 
that some girls felt the responsibility of being a 
prefect as something that was a strain, and reacted 
from it during their first year at college. A break 
between school and university would nearly always 
be beneficial, as for many people the change was too 
abrupt. This especially applied to day-girls, who 
were often miserably homesick when they first went 
to college. The difliculties in the way of this break 
were the loss to the school of a girl at a time when 
she was most useful, and the necessity of the scholar- 
ship. It would be a very good thing if the idea could 
be disposed of that university education was a mark 
of special distinction at which every intelligent girl 
should aim. The present tendency was to judge the 
worth of a school by the number of girls it sent to 
a university, and girls who were not really suitable 
were pushed into college life. Very few entrance 
candidates showed much evidence of thinking for 
themselves, and the general attack on and defence 
of all kinds of opinions encountered at the university 
were often a shock. One of the weaknesses in school 
training was lack of precision in thought and expres- 
sion; there was no evidence of the present generation 
thinking more clearly or accurately than the last. 
Its interests, however, were world-wide, and the 
tone of Oxford was one of conscious responsibility as 
citizens. Young Oxford passionately desired to be 
just. The present generation had got over the 
tendency of the immediate post-war group to kick 
against every kind of restriction. Like every genera- 
tion, they wanted experiment and adventure, but 
their sense of justice and citizenship stood out 
conspicuously. 

Mr. G. A. Lywarp (director, The Clinic and School, 
Finechden Manor School, Tenterden) said that he 
proposed to speak about honesty but to call it 
teachability. He quoted a question presented to him 
recently by a group of 20 neurotic adolescents after 
a discussion on coöperation., ‘* Doesn’t it look,” they 
said, “as if clear thinking is feeling ? ” There were 
two kinds of stealing in adult life: the open and 
direct, or the indirect dishonest way of, for example, 
telegraphist’s cramp. Both types of thieving were 
apt to end in confinement: though one place of 
detention was called a prison and the other was not, 
both were but external indications of an already 
imprisoned condition. All of us started life in a prison 
of some kind, and those who had the care of us 


THE LANCET] 


from 0 to 14 helped us to pay off the original debt 
and enabled us to live like the kings of old, “‘of his 
own.’ Those who were neglected or indulged and 
so robbed of this capacity remained credit-seekers. 
They were not the joy-finders, for joy was born of 
pleasure and pain, success and failure. It did not 
come to those who lived to please mother. An adult 
might be defined as a person that had at last grown 
able to rely upon himself as teachable. The physically 
grown-up who were not adults in this sense were 
still fundamentalists and never clear thinkers. The 
unteachable group included those who were already 
neurotic at 14. They held on tenaciously to a variety 
of ideas and ideals which were dangerously different 
from what they could afford to feel about the same 
issues. They did not feel personally at all, having 
as it were numbed themselves against the pain of 
loss and failure. They were easy prey to the too 
good and the too bad around them. 


. The aim of the educationist must be to render 

teachable, to wean the babe from his delinquency, 
Wwaywardness, or indebtedness, so that he could con- 
centrate and consecrate body and mind to an ordered 
life and service which were increasingly free. From 
14 onwards was the time when it was necessary to 
do what the baby could not do: to make distinctions. 
The whole question involved in differences had to be 
faced. Before 14 it was comparatively easy to shut 
one’s eyes to differences. At 14 the thinking apparatus 
might work in either of two opposite ways: it could 
clarify or confuse and camouflage. It was a shame 
that the world so often fell to pieces for the child 
of 14. It would be a sign of grace if the public 
schools would open their eyes to the fact that a 
system in many ways desirable for the 14-year-old 
was not suited to the hundreds who went to public 
schools still at an emotional age of 3. The number 
of such would be considerably reduced if more prepara- 
tory schoolmasters would appreciate the value of 
real chaos plus security. Thousands of 14-year-olds 
were not at public schools but were leaving State 
schools for all kinds of occupations. At that age 
they were not so much teachable as suggestible, and 
wher they could not stomach what they met they 
might either identify themselves with it so that 
they lost their play and became industrial personali- 
ties, or let themselves become machines in work 


and compensate by an equally mechanical pleasure- 


world. 


All education should be organised with an eye to 
the danger and ease with which escape from life 
- could be made. There should be more bureaux 
where adolescents could be saved if possible from 
drifting into jobs on motives which could not long 
remain adequate. 
might be found in all sorts of culture and even in the 
scholarship system. Curing was not so effective when 


the healer did not relate the child’s emotional problems 


to his classroom difficulties, and the true task of the 
teacher everywhere was to discover the child through 
his classroom difficulties and vice versa. 
still many teachers as blind as their pupils to the 
fact that all subjects and all work revealed mind at 


its creative task of carrying life from the vine to the 
The unphilosophical teacher was a dan- 


branches. 
gerous teacher, afraid to teach to the feeling because 
he himself confused ‘feeling’? with ‘“‘ feelings.” 
Children must be so taught that they would expect 
to find differences within sameness, for in that lay 
tbeir hope of ultimately finding a unity in the differ- 
ences. Only such a person was truly honest, truly 
loving, truly human, and teachable. 


MEDICINE AND THE LAW 


Ways of escape from growing up 


There were 


[FEB. 1, 1936 277 


MEDICINE AND THE LAW 


Respite of Death Sentence after Medical Inquiry 


REFERENCE was made under this heading last 
week to the case of R. v. Mortimer, the man who 
was found guilty of murder in that he had deliberately 
driven a motor-car so as to run down a woman on 
her bicycle. There had been a question of the admis- 
sibility of evidence of his having similarly driven a 
car at other women both before and after this parti- 
cular occasion. The comment was ventured that the. 
defence, having relied on disputing the identity of 
the motorist, had been debarred from raising the 
question of insanity. The case established conduct 
so abnormal that it seemed inevitable that the Home 
Office would intervene before execution of the 
sentence. 

Hardly had this comment been made before it 
was officially announced that the Home Secretary, 
acting under Section 2 of the Criminal Lunatics Act, 
1884, had caused a medical inquiry into Mortimer's 
state of mind, and, after considering the medical 
experts’ report, had recommended the respite of 
the capital sentence. Thus Mortimer’s punishment 
is nominally commuted to penal servitude for life, 
and he goes to a convict prison where he will be kept 
under medical observation. We see therefore how 
narrow the scope of a criminal trial must necessarily 
be. Mortimer’s conduct was that of a madman, but 
the issue of his mental state (which must have been 
the dominant question for the average spectator at 
the trial) was excluded. In other words, the case 
illustrates the two different standards which the 
community applies at different stages of the adminis- 
tration of justice. To the judge and the jury at 
Winchester assizes, and to the Court of Criminal 
Appeal, Mortimer was 100 per cent. sane and was 
fit to be hanged ; to the authority which carries out 
his sentence Mortimer was partially insane and unfit 
for the death penalty. Naturally the assize court 
was concerned with his mental state at the date of 
the offence, whereas the Home Office was concerned 
with it at-the date of the medical examination after 
the trial; but it will probably not be asserted that 


. Mortimer suddenly changed from sanity to insanity 


between the two dates. The difference of standard 
is clear. The criminal court would be concerned 
with the question whether the prisoner, at the time 
of the offence, was insane within the limits of the 
doctrine of criminal responsibility as laid down by 
the courts. The Home Office is concerned with the 
question of his insanity under the ordinary law 
whereby a man can be certified and removed to an 
asylum. The distinction was brought out by the 
Home Secretary in the House of Commons after 
Ronald True’s case (Commons Debates, June, 1922, 
p. 210), and was carefully examined by the Atkin 
Committee on Insanity and Crime (see the report, 
Cmd. 2005, published in 1923); possible change in 
the law and practice of cases falling within Section 2 (4) 
of the Criminal Lunatics Act, 1884, was one of the 
questions specifically referred. to the committee. 
There is an ancient legal repugnance to the execution 
of an insane criminal. Sir Edward Coke, for instance, 
observed that such a course would be “a miserable 
spectacle, both against law and of extreme inhumanity 
and cruelty, and can be no example to others.” 
The repugnance is due to the two ideas that a man 
of unsound mind is barred from submitting some 
possible point in stay of execution, and that it is 
not Christian charity to send him into another world 


278 THE LANCET] 


MEDICINE AND THE LAW.—PARIS 


[FEB. 1, 1936 


when he is not of capacity to fit himself to meet his 
Maker. 


Use of Inquest Depositions in Criminal Court 


When a man and woman were charged, at Clerken- 
well Police-court last week, with the murder of a 
woman who died after an alleged illegal operation, 
the prosecution put in the depositions taken at the 
inquest. Counsel for the male defendant objected, 
on the ground that, though the man had been called 
upon to give evidence on three occasions before the 
coroner, he had never been cautioned that what he 
said might be used in evidence against him. Counsel 
suggested that the accused had been severely cross- 
examined at the inquest which had in effect developed 
into an inquiry whether the witness had not been 
an accessory to the alleged illegal operation. Asked 
by the magistrate if he asserted that the inquest 
had been improperly conducted, counsel replied that 
he did not go quite so far, but he did complain that 
something not proper was done. The prosecution 
contended that it had been clearly laid down that 
the question of being cautioned was a point to be 
taken by the witness and was not for the coroner. 
This was possibly a reference to a case in which 
THE LANCET has a special interest,Wakley v. Cooke, 
where the judges supported the view that people 
should be allowed to make any statement they desire 
at an inquest and, while not bound to incriminate 
themselves, must look after their own interests in 
giving evidence. The prosecution at the Clerkenwell 
Police-court further referred to a dictum of Mr. 
Justice Swift that cases of alleged illegal operation 
would never be brought into court at all if witnesses 
were cautioned. The magistrate allowed the inquest 
depositions to be admitted. This course seems clear 
in view of Section 5 (3) of the Coroners Act, 1887, 
though doubts have arisen in the past over admitting 
a witness’s deposition taken before a coroner where 
the accused was not present at the inquest. 


Inquest on Death in Nottingham Nursing-home 


The Nottingham inquest on Miss Ada Louisa 
Baguley, a cripple aged 50, who died in an unregis- 
tered nursing-home carried on by Nurse Waddingham 
and Mr. R. J. Sullivan, stands adjourned in view 
of the ill-health of an important witness. 
its completion, it is not possible to comment on the 
important elements of the case and the light it throws 
on the safety of the system of certification before 
cremation. Reference may however be made to a 
point taken by the legal representatives of the pro- 
prietors of the nursing-home. Mr. William Smith, 
on their behalf, drew attention on Jan. 21st to the 
fact that the coroner had stated that Dr. Roche 
Lynch, the Home Office analyst, would be called at 
a later stage. Dr. Roche Lynch had already given 
evidence, and Mr. Smith expressed the fear that the 
calling of Dr. Roche Lynch a second time might 
have the effect of completely shattering any point 
which might have been made in favour of his clients. 
He considered he ought to have the assistance of an 
analyst of equal standing, if that were possible. 


Pending 


witnesses in his own discretion for that purpose. 
The legal representative of an interested party may 
seek to shut out evidence or may press for the prin. 
ciples of a criminal trial where there comes a stage 
when the case for the prosecution is definitely closed. 
While all coroners will wish to observe the rules of 
fair play on which British criminal procedure is 
based, it is certainly impossible to coérdinate inquest 
procedure with that of assize courts where a specific 
person is accused of a specific offence. So long as 
the coroner’s court continues, he must have a dis- 
cretion to conduct the proceedings in his own way. 


PARIS 
(FROM OUR OWN CORRESPONDENT) 


FRENCH DENATALITY 


THE decline of the birth-rate has for many years 
been a popular theme for French Jeremiahs, the 
latest of whom is Dr. L. Devraigne who, in a com- 
munication to the Academy of Medicine on Christmas 
Eve, entertained his audience with certain lugubrious 
statistics. In 1868 there were 1,034,000 births, 
whereas in 1934 there were only 667,000, of which 
50,000 were in the families of foreigners. Between 
1868 and 1934 the population of France has risen 
only from 38 to 41 millions. Even in the brief 
interval between 1932 and 1934 there has been a 
decline of 45,000 in the birth-rate, whereas in 
Germany in the first quarter of 1935 there were 
47,000 more births than in the corresponding quarter 
in 1934. In the four years 1930-34 the number of 
marriages was reduced by 44,000 to 298,000, a decline 
so prodigious that Dr. Devraigne is surely justified in 
commenting on it with an exclamation mark. It is 
true that infant welfare work is much more effective 
now than it was forty years ago, when 150,000- 
180,000 infants died every year, and in 1934 there 
were only 47,000 deaths during the first year of life. 
But even if, as Dr. Devraigne believes, this figure can 
be further reduced, the denatality of France will 
not have been successfully combated. If the country 
is not to become one vast infirmary for old folk, 
there must be an average of three children per famuly, 
and even this modest standard can only be attained, he 
thinks, by generously subsidising large families from 
public funds. 


THE FAMILY DOCTOR OF THE FUTURE 


A correspondent of Concours Médical, who signs - 
himself Briau, draws a modest but quite attractive 
picture of the family doctor of the future. The 
family doctor of to-day has died a more or less 
natural death, the cause of which is specialisation. 
Perhaps this is just as well for, according to Brian. 
he had fallen from that high estate enjoyed by the 
contemporaries of Balzac. In those days the practice 
of medicine was an art: now it is supposed to be 
a science. The transition from one to the other has 
left the family doctor in the lurch; losing the art 


The coroner replied that Dr. Roche Lynch was not 
in opposition to Mr. Smith or his client, but was 
present to help them all in the case. 

The incident aptly illustrates the problem inherent 
in inquest procedure. It is the coroner’s inquiry, 
held in the public interest. To him it is an investi- 
gation. On the other hand, to parties or witnesses 
possibly involved, the inquest, as it develops, may 
assume the nature of a trial. The coroner naturally 
wants all the help he can get, and will call and recall 


of his predecessors, he has not compensated for this 
loss by acquiring the science of his contemporaries. 
the specialists. Having recorded his death with the 
causes thereof, Brian proceeds to model from the 
corpse a new family doctor, less resplendent but more 
useful. He must not expect great emoluments or 
great honours, but the modesty of his income and 
station in life is to be compensated for by the feeling 
that he fits into the picture. His education is to be 
general and thorough, essentially practical and 


THE LANCET] 


PANEL AND CONTRACT PRACTICE 


[FEB. 1, 1936 279 


unembarrassed by post-graduate courses in special 
subjects which divert his attention from his primary 
function. Like a station-master, he is to control 
and supervise rather than to lay his own hands on 
any task requiring great technical skill. “He is to be 
responsible for prenatal and postnatal infant welfare, 
but the confinement itself is to be in the hands of 
the specialist that he has advised the family to 
summon. As the child grows older and the parents 
are tempted to offer themselves the luxury of an 
imperious (sic) English nurse, he must not let himself 


be ousted, and he must remember that what may be 
good for little Anglo-Saxon children born in the fog 
of their cold and wet country is not necessarily just 
what Latin or Celtic babies need. He will prevent 
scolioses, dystrophies, and the rest by shunting the 
incipient patient off to an appropriate specialist. 
Though he must not specialise, the future family 
doctor must read medical periodicals and attend 
medical meetings in order to keep abreast of the times 
and to distinguish between the specialists to avoid 
and those to consult. 


PANEL AND CONTRACT. PRACTICE 


Temporary Residents 


THe London local medical and panel committee 
recently suggested to the insurance committee that 
the distribution scheme should be amended so as to 
provide that in respect of temporary residents in 
convalescent homes or similar institutions credits 
shall be given only in those cases in which a con- 
tinuation card is submitted containing evidence that 
medical treatment (which should not include an 
examination for the purposes of the home) has been 
given. The subcommittee of the insurance com- 
mittee expressed the opinion that the proposal was 
worthy of adoption if made applicable to all temporary 
residents and the panel committee has now decided 
to vary its proposal accordingly. 


Another Case for Clause 7 (2) 


Two insurance doctors have just had to appear 
before the London medical service subcommittee 
simply because, according to the facts found by the 
subcommittee, they had handled a case in their own 
way instead of acting in accordance with the terms 
of service. A girl, aged 16} years, became ill and 
went with her mother to the surgery of the senior 
partner, receiving treatment for which a fee was 
demanded. According to her statement to the sub- 
committee, the mother demurred, pointing out that, 
although her daughter had not received a medical 
card, she was in fact insured. The doctor said she 
should pay and then apply to the committee for a 
refund, but no fee was actually paid as the doctor 
had not the necessary change. Next day the junior 
partner visited the girl at home, and a similar con- 
versation ensued but no fee was paid on this occasion 
either. A third consultation took place two days 
later but on this occasion no reference was made 
to insurance. An account was rendered and was 
paid, the junior partner telling the mother that she 
should apply to the committee for reimbursement. 
The senior partner told the committee that he had 
no recollection of anything being said about the 
patient being insured, while the junior partner was 
positive that nothing was said when he saw the 
virl. The mother, on the other hand—she is an 
insured person on the list of the junior partner— 
was equally positive that both the doctors were 
made aware of the position and in fact that her 
application for reimbursement was made at the 
suggestion of the junior partner. At the conclusion 
of the hearing both doctors agreed that there had 
probably been a misunderstanding and they expressed 
their willingness for the case to be dealt with as 
though they had issued form G.P.4. The committee 
found that there had been a failure on the part of 
the junior partner to comply with the terms of 
service, but in view of his offer to refund the amount 


charged, decided to take no further action in the 
matter. And all this trouble might have been saved 
if the practitioners had followed the procedure laid 
down for their protection in Clause 7 (2) of their 
Terms of Service. 


The Chemist who was Annoyed 


A test prescription for Mist. gent. acid. was recently 
presented to a certain chemist, and in due course 
the medicine was analysed. The analysts stated that 
in addition to a trace of hydrochloric acid and possibly 
a small proportion of infusion of gentian (there 
should have been 200 and 300 minims respectively) 
the sample contained hydrobromic acid equivalent 
to 146-8 minims of acid. hydrobrom. dil., and 
alkaloids of nux vomica equivalent to approximately 
16 minims of extr. nuc. vom. liq. or 190 minims of 
tinct. nuc. vom. in the 10°65 fluid ounces dispensed. 
The chemist was invited to explain the discrepancy, 
but the only remarks offered by him were that 
‘‘ whatever concoction the analyst has been analysing 
it has nothing whatever to do with the mixture that 
I dispensed and supplied.” In further letters he 
attacked the staff of the insurance committee, and 
when writing to say that he did not propose to 
attend the hearing by the pharmaceutical service 
subcommittee, he made the somewhat naive suggestion 
that it would be remarkable if he could compound 
Mist. gent. acid. without getting any of the ingredients 
into the bottle. But he did not take the precaution 
of having the second half of the mixture analysed 
by an independent analyst and has only himself to 
thank that the committee are asking the Minister to 
withhold the sum of £5 from his remuneration. 


A Part-time Assistant 


Three insurance doctors, each with the maximum 
number of insured patients, are in partnership and 
have recently had to refuse new acceptances in order 
to bring their lists within the permitted maximum. 
The partners realise that to refuse acceptances may 
adversely affect their practices, and have applied for 
the consent of the insurance committee to their 
employing an assistant, but they take the view that 
the extra number of insured persons likely to secure 
inclusion in their lists would not justify the expense 
of a whole-time assistant, and so they have asked to 
be allowed to have an assistant for two days a week 
until the extra number of insured persons justifies 
the appointment of a full-time assistant. The 
maximum additional number of patients who may be 
accepted by virtue of employing an assistant is 1500. 
and the committee have acceded to the doctors’ 
request upon the condition that while the assistant is 
employed for not less than two days a week the 
additional number of insured persons accepted shall 
not exceed 350. 


THE LANCET] 


280 


———_—- 


[FEB. 1, 1986 


PUBLIC HEALTH ok 


Diphtheria v. ‘‘ Bacteriological Diphtheria ”’ 


PUBLIC authorities who control not only schools, 
day and residential, in which cases of diphtheria 
may occur but also infectious diseases hospitals to 
which they are removed are as much concerned 
to limit the number of cases as to economise the 
occupation of beds. There can be no question that 
the child with definite or even suggestive clinical 
evidence of diphtheria is properly removed to hos- 
pital for further investigation and treatment. There 
is equally no question that the increasing practice 
of indiscriminate swabbing without virulence tests 
and without determination of the state of immunity 
by Schick tests results in the unnecessary hospitalisa- 
tion of numbers of children who are neither in danger 
themselves nor dangerous to the community from 
which they are removed. Entitled ‘‘ Nomenclature 
of Diphtheritic Infections,” a report just published * 
presents the conclusions of a L.C.C, departmental 
committee appointed by Sir Frederick Menzies. The 
title is an understatement of the contents of the 
report which covers far wider ground, since 
procedure is suggested for dealing with children, both 
immunised and non-immunised, in schools and homes 
of all types from whom positive swabs have been 
obtained but who show no clinical manifestations 
of diphtheria. 

Diphtheritic infections include the various clinical 
forms of the disease, ‘‘ bacteriological diphtheria ’’— 
that “tautological and meaningless” label—and 
carriers both convalescent and contact. Diphtheria is 
defined in the report as the reaction of the body to 
virulent strains of the C. diphtheria, and the keynote 
throughout is insistence upon virulence tests of the 
organisin in the absence of clinical signs of the disease. 
Attention is drawn to the danger to others of the 
child suffering from anterior nasal diphtheria, in 
the opinion of the committee the commonest source 
of infection, particularly in schools and hospital 
wards. The condition, although intensely infective, 
produces as a rule nothing more than nasal dis- 
charge and debility which may be unremarked until 
severe types of the disease have arisen in other 
children as the result of contact. There can be no 
doubt that frank nasal diphtheria is a greater menace 
than the occult carrier state, since the dosage of 
infection transmitted is likely to be greater. 

In the production of convalescent carriers there 
are, the report says, only two factors: a clinical 
attack of the disease and an unhealthy condition 
of the nasopharyngeal, mucosa. The factors which 
are operative in producing “healthy ’’ or contact 
carriers are the opportunity for and amount of 
infection and the local condition of the respiratory 
passages under which the bacillus may survive. What 
results from the contact-carrier state depends upon 
the state of immunity at the time of infection. Thus 
non-immunes may contract clinical diphtheria or, 
as the result of summation of subclinical doses of 
infection, attain ‘‘natural’? immunity. Immunes 
may be transient contact carriers or become chronic 
carriers. It is emphasised that since they do not 
contract clinical diphtheria, the greater the number 
of immunes in a closed community the higher the 
carrier rate tends to become. In a community 
wholly immune, carriers are not harmful but bene- 
re a a Sree ee ee 

1 Report of Departmental Committee (A, F. Cameron, E. H.R. 


Harries, A. Joe, J. E. McCartney, and A. Topping). London : 
P. S. King and Son, Ltd. No. 3161. 3d. 


ficent, since the repeated infection of immunes tends 
to raise, or at least to maintain, the Jevel of anti- 
toxic immunity. The moral of this is obvious. The 
presence of virulent strains of the diphtheria bacillus 
in any considerable community of children is well- 
nigh inevitable. If some of these children are suscep- 
tible to the disease, outbreaks of clinical diphtheria 
are from time to time almost as inevitable. 

Hence the report advocates the determination of 
the state of immunity of all inmates by means of 
the Schick test and the active immunisation of all 
positive reactors, confirmatory Schick tests being 
insisted upon. Half-measures are not only useless 
but detrimental to the progress of immunisation. 
It is among institutions whose inmates are only in 
part immune, or whose state of immunity following 
prophylactic injections has not been verified, that 
the objector (always on the lurk for mischief) finds 
some of his most venomous barbs. This lead from 
the largest public health authority in the world is 
to be welcomed by those who would put an end to 
the suffering of children from a preventable disease. 
The report proceeds to lay down the steps which 
should be taken for the disposal of cases under the 
various conditions of institutional practice, and 
concludes with an appendix in which are described 
the correct method of swabbing and the details which 
should be supplied to the bacteriologist ; the inocu- 
lation of media; standard forms of report which 
should be used by bacteriologists; and the clinical 
significance of the bacteriological findings. 

Practitioners who rely upon the morphological 
diagnosis of the diphtheria bacillus in a smear or 
culture may study with advantage the following 
scheme for the complete identification of the organism 
given on p. 16 of the report. 


Slages in the Complete Identification of Virulent Diphtheria 
| Bacilli and Time Occupied (in Days) from Taking 


the Swab 
Day Stage 
0 Ist cia 
0 2nd LotHer 
| 
| | 
1 3rd Micro. positive Micro. negative. 
1 4th Inoculate 
tellurite plate 
| 
j | 
3 (m.) 5th Diphtheria-like Negative 
colonies (diphtheroids 
or Hofmann 
only). 
3 (m.) 6th Inoculate 
serum agar 
3 (aft.) 7th Inoculate 
fermentation 
tubes 
an : | 
Sth Read fermentation Negative 
tests (diphtheroids 
or Hofmann 
only). 
True diphtheria 
bacilli 
4 9th Virulence test 
| | 
5 or 6 10th Result of test Non-virulent 
diphtheria 
bacilli. 


Virulent diphtheria 


bacilli 
m. = morning ; aft. = afternoon. 


Intended primarily for the guidance of medical 
officers in the L.C.C. service, the report, which is a 


THE LANCET] 


reflex of modern practice in the control of diphtheria 
in institutions, should find a wider medical public. 
It contains a good deal for threepence. 


Rat Plague 


Early in December last a dead rat found in a 
grain warehouse at the docks at Liverpool was sub- 
mitted to the bacteriologist for examination and 
found to be infected with plague. An intensive 
search and rat destruction campaign was immediately 
carried out in the vicinity, with the result that a 
few days later one of many trapped rats was also 
found to be infected. Although vigorous action has 
continued to be taken it would appear that no other 
plague-infected rats have been found, and there have 
been no human cases. The docks of Liverpool have 
an extensive trade with South America and the 
- East, from both of which parts of the world plague- 
infected rats may gain access to this country, especi- 
ally from grain-bearing ships. 

It would probably be true to say that the destruc- 
tion of rats on ships and on docks, and the search 
for plague-infected rats, has come to be the major 
activity of port sanitary authorities. During the 
year 1934, 2739 rats were caught in ships at the 
port of Liverpool, of which all but 2 were of the 
black variety, and in addition 2121 rats were caught 
on the quays, of which all but 156 were black. It is, 


THE SERVICES 


[FEB. 1, 1936 281 


of course, the black variety of rat which is most 
likely to be infected with plague. The examination 
of rats for evidence of plague infection is carried out ex- 
tensively ; the number of rats examined at Liverpool 
in 1934 was 3486, of which all but 227 were black. 
Although the most careful precautions are taken 
(by exercising the powers and duties prescribed by 
the Port Sanitary Regulations, 1933) to keep down 
the rat population on ships, and to prevent the 
access of rats from ships to the shore, the danger of 
the introduction of plague is a cause of, constant 
concern to port medical officers of health, and the 
prompt detection of the presence of plague-infected 
rats at Liverpool is evidence of the attention given 
to the subject.: The more intensive activities which 
have followed the discovery seem to give assurance 
that no enzoédtic will occur in the area. Under 
present-day powers and administration a recurrence 
of the widespread rat infection which took place 
in Kast Anglia early in the century is highly 
improbable. 

It is only occasionally that the importance of the 
large-scale routine work of the port sanitary authori- 
ties ig prominently brought before the public, but 
port medical officers are well aware that if the work 
of their staffs was not carried out with assiduity 
and inteliigence occurrences of this kind would not 
only be more frequent, but also much more serious. 


THE SERVICES 


ROYAL NAVAL MEDICAL SERVICE 


The death of H.M. King George V.—The London Gazette 
of Jan. 24th publishes Orders in detail for the mourning 
to be worn by Officers of the Royal Navy and Royal 
Marines, Officers of the Army, and Officers and Warrant 
Ofticers of the Royal Air Force for six months from 
Jan. 21st, ending July 20th, 1936. 

Surg. Comdrs. G. W. Woodhouse to R.N. Hospital, 
Portland; R. W. Higgins to President for course; and 
W. G. C. Fitzpatrick to Victory for R.N.B., and to Vernon. 

Surg. Lt.-Comdr. T. F. Crean to Pembroke for R.N.B., 
Chatham. 

Surg. Lt. (D.) R. W. Stevens promoted to rank of Surg. 
Lt.-Comdr. (D.). 

Surg. Lts. D. W. Walker to Pembroke for R. M. Infirmary, 
Deal; and T. McCarthy to Furious. 


VACANCIES FOR MEDICAL OFFICERS AND SURGEON 
LIEUTENANTS (D.) 

Applications are invited for cight vacancies in April 
for Medical Officers in the Royal Navy. Copies of the 
regulations for entry, conditions of service, &c., may be 
obtained from the Medical Director-General of the Navy, 
Admiralty, S.W.1, and from the Deans of all Medical 
Schools. Applications for entry must be received not 
later than Feb. 22nd. 

The establishment of Dental Officers in the Royal 
Navy has been increased and applications are invited 
for appointment to commission as Surgeon Lieutenants (D.). 
Application forms and a pamphlet may be obtained from 
the Medical Director-General of the Navy, Admiralty, 
S.W.1. Applications for entry in March must reach the 
Medical Director-General not later than Feb. 6th. 


ROYAL NAVAL VOLUNTEER RESERVE 


H. B. Howell entered as Proby. Surg. Lt. 

Proby. Surg. Lt. H. J. Wade to Excellent. 

Proby. Surg. Sub-Lts. D. S. Macphail and J. A. Shepherd 
to be Surg. Sub-Lts. 


ROYAL ARMY MEDICAL CORPS 


Maj. T. C. Bowie retires on ret. pay. 

Capts. T. W. Davidson and C. R. Christian to be Majs. 
(Substituted for notification in the Gazette of May 8th, 
1934.) (Wide Tue Lancet, May 19th, 1934, p. 1080.) 

Capt. J. G. E. Vachell to be Maj. (Substituted fo 


notification in the Gazette of Feb. 15th, 1935.) (Vide THE 
LaNnceET, Feb. 23rd, 1935, p. 450.) 


TERRITORIAL ARMY 

Capt. G. W. Wright, M.M., T.D., to be Maj. 

Lt. R. Rutherford to be Capt. 

Hugh Weir (late Cadet Serjt., Glasgow Univ. Contgt., 
Sen. Div., O.T.C.), to be Lt. 

James Lockhart Gowan (late Cadet, George Watson’s. 
Coll. Contgt., Jun. Div., O.T.C.), to be Lt. 


ROYAL AIR FORCE 


The undermentioned Flying Offrs. are promoted to the 
rank of Flight Lt. :— 

A. W. Smith, J. W. Patrick, J. S. Wilson, C. A. Lewis, 
R. G. James, and G. H. Stuart. 

Flying Offrs. C. M. Carlyle-Gall to R.A.F.. Station 
Aldergrove; E. B. Harvey and D. S. MacL. MacArthur 
to Medical Training Depôt, Halton, on appointment, to 
short service commissions. 

Flying Offr. R. S. Peil to R.A.F. Station, North Coates 
Fitties. ‘ 

Dental Branch.—Flight Lt. J. G. Stewart is transferred 
to the Reserve, Class D. 

Flying Offrs. D. P. Boyle to No. 5 Flying Training 
School, Sealand; K. G. Swiss to No. 3 Flying Training 
School, Grantham; and H. M. G. Williams to Head- 
quarters, Coastal Area, Lee-on-the-Solent. 


VACANCIES FOR COMMISSIONS IN THE MEDICAL BRANCH 


Applications are invited from Medical Men for appoint- 
ment to Commissions in the Medical Branch of the Royal 
Air Force, for entry in May, 1936. Copies of the regula- 
tions and form of application may be obtained on 
application from: The Secretary, Air Ministry (D.M.S.), 
Adastral House, Kingsway, W.C.2. Completed applica- 
tions from intending candidates for the vacancies in May, 
1936, must be received in the Air Ministry not later than 
March 17th, 1936. 


INDIAN MEDICAL SERVICE 


Col. W. H. Hamilton, C.I.E., C.B.E., D.S.O., F.R.C.S., 
I.M.S., is apptd. Hon. Physician to the King, Oct. 22nd, 
1935, vice Col. E. C. Hodgson, D.S.O., I.M.S., retd. 

Indian Medical Department.—Maj. (Sen. Asst. Surg.) 
L. P. Gernon retires. | 


282 THE LANCET] 


USE OF ANALGESICS BY MIDWIVES 


REPORT OF AN INVESTIGATION BY THE BRITISH 
COLLEGE OF OBSTETRICIANS AND GYNZXCOLOGISTS! 


At the request of the National Birthday Trust 
Fund the British College of Obstetricians and Gyne- 
cologists has carried out an investigation to ascertain 
if there is any form of analgesia (relief from pain) 
which can be used with safety and success by a mid- 
wife in the absence of a medical practitioner. The 
trial has been made in institutions, as adequate 
medical supervision and facilities for the necessary 
observation and accurate recording of results are 
more readily available in such places. Thirty-six 
hospitals, for the most part maternity hospitals or 
departments attached to medical schools, accepted 
the invitation to take part in the investigation. 

Five methods were adopted for investigation : 
(1) chloroform capsules, (2) the Christie Brown chloro- 
form inhaler, (3) the Mennell chloroform inhaler, 
(4) the Minnitt gas-and-air apparatus, (5) the adminis- 
tration of paraldehyde per rectum. The records of 
nearly 10,000 cases have been studied and classified 
into three main groups: (1) nitrous oxide and air, 
(2) chloroform, (3) paraldehyde. 


Nitrous Oxide and Air 


Nitrous oxide and air was administered with the 
Minnitt apparatus to 3865 cases, and in 627 of them 
an additional anesthetic was administered, mainly 
on account of some obstetric difficulty. Nitrous 
oxide and air was thus administered to 3238 cases 
without any supplementary anwsthetic or analgesic. 
In this series there were three maternal deaths which 
were in no way due to the analgesia. Among the 
627 cases in which an additional anaesthetic was 
administered there were six maternal deaths ; in 
every case the death was the result of serious obstetric 
difficulty and in no case was it attributable to the 
administration of the gas and air. 

The stillbirth-rate when the Minnitt apparatus 
alone was used was 2-0 per cent. When administered 
by a sister, staff-nurse, or pupil-midwife it was 
1:2 percent. The higher stillbirth-rate jn cases under- 
taken by a medical practitioner is accounted for by 
the fact that he would be more likely to be called 
upon in difficult cases in which a relatively high still- 
birth-rate is to be expected. When a full anesthetic 
was given (frequently on account of some obstetric 
abnormality) the stillbirth-rate was 4:3 per cent. 
The stillbirth-rate for the whole series, however, 
shows that the method does not involve any added 
risk to the fotus, and the low stillbirth-rate when 
the analgesic was self-administered (or administered 
by a pupil-midwife) indicates that the actual adminis- 
tration does not call for more special skill than that 
which may be acquired by a midwife during her 
period of training. l 

The number of cases in which obstetric interference 
was necessary is an indication of the degree to which 
the normal forces of labour were interfered with. 
In the series of 3865 it was 8-4 per cent. (forceps deli- 
very alone 6:6 per cent.), and as these figures compare 
favourably with the interference-rate in ordinary 
practice, the conclusion is justified that this method 
has no deterrent influence on the natural course of 
labour. 


1 The report, of which this is a summary, was passed by the 
College at its meeting on Jan. 25th, 1936, and is signed by the 
president, Sir Iwen Maclean. Copies may be had, price Is., 
from the hon. secretary of the College, 58, Queen Anne-strect, 
London, W.1 


REPORT ON THE USE OF ANALGESICS BY MIDWIVES 


Fh ete sa ees i in Ph se ae ig a SS ae 


[FEB. 1, 1936 


The records of the patients who received analgesia 
from the Minnitt apparatus have been analysed 
(Table I.) as regards the efficacy of the method. 


TABLE I 
Efficacy of Gas-and-Air Analgesia 
Per cent. 
Satisfactory 77:0 
Doubtful.. 5°3 
Unsatisfactory 17:7 


Investigation was further made into the relative 
effectiveness of this form of analgesia when self- 
administered or when administered by persons of 
varying degrees of experience. The proportion of 
cases in which satisfactory analgesia was obtained 
with various classes of administrators is set out in 
the table below. Table II. is an analysis of 3238 
cases in which the Minnitt gas-and-air apparatus 
was used without any additional anæsthetic or 
analgesic. 


TABLE II 
Efficacy of Gas-and-Air Analgesia in the Hands of Various 
Administrators 
Percentage of 
Administered by— Total satisfactory 
cases. cases. 
Patient herself 1086 88°0 
Pupil midwife or 4 . ; 
Medical student | 227 sonia 
Midwife oe 197 82°1 
Medical practitioner 802 82°38 
` CONCLUSIONS 


(1) The investigation has proved that the adminis- 
tration of gas and air by the Minnitt apparatus js 
safe for use by midwives in hospital, provided that 
a recent examination by a medical practitioner has 
revealed no contra-indication thereto. 

(2) The use of that apparatus should be restricted 
to those midwives who have had a special training 
in its use, and who have shown themselves capable 
of managing it. Such training could be carried out 
concurrently with that for the certificate of the 
Central Midwives Board when the proposed longer 
period of training is adopted. For those already 
holding the C.M.B. certificate a special course would 
be required. The reasons for stressing the import- 
ance of a long training are that it requires consider- 
able experience to learn the essentials of obstetrie 
analgesia. Furthermore, experience in mechanical 
adjustments and in the changing of gas cylinders is 
essential if the machine is to work efficiently. 

(3) Gas ‘and air administered by the Minnitt 
apparatus produces satisfactory analgesia in a high 
proportion of cases. Sometimes, however, there is 
a restlessness and difficulty in controlling the patient ; 
it is essential, therefore, that one other responsible 
person should be present in addition to the midwife 
in charge of the case. 

(4) Further experience is necessary before the 
suitability of the Minnitt apparatus for domiciliary 
practice is proved, as this investigation has only 
been carried out in hospitals where additional help 
was always readily obtainable. 

(5) Owing to the weight and bulk of the apparatus, 
transport would present serious difficulties if used in 
domiciliary practice, but it is possible that the wider 
use of “light” cylinders and further simplifications 
of the apparatus may go far to solve this problem. 

(6) The apparatus presents certain mechanical 
difficulties which have necessitated return to the 
makers. Whilst due regard must be given to those 
difficulties, it may be possible to overcome them. 
once there is a suflicient demand to stimulate mecha- 


THE LANCET] 


nical improvements. It must be borne in mind, 
however, that a certain amount of mechanical 
aptitude would be still required to change cylinders 
of gas and to make minor adjustments. Such 
adjustments involve the use of a spanner and the 
frequent inspection of washers and joints. 

(7) The cost of the apparatus is a handicap to 
general use. Apart from the initial expense, the 
cost of the nitrous oxide is high. Moreover, there 
is a serious risk of wastage owing to the fact that, 
as the apparatus is now constructed, leakage may 
occur at many places unless constant attention is 
given to minor adjustments. 


Chloroform 


. In the majority of patients chloroform analgesia 
was used alone, but in some it. was necessary (fre- 
quently on account of some obstetric abnormality) 
to supplement the analgesia with general anesthesia. 
Thus, for each method the patients have been divided 
into two groups (Table III.), and the maternal deaths 
in each group have been recorded. 


TABLE III 
Maternal Deaths with Different Methods of Chloroform 
Analgesia 
Analgesia Analgesia 
aod alone. Ta 
Tota. Deaths. Toras | Deaths. 
Chloroform capsules 2338 1 194 0 
Mennell inhaler 1430 1 141 2 
Christie Brown inhaler.. 809 0 63 2 
~ Toal .. o| $577 | 2 | 308 4 


Thus the maternal mortality-rate in this group of 
4975 patients was 1'2 per thousand. From a study 
of the details of these six deaths, the conclusion 
reached is that chloroform was directly responsible 
for death in one case, that it was probably an impor- 
tant factor in the fatal issue in two cases, and that 
it was in no way responsible for death in three cases. 

The total stillbirth-rate for all cases in which the 
analgesia was obtained (Table IV.) by the use of 


TABLE IV 


Stillbirth-rate with Different Methods of Chloroform 
Analgesia 


Analgesia 


Analgesia plus general 


alone. 


anesthesia. 
Method. 
Cases ber ee nt.| C2565. | percent. 
Chloroform capsules... 2338 2-4 194 17°5 
Mennell inhaler 1430 1°3 141 4°3 
Christie Brown inhaler.. 809 1'9 63 372 


chloroform was 2°6 per cent. It includes all cases 
in which obstetric interference became necessary 
after the analgesia had been started, so that it may 
be said that there is no evidence that the chloroform 
analgesia is attended by increased risk to the foetus. 
The interference-rate for all cases receiving chloro- 
a capsules was 5'3 per cent. (forceps “delivery 
7 per cent.). Thus there is no evidence that the 


REPORT ON THE USE OF ANALGESICS BY MIDWIVES 


[FEB. 1, 1936 283 


use of chloroform as an analgesic in these cases 
caused any material interference with the normal 
forces of labour. Table V. shows the efficacy of the 
analgesia produced by the three methods investi- 
gated. 


TABLE V 
Efficacy of Analgesia with the Three Methods of Chloroform 
Analgesia 
Chloroforn. Mennell Christie Brown 
capsules, inhaler, inhaler, 
per cent. per cent. per cent. 
Satisfactory 81°8 si 84°9 sa 78:8 
Doubtful .. .. 3°7 oi 2°7 za 6:3 
Unsatisfactory 14°5 12:4 149 


Investigation has been made into the proportion 
of the patients in whom satisfactory analgesia was 
obtained when the analgesic was administered by 
persons of varying degrees of experience. Table VI. 
is an analysis of the cases in which no additional 
anæsthetic was given. 


TABLE VI 


Efficacy of Chloroform Analgesia in the Hands of Various 
Administrators (percentage of patients who obtained 
satisfactory analgesia) 


Christie 
Chloroform Mennell 
. Brown 
capsules. inhaler. inhaler. 
Administered 
by— 
Der Cases. per Cases, Lae Cases 
Patient herself 87:7 | (277) | S83°4 | (ATT) | 82°1 | (252) 
Pupil midwife or 
medical student 81:8 1(1239)} 81°5 (92)| 82°2 | (157) 
Certified midwife 83°9 | (695)| 92°1 | (559){ 81°3 | (347 
Medical practitioner, 86°6 | (127) | 93°7 | (302) | 86°8 (53) 


Note.—The figures in parentheses represent the total numbers 
of cases in the several groups. 


CONCLUSION 


Chloroform by any method should not be used by 
midwives acting alone. This conclusion has been 
reached with regret, but both the immediate and 
delayed dangers which are well recognised occurred 
in this investigation, and it is not possible fully to 
guard against such occurrences if the administration 
of chloroform is in inexperienced hands. This finding 
should not be taken to prejudice the administration 
of chloroform in midwifery by registered medical 
practitioners who, aware of the dangers, can take 
precautions to lessen the risks. 


Paraldehyde 


While there can be no doubt that in some selected 
cases the use of paraldehyde, given in oil per rectum 
during the first stage of labour, may be a valuable 
means of relieving pain, the general opinion of those 
who have used it as a routine method in this investi- 
gation is that it is unsuitable for general use by 
midwives. In arriving at this conclusion they have 
had in mind the technical difficulties in administering 
the drug, the need for careful selection of suitable 
patients, the choice of time for giving the injection, 
its variable action even when patients are carefully 
selected, and the inadequate analgesia at the time 
of the actual birth of the child. This last is probably 
the most important objection to its widespread use 
by midwives, since, even if effective in the early 
stages of labour, some additional method of analgesia 
must be provided if the pain associated with the 
moment of birth is to be relieved. 

e 


984 THE LANCET] 


[FEB. 1, 1936 


CORRESPONDENCE 


BACTERIOLOGICAL TESTING OF MILK 
To the Editor of TuE LANCET 


Sir,— Your issue of Jan. llth comments on an 
extract from my annual report for 1934, dealing 
with the bacteriological examination of samples of 
graded milk, which appeared in the Medicul Officer 
of Dec. 28th, 1935. “ Dr. Howell,” it is remarked, 
“is hardly being fair when he assumes that variations 
in count are due to the failure of bacteriologists to 
‘faithfully and carefully carry out the suggested 
procedure.’’’ Other factors are suggested as the 
likely cause of the widely different results given by 
different laboratories of the examination of samples 
of the same milk. ‘‘ The factor which probably has 
most effect on the bacterial content of milk is the 
state of the weather, which is altogether outside the 
bacteriologist’s control.” Unless samples are trans- 
ported to the laboratory on ice “‘there may be big 
variations in bacterial growth within a short period 
of transit.” 

This fact is of course well known by everyone 
with an elementary knowledge of milk bacteriology, 
but cannot be advanced as an explanation of the 
wide divergence of the figures in the reports I have 
quoted. One bottle of milk was taken and after 
thorough shaking was divided into six parts. The 
milk, before division, and the bottles into which it 
was placed were of an even temperature. The bottles 
were immediately packed into an efficient ice-box 
and conveyed to the laboratories. The difference in 
time taken for delivery of the parts which were 
reported to have the lowest (9270) and the highest 
(3,400,000) total counts was about 20 minutes. The 
temperature of the milk upon arrival was stated by 
the laboratories to be 13°C. in the first case and 
11°C. in the second case. 
part for which the lower temperature was given was 
stated to have a bacterial count 360 times greater 
than that of the part for which the higher temperature 
was given. As a further proof that the temperature 
of the milk had nothing to do with the difference in 
the figures I have quoted, I would point out that 
each laboratory gave the same temperature for the 
two ‘parts which they each examined, yet each 
laboratory gave different figures for the two parts, 
in one case the results varied from 147,000 to 3,400,000. 

I fully appreciate the difficulties of trying to 
standardise a test of this sort and I have pointed out 
that particular attention must be paid to every 
detail. Your article states, ‘‘There are mechanical 
faults such as errors in the graduation of pipettes to 
be controlled ’°—but surely this is a difficulty quite 
easy to overcome. Every properly equipped labora- 
toty should have standardised equipment. 

The Milk and Dairies (Amendment) Act gives power 
to a local authority to withdraw a licence to sell 
graded milk, if reports on a dairyman’s milk show 
that samples do not comply with the standards laid 
down. It would be most unfair if such action was 
taken on reports which gave incorrect figures due to 
the use of improperly graduated pipettes in the 
laboratory. I agree that the human element plays 
an important part in the bacteriological examination 
of milk. I still consider, however, that the tests are 
worthless unless they give more comparable results. 
I hold no brief for the dairyman who does not take 
every precaution to safeguard his milk but, at the 
same time, I sympathise with the man who may be 
called upon to answer charges on unreliable data. 


It will be seen that the - 


Dairymen have been and are being prosecuted for 
selling graded milks not in conformity with the 
standards. In view of my experience it may well 
be that some at least are innocent of the charges 
made against them.—I am, Sir, yours faithfully, 


J. B. HOWELL, 


Jan. 24th. Medical Officer of Health, Hammersmith. 


MEDICAL EDUCATION AND BLOOD 
EXAMINATION 


To the Editor of THE LANCET 


Sir,—lI should like to endorse all that Dr. Herbert 
Brown says in his letter in your issue of Jan. 11th. 
The medical journals have unfortunately given little 
encouragement to the routine examination of the 
blood in diagnosis and prognosis in their editorials 
on the subject, and I was told by the head of a 
preparatory school that he wished me to discontinue 
‘‘ blood examinations’’ as ‘‘the boys didn’t like 
it and other doctors were able to do their job 
without it.” 

The discovery of early leucocytosis in a lobar 
pneumonia saves much exhausting examination of 
the chest. The search for the return of the eosino- 
phils justifies a daily differential count, the ‘‘ drift 
from the left” being also noted, and are signs of 
improvement so much more certain than any 
symptom. There is just one additional point to 
stress—one should have a record of the patient’s 
blood picture in normal health. To quote Dr. Brown, 
“the process is interesting, even fascinating ° and 
extremely valuable. He has, I think. mentioned the 
one drawback—it takes an hour in each case. 

I am, Sir, yours faithfully, 
Battle, Sussex, Jan. 22nd. H. ANGELL LANE. 


INFECTIOUS DISEASE 


IN ENGLAND AND WALES DURING THE WEEK ENDED 
JAN. 1STH, 1936 


_Notifications.—The following cases of infectious 
disease were notified during the week: Small-pox, 0: 
scarlet fever, 2554; diphtheria, 1283; enteric fever. 
13; acute pneumonia (primary or influenzal), 1219 ; 
puerperal fever, 46 ; puerperal pyrexia, 105 ; cerebro- 
spinal fever, 22; acute poliomyelitis, 3; acute polio- 
encephalitis, 2 3 encephalitis lethargica, 5; dysentery, 
233; ophthalmia neonatorum, 87. No case of cholera, 
plague, or typhus fever was notified during the week. 

The number of cases in the Infectious Hospitals of the London 
County Council on Jan, 24th was 3964, which included : Scarlet 
fever, 1120; diphtheria, 1129; measles, 475; whooping- 
cough, 610; puerperal fever, 19 mothers (plus 13 babies) 
encephalitis lethargica, 283; poliomyelitis, 5. At St 


Margaret’s Hospital there were 20 babies (plus 5 mothers) with 
ophthalmia neonatorum. 


Deaths.—In 121 great towns, including London, 
there was no death from small-pox, 3 (3) from enteric 
fever, 58 (7) from mealses, 6 (1) from scarlet fever, 
27 (11) from whooping-cough, 42 (3) from diphtheria, 
37 (11) from diarrhea and enteritis under two years, 
and 89 (18) from influenza. The figures in paren- 
theses are those for London itself. 

The mortality from influenza is falling, the total deaths 
the last seven weeks (working backwards) being 89, 110, ie 
80, 67, 62, 45. The deaths this week are scattered over 52% 
great towns, Leeds reporting 7, Birmingham 6, Newcastle-on - 
Tyne 3, no other great town more than 2, Liverpool bad to 
report 19 deaths from measles, Manchester 9, Croydon and 
Salford cach 3. Liverpool also had 4 deaths from whooping- 
cough, Manchester 2. Deaths from diphtheria were reported 
from 28 great towns, Hull, Manchester, Oldham and Sunderland 
oun reporting 3; Leeds, Liverpool, Birmingham, and Swindon 
each 2, ` 
The number of stillbirths notified during the week 
was 259 (corresponding to a rate of 42 per 1000 total 
births), including 43 in London. 


THE LANCET] 


[FEB. 1, 1936 285 


OBITUARY 


WILLIAM BLAIR-BELL, M.D. Lond., 
F.R.C.S. Eng. 


LATE PRESIDENT, BRITISH COLLEGE OF OBSTETRICIANS AND 
GYNZECOLOGISTS 


THE news of the sudden death of Prof. Blair-Bell, 
which occurred on Saturday last, Jan. 25th, has been 
received with deep regret by the medical world and 
a large circle of public and private friends. He 
enjoyed a great and even international reputation as 
gynecological and obstetrical surgeon with a large 
scientific outlook. 

William Blair-Bell was born at Wallasey in 1871, 
the son of the late Dr. William Bell, J.P., and Helen, 
daughter of the late General Butcher. He received 
his general education at Rossall and went for his 


medical training to King’s College, London, where 
he was a successful 


student, Warneford 
and Junior medical 
scholar, prizeman 
in physiology and 
obstetric medicine, 
and Tanner prize- 
man in gynecology. 
He took the double 
English diploma in 
1896 and graduated 
as M.B. London in 
the following year, 
when he was elected 
an Associate of 
King’s College. He 
was prosector at 
the Royal College 
of Surgeons of 
England, and 
demonstrator of 
anatomy and physi- 
ology in King’s 
College, and early 
showed his mark 
as clinician and observer by papers in the King’s 
College Hospital Reports, the Edinburgh Medical 
Journal, and The Lancet. He proceeded to the 
M.D. Lond. in 1902 and took the B.S. Lond. in 1904. 

He now returned to Liverpool, with which city 
he was for the next 30 years and more so importantly 
connected. He was appointed in 1905 gynecological 
surgeon in charge of out-patients at the Royal 
Infirmary, Liverpool, and held appointments also at 
the Wallasey Cottage Hospital and the Wallasey 
Dispensary. His work immediately attracted wide 
attention. He communicated regularly to the 
Proceedings of the North of England Gynecological 
Society, and his coöperation became sought by the 
editors of systematic treatises. He wrote the articles 
on malformation of the uterus, injuries to the uterus, 
fistulæ of the uterus, and subinvolution of the uterus, 
in Latham and English’s system of treatment; he 
wrote the section on obstetric operations and on 
sexual functions in women in the “ Practitioners’ 
Encyclopedia,” and the chapter on operations on 
the Fallopian tubes in Burghard’s ‘“‘System of 
Operative Surgery.” His papers in The Lancet, 
British Medical Journal, Practitioner, and the Pro- 
ceedings of the Royal Society of Medicine, sometimes 
alone and sometimes in collaboration, all showed 
him to be a resourceful surgeon with an unusual 
knowledge of physiology—papers published in the 
British Medical Journal on the physiology of the 


PROF. BLAIR-BELL 
Photograph by Elliott & Fru 


female genital organs (in collaboration with Pantland 
Hick) and a communication to the Royal Society of 
Medicine on the relations of calcium metabolism to 
menstruation may be instanced. : 

In 1910 Blair-Bell gained the John Hunter medal 
of the Royal College of Surgeons of England and the 
triennial prize for an essay on the anatomy and 
physiology of the pituitary body and the relationship 
with disease of its abnormal and morbid conditions. 
Two years later he delivered the Arris and Gale 
lectures before the College, taking as his subject the 
genital functions of the ductless glands in the female. 
The lectures which were printed in TRE LANCET 
with full illustrations showed not only the advanced 
nature of Blair-Bell’s physiological studies and his 
acquaintance with detailed laboratory work in bio- 
chemistry, but also his wide reading and philosophical 
outlook. In 1913 he became full gynecologist and 
surgeon at the Royal Infirmary, and in 1921 he was 
appointed professor of these subjects in the university. 
He held the chair in the university for ten years 
and was emeritus professor at the time of his death. 
As a teacher he was thoroughly in his element; it 
is not too much to say that under him there flourished 
the best teaching department in gynecology of any 
British school. 

Blair-Bell, who had now been president of the 
North of England Gynecological Society and vice- 
president of the section of obstetrics and gynxcology 
at the Royal Society of Medicine, made in 1925 his 
first long and formal statement of views upon cancer, 


. which afterwards became the subject of much 


discussion. He delivered on Nov. 10th of that year, 
before the Academy of Medicine in Toronto, an address 
on the specific character of malignant neoplasia with 
special reference to the control of cancer from this 
standpoint, and in-the course of the address revealed 
the intensive study of the subject on which he had 
been engaged in coöperation with a group of Liverpool 
workers. 
HIS WORK ON CANCER 

Prof. Walter J. Dilling, director of the department 
of pharmacology of Liverpool University, sends the- 
following account of this work :— 

“It is a sorrowful privilege for one who has been 
closely associated with Blair-Bell’s investigation into 
the nature and control of malignant disease to write 
a historical eulogy upon his brilliant and indefatigable 
endeavours to elucidate this problem. He was urged 
to research upon cancer by a yearning for knowledge 
with which he might alleviate human suffering and 
prolong life, and, in 1909, he formulated his “ working 
hypothesis ’’—namely, that the chorionic epithelium, 
particularly the syncytium, was a normally malignant 
tissue and that a means, which could check its 
development, would be useful in arresting the progress 
of malignant growths. | 

“ At first he explored the idea that the invasive 
properties of chorionic epithelium might be arrested 
by embryonic or placental extracts, but, when these 
failed, he concentrated his attention on the fact that 
lead salts caused abortion and were particularly 
deleterious to young life, surmising, as a corollary, 
that they might restrain the growth of neoplasms. 
The discovery that lead destroyed spermatozoa in 
the testes and induced coagulation necrosis in the 
ectodermal tubules of the chorion, encouraged him 
to treat, on Nov. 9th, 1920, an inoperable spheroidal- 
celled medullary carcinoma of the breast by intra- 
venous injections of a partly colloidal lead iodide— 


986 THE LANCET] 


within a month the growth had practically dis- 
appeared, the enlarged glands subsided, and this 
patient is still alive. Other hopeful improvements 
were achieved in a variety of cases and, at a meeting 
on Jan. 30th, 1923, the late vice-chancellor of Liver- 
pool University, Dr. J. G. Adami, inspired the 
formation of a Cancer Research Committee, which 
consisted originally of Sir Robert Jones, Messrs. 
J. A. Smith and Rex Coben, with the present registrar 
of the university, Mr. Edward Carey, as acting secre- 
tary, in order to subsidise and facilitate researches 
upon Blair-Bell’s theories and remarkable clinical 
results. 

“ Blair-Bell’s knowledge of the modern advances 
in the medical sciences was admirably and amazingly 
comprehensive, but he recognised that satisfactory 
and rapid progress towards his objective could be 
achieved only by employing the ‘ Aggregate Mind’ 
of his scientific colleagues. His preliminary results 
and his aspirations were communicated to Prof. 
W. C. M. Lewis (physical chemistry), the late Prof. 
E. E. Glynn (pathologist), and the writer (pharma- 
cologist), who agreed to assist in the investigation. 
Funds, provided at first through the generosity of 
the Cancer Research Committee—notably by Mr. Rex 
Cohen—defrayed the cost of early researches and 
provided free treatment for poor patients in nursing 
homes; but, later, when the Liverpool Medical 
Research Organisation was incorporated for charitable 
purposes, financial support for the work was derived 
partly from voluntary subscriptions and partly from 
the fees of patients. Cordial coöperation was main- 
tained between the scientific and clinical workers at 
the frequent meetings with Blair-Bell, when results 
were criticised and the scientific staff informed of 
the clinical effects or defects of new preparations of 
lead. At these discussions Blair-Bell’s intellect was 
dominant, and displayed an alert elasticity with 
quickness of perception which justified his position 
as director and organiser of researches covering 
extensive fields of modern science. 

“ Publications by Blair-Bell and members of the 
scientific and clinical staff appeared from 1922 
onwards, and by 1930 some 64 papers had recorded 
the results of intensive investigations on many aspects 
‘of the cancer problem and of the influence of lead on 
normal and malignant tissues. These researches were 
subsequently collected and co-related by Blair-Bell 
in ‘Some Aspects of the Cancer Problem,’ and a 
consideration of the evidence contained therein will 
vindicate Blair-Bell’s reputation from the suggestion 
that he maintained undue reticence about his methods 
or results, will substantiate the reasons for his caution 
in endeavouring to restrict the general therapeuticai 
use of lead compounds in malignant disease until 
their specific value was more definitely determined 
and their toxicity more easily controlled, and will 
also justify his belief that lead salts exert an inhibitory 
influence on some forms of neoplasms. Interest in 
the work was excited in many parts of the world, 
and supporting evidence accumulated from many 


sources, amongst others from Carter Wood in 
America. As the investigation proceeded, changes 
and—latterly from lack of funds—restrictions in the 


fields of the research became necessary. Prof. I. M. 
Heilbron’s collaboration—and recently that of Prof. 
A. Robertson—achieved the synthesis of many less 
toxic compounds of lead and the beneficial effects of 
these in selected cases continued to maintain the 
hope that the pursuit of this line of inquiry would 
ultimately yield a compound of lead which possessed 
greater and more reliable inhibitory effects on 
tumours both in animals and in man. 


OBITUARY 


[FEB. 1, 1936 


‘* Although he retired from his chair and active 
practice in 1931, Blair-Bell still maintained an 
intimate relationship with this research work which, 
under the direction of Dr. Morris Datnow, continues, 
so far as restricted funds permit, to be prosecuted 
actively in Liverpool, both in its scientific and clinical 
aspects and with results which continue to support 
the view that intravenous injections of suitable lead 
compounds do cause in a percentage of cases a 
retardation or even retrogression of some malignant 
growths. The work of the Liverpool Medical Research 
Organisation as a scientific body is a memorial, if 
still imperfect and incomplete, to the untiring zeal 
and devotion of Blair-Bell to the advancement of 
medical science, an objective for which he was 
always prepared to make personal sacrifices.” 


Blair-Bell, while frequent in his contributions to 
contemporary literature, had a useful treatise to his 
credit dating from an early period in his career. 
In 1911 appeared his large treatise, the Principles 
of Gynecology, in which he endeavoured to present 
a complete and modern survey on which gynecology 
should be established. The work was concise and 
readable, drawn up on a simple and logical arrange- 
ment, and admirably produced. While following 
academic lines in general he challenged attention by 
the stress which he laid on the importance of the 
calcium content of the blood and on the large part 
played by the secretions of the ductless glands in the 
causation of certain gynecological conditions. In 
many directions the lapse of time would seem to have 
confirmed observations which were not all at the 
time generally accepted. This was his only text- 
book. 


FOUNDATION OF THE COLLEGE 


Blair-Bell erected a permanent memorial to his 
energies and his high conception of his branch 
of medical and surgical work when he became the 
prime advocate of the foundation of the British 
College of Obstetricians and Gynecologists. He put 
forward vigorous arguments for the institution of 
such a college; he replied trenchantly to those who 
held the opposite view, and when in 1929 the college 
came into being it was recognised as absolutely 
fitting that he should be elected the first president. 
At the last dinner of the college Lord Dawson spoke 
of him as ‘‘the restless, lovable torch-bearer who 
never forgot—or allowed anybody else to forget— 
that he was bearing a torch.” and his branch of 


the profession will never forget their debt to him. 


Dr. J. S. Fairbairn, Blair-Bell’s immediate successor 
in the presidency, writes : 

“ Blair-Bell’s was a striking and forceful personality. 
Gaunt with ascetic features that did not belie the 
earnestness and grim determination that lay beneath 
them, he pursued whatever he took up with almost 
fanatic zeal. Gifted with a fine intellect, the power of 
dramatic expression, and of wide interests, he was a 
delightful host and companion. No one of his day 
and generation exercised a greater influence on British 
gyneeology than Blair-Bell, an outstanding instance 
of which was his prominent part in the foundation 
of the British College of Obstetricians and Gynivco- 
logists. In spite of indifferent health, he threw 
himself, body and soul, into the work of drawing up 
its constitution and seeing through its incorporation, 
and, after his election as its first president, of esta blish- 
ing it in the position he had determined it should 
occupy. Ife had ambitions regarding the high place 
the new college should take and was inclined to be 
impatient with those, both within and without the 


THE LANCET | 


OBITUARY 


[FEB. 1, 1936: 287 


college, who were unable to accept his own estimate. 
There can be little doubt that this impatience arose 
in great measure from the knowledge that his life 
hung by a thread and might end as it did. He was 
certainly lavish in the expenditure of his strength 
and energy, for no details escaped him or were too 
small for his undivided attention. Nowhere will the 
passing of William Blair-Bell be more deeply mourned 
than in the college that meant so much to him and 
owes so much to him.” 


The following is a brief enumeration of the appoint- 
ments that Blair-Bell held at the time of his death. 
He was consulting gynecological and obstetrical 
surgeon to the Royal Infirmary and the Maternity 
Hospital, Liverpool, and emeritus professor at the 
university of those subjects. He was the consulting 
director of the Liverpool Medical (Cancer) Research 
Organisation, president of the Royal Infirmary, 
Liverpool, and honorary fellow of many obstetrical 
societies, British and foreign. He was elected fellow 
of King’s College, London, in 1928, and F.R.C.S. Eng. 
in 1929. He was an honorary fellow of the American 
College of Surgeons, the universities of Liverpool and 
Glasgow gave him the LL.D. degree, and he was a 
Commander of the Royal Order of the Star of 
Roumania. 

Prof. Blair-Bell married his cousin, Florence, 
daughter of Mr James Bell, who predeceased him. 
They had no children. Those who enjoyed his 
friendship or acquaintance cannot fail to remember 
his personality, and to recognise the aptness of 
Dr. Fairbairn’s words. Blair-Bell was of the stuff 
from which great men are made, and he was a great 
man both in example and accomplishment. 


CHARLES ANDERSON FERGUS, L.R.C.P. Edin. 


THE death is announced in his eightieth year of 
Dr. Charles Anderson Fergus, for many years medical 
officer for East Kilbride parish where the whole of 
his medical career was spent. He practised with 
his father, and within the memory of many he was 
always entitled ‘“‘the young doctor,” then he became 
popularly known as “Dr. Charles,” and lived to be 
affectionately spoken of as “the old doctor.” He 
had a particularly strong hereditary claim on the 
regard of the neighbourhood. His grandfather was 
ordained minister of the Relief church 140 years ago, 
while his father, Dr. James Fergus, who graduated 
in medicine 95 years ago, founded the medical prac- 
tice in Kilbride immediately after qualification. 
Of Dr. James Fergus’s two sons, the elder, who 
practised in Yorkshire, is still living at the advanced 
age of 88 years. 


MURDO TOLME MACKENZIE, M.B. Edin. 


Dr. Murdo Mackenzie, who died on Jan. llth in 
his seventy-eighth year, had seen 50 years’ service 
in the Scottish islands. He was the son of the factor 
of the MacLeod estate and was educated at Daniel 
Stewart’s College and the University of Edinburgh, 
graduating. as M.B., C.M. in 1880. He was early 
appointed medical officer for the whole parish of 
North Uist, and until recently had charge single- 
handed of the island and also of Grimsay, Heisker, 
and Berneray, but under the reorganisation of the 
Highlands and Islands service he became responsible 
only for the west side of North Uist. There he was paro- 
chial medical oflicer and M.O.II., surgeon to the Lock- 
maddy prison, and acted as sheriff substitute for 
Inverness-shire, of which county he was a J.P. He 
was also medical officer to the post oflice, and after 


the war did considerable work under the Ministry 
of Pensions. He endured for most of his working 
life the great physical hardships of practice in the 
island district, and became an absolute repository 
pf the physical and family stories of his whole environ- 
ment, having been either publicly, professionally, or 
personally in contact with practically everybody. 
He had a fine record of service and his reputation is 
safe in the recollection of the people of North Uist. 


— 


THE LATE PROF. STARR JUDD 


Edward Starr Judd was born in Rochester, Minn., | 
on July llth, 1878, and died on Nov. 29th, 1935, 
when on the way to address a meeting at Philadelphia. 
Having graduated at Minneapolis in 1902 he became 
an intern at St. Mary’s Hospital, Rochester, and in 
the following year first assistant to Dr. C. H. Mayo, 
the remainder of his life being spent as a member 
of the Mayo Clinic. In 1918 he was appointed to 
the graduate chair of surgery in the University of 
Minnesota. 

Prof. Grey Turner writes: ‘‘ Those who know the 
Mayo Clinic will be very sorry to hear of the death 
of Edward Starr Judd while still on the good side 
of 60. At the time of my first visit to Rochester 
thirty years ago Judd was an able second to the 
brothers Mayo, and in fact those three constituted 
the sole surgical team of that day. He was even 
then doing a fair share of the operative work and 
appeared to be thoroughly familiar with all branches 
of surgery. From that time to his death, save for 
short vacations, he operated every day of the week 
except Sunday, and his lists seldom ran to less than 
six cases, so that in the course of his career he prob- 
ably did more operations than any other surgeon. 

«Judd was a first-rate all-round man, and though 
in recent years his work was mostly confined to the 
abdomen, he was never a specialist in any sense of 
the word. He was a beautiful steady operator, 
always the same, never fast never slow, and above 
all never put out or fussy. The patient always 
seemed safe in his hands, and many a spectator 
picked him out as the man to operate on those near 
and dear. But he was not only a renowned operator 
but a great doctor, and the investigation and care of 
his patients was thorough and sympathetic. His 
writings were not voluminous but were always 
practical and sound, and like his operative work 
showed good judgment throughout. In the clinic 
Judd was obviously an influence for good, and his 
earnest conciliatory manner must have been an 
enormous asset in such an organisation. He pos- 
sessed the highest of all distinctions in that he was 
a maker of surgeons, and I have heard many now 
well known in the surgical world who have acknow- 
ledged this indebtedness to him. 

“Judd was of a quiet, restful disposition, delight- 
ing in his work, in his home, and in loyalty to his 
chiefs, ever on his lips as ‘W. J.’ and ‘C. H? His 
one relaxation appeared to be duck shooting, but 
even that fascinating sport only lured him away 
from work for short periods. Ie will be missed far 
beyond his immediate circle.” 

In 1931-32 Prof. Judd was president of the 
American Medical Association. 


ST. BARTHOLOMEW’S IIOSPITAL, LONDON. — The 
Smithfield Benevolent Fund committee has raised 
£10,000 to establish visitors’ rest rooms and a canteen 
at this hospital. 


288 THE LANCET] 


MEDICAL 


University of Oxford 
Radcliffe Travelling Fellowship.—An examination for 


this fellowship, which is of the annual value of £300 and’ 


is tenable for two years, will be held on Feb. 18th. Can- 
didates must have passed all the examinations for the 
degrees of B.M. (not more than four years previously) 
and B.A. Further particulars may be had from the 
regius professor of medicine, University Museum, Oxford, 
to whom all intending candidates should send their names 
before Feb. 13th. 

George Herbert Hunt Travelling Scholarship.—Applica- 
tions for this scholarship, which is awarded without 
examination, are invited from graduates in medicine of 
the university of not more than five years’ standing 
who wish to travel abroad for at least three months for 
the purpose of clinical study or research in medicine. 
Preference will be given to those who intend to become 
surgeons or general practitioners, and applications should 
be sent to the dean of the medical school, University 
Museum, before Feb. 24th. 


University of Cambridge 


On Jan. 25th the following degrees were conferred :— 


e M.D.—B. C. Thompson, C. H. Wrigley, and D. N. Rocyn 
ones. 

M.B. & B.Chir.—S. M. Davidson and K. C. Bailey. 

M.B..—Wilfrid Warren. 

B.Chir.—L. J. Bacon, T. L. H. Shore, G. N. St. J. Hallett, 
J. R. Kerr, J. R. G. Harris, A. G. Salaman, J. R. J. Winter, 
C. A. Dowding, Frank Stansfield, and R. D. Ewing. 


Royal College of Surgeons of England 

Tho Begley studentship will bo awarded to the candi- 
date who this year obtains the highest marks in the anato- 
mical part of the examination in anatomy and physio- 
logy held by the conjoint examining board in March and 
April. The studentship is tenable for three years, and 
has an annual value of £20. Further information may 


be had from the secretary of the college, Lincoln’s Inn 
Fields, W.C. 


British Postgraduate Medical School 

Six lectures on fractures will be given by Prof. Hey 
Groves on Fridays from Feb. 7th to March 13th, and four 
lectures on cerebro-spinal syphilis by Dr. Gordon Holmes, 
F.R.S., on Mondays from March 2nd to 23rd. Both 
series will be held at 2.30 P.M. at the school, and applica- 
tions for tickets should be sent to the dean. Further 
particulars will be found in our advertisement columns 
this week. 


Demonstrations of Contraceptive Technique 

On Thursday, Feb. 6th, at 2.30 p.m., a demonstration 
of the technique of the use of a variety of contraceptive 
methods will be given by Mrs. Mario Stopes, D.Sc., and 
Dr. Evelyn Fisher at the Clinic for Constructive Birth 
Control, 108, Whitfield-street, London, W.1. Tickets 
will be issued to medical practitioners and senior students 
who apply in writing to the hon. secretary at the clinic. 


British College of Obstetricians and Gynecologists 

The quarterly meeting of the council of the College 
was held on Jan. 25th in the College House, when Sir 
Ewen Maclean, the president, reported that a loyal 
address had been sent to H.M. King Edward VIII. He 
reported further that the outline of a scheme for a national 
maternity service had been submitted to the Minister of 
Health. The report of the investigation into the use of 
analgesics suitable for administration by midwives was 
passed. 

The following were elected to the membership of the 
College :— 


Alan John Stewart Lawson Boyd, South Africa; Mildred 


Isabel Kaling, London; Barton Gilbert. London; Stanley 
Henderson, Liverpool; Edwin Holmes, Hove: Charles Roy 
MacDonald, Shetlield; John Sinclair MacVine, London ; 


Thomas N. MacGregor, Edinburgh ; Stanley Devenish Meares, 
Sydney ; Klizabeth Main Moore, London; Frederick Walter 
Gifford Nash, Bedford; John Gregory O’Donoghue, Mecel- 
bourne ; Patrick Playfair, London; Anthony Watson Purdie, 
Glasgow ; Cleveland Patrick Scott, London ; Edward Solomons, 
Dublin; William Ralph Winterton, London; Bryan Leslie 
Jealfreson, Leeds; Israel Goldberg, Cape Town; Presley 
Archer McLeod, Ontario; Cyril Macdonald Phunptre, Madras ; 
and Harold Rowntree, Lahore—the four last-named in absentia. 


P [FEB. 1, 1936 
NEWS 


Post-graduate Course in Orthopedic Surgery 


A special course will be held at the Royal National 
Orthopedic Hospital, 234, Great Portland-street, London, 
W.1, from March 9th to 2lst. Applications should be 
made to the secretary of the hospital. 


Journtes Médicales de Bruxelles 


This congress will be held from June 20th to 24th 
under the presidency of Prof. Robert Danis. Further 
information may be had from the secretary of the meeting, 
Dr. R. Beckers, 141, rue Belliard, Bruxelles. 


Physical Exercise and Education 


On Tuesday, Feb. 4th, and on the following three days, 
at 6 P.M., Dr. J. Alison Glover, senior medical officer of 
the Board of Education, will lecture at Gresham College, 
Basinghall-street, E.C., on some aspects of exercise, 
physical education and swimming. The lectures are open 
to all. : 


The Psychological Clinic and Community Welfare 


Four lectures on this subject will be held at the Liver- 
pool Psychiatric Clinic (56, Bedford-street North) on 
Wednesdays from Feb. 5th to 26th at 5.15 P.M. Juvenile 
courts, probation work, patrol work, and industrial and 
vocational psychology are the aspects which will be 
diseussed. 


A Memorial to Prof. A. F. Dixon 


A meeting of friends and colleagues of the late Prof. 
Francis Dixon was held in the Common Room, Trinity 
College, Dublin, on Jan. 24th, to consider the establish- 
ment of a suitable memorial to him. In the absence of 
the provost of the college the meeting was summoned 
by the vice-provost, Mr. W. E. Thrift, who presided over 
the deliberations. Several projects having been discussed, 
a general committee was appointed to forward the move- 
ment, and an executive subcommittee was requested to 
study and report on the most suitable form of memorial. 
Prof. J. W. Bigger is acting as honorary secretary and 
Mr. G. A. Dunean, F.T.C.D., as honorary treasurer. 


Standard Blood Counting Apparatus 


A committee of the British Standards Institution 
have prepared a specification for hemacytometer counting 
chambers and dilution pipettes. The institution is desirous 
that this draft should receive the widest possible con- 
sideration, so that the specification, when finally pub- 
lished, may command the greatest possible measure of 
agreement. A copy of the draft specification may be 
obtained, post free, on application to the Director, British 
Standards Institution, 28, Victoria-street, London, S.W.1, 
to whom suggestions for amendment of the draft may 
be sent. Any comments submitted will receive care- 
ful consideration when the draft is being revised for 
publication. 


Association of Industrial Medical Officers 

The second mecting of this association was held in the 
London School of Hygiene and Tropical Medicine on 
Friday and Saturday, Jan. 24th—25th, under the chairman- 
ship of Dr. H. B. Trumper (Imperial Chemical Industries 
Ltd.), in the absence of Dr. Howard Mummery through 
illness. On Friday a discussion took place on Physical 
Standards in Industry, opened by Sir David Munro, 
secretary of the Industrial Health Research Board (whose 
address is summarised in a leading article on p. 265). He 
was followed by Dr. H. H. Bashford, chief medical officer 
to the Post Office. In the evening members dined 
together. On Saturday, Dr. T. O. Garland (Carreras 
Ltd.) read a paper on The Relation between the Industrial 
Medical Officer and the General Practitioner. He was 
followed by Dr. J. C. Bridge, chief medical inspector to the 
Home Oflice. Dr. Garland spoke of the importance of 
closer coöperation and contact between industrial medical 
services and other medical practitioners, and referred to 
the place of treatment in the industrial clinic. He also 
discussed briefly the position of the employee and emplover 
in relationship to the industrial doctor. Dr. Bridge 
dealt with the relationship of the certifying surgeon to the 
industrial medical officer. 


THE LANCET] 


MEDICAL DIARY.—APPOINTMENTS. 


[FEB. 1, 19386 289 


Medical Diary 


SOCIETIES 
ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W. 


TUESDAY, Feb. 4th 
(Cases at 4.30 P.M.) Mr. Eric 


Orthopedics. 5.30 P.M. 
Lloyd: A Director for the Insertion of the Smith- 
Petersen Nail in Collum Femoris Fractures, Mr. 

. P. Brockman: 1. Osteochondritis of ithe Head 
of the Radius. Mr. W. H. Ogilvie: 2. Deformity of 
Spine and Hips. Mr. T. T. Stamm: 3. Occupational 
Deformity of the Hands. 

Pathology. 8.15 P.M. (department of pathology, Medical 
School, St. Thomas’s Hospital, S.E.). J. Bamforth : 
1. Carcinoma of Thymus with Malignant Cells in 
Sputum. 2. Teratoma of Testicle with Positive Fried- 
man Test. 3. Endotheliomatous Change in a Uterine 
Fibroid. C. L. G. Pratt: 4. Effect of Toxins on 
Electrocardiograms of Aninals. 5. Method of Con- 
stant Intravenous Injection in Anzesthetised Animals. 
J. St. C. Elkington: 6. Actinomycosis of Brain and 
Meninges. 7. Hwmangioma of Spinal Cord with 
Syringomyelia. 8. Oligodendroglioma of Third Ven- 
tricle. J. liver: 9. Gonococcus Ecto-antigen. 
10. Heemochromatosis with Analysis of Organs. 
11. Widespread Hepatic Thrombosis. 12. Pulmonary 
Thrombosis with Calcitication of Clot. N. R. Barrett : 
13. The Examination of New Growths by the Wet 
Film Method. D. CŒ. L. Derry: 14. Plasma-celled 
Myclomatosis. 15. Chronic Inflammatory Lesion of 
the Lung with Complete Necrosis of Spleen. 16. Rheu- 
matic Carditis Associated with the Presence of Bacteria 
in the Mitral Valve. C. H. Wrigley: 17. Demonstra- 

. tion of Particles of Malignant Growths in Sputum. 

WEDNESDAY, 

History of Medicine. 5 P.M. Prof. Alexander Haddow : 
Historical Notes on Cancer from the MSS. of L. W. 
Sambon.. 

Surgery. 8.30 P.M. Sir W. Dalrymple-Champneys : 
The Sterilisation of Surgical Catgut (cinematograph). 

THURSDAY. 


Tropical Diseases and Parasitology. 8.15 P.M. Prof. 
R. T. Leiper: The Crustacea as Helminth Inter- 
inediaries. Dr. B. G. Peters: Some Recent Develop- 
ments in Helminthology. 

FRIDAY. 
Otology. 10.30 A.M. (Cases at 9.30 A.M.) Mr. W. Stirk 


Adams, Mr. T. E. Cawthorne, and Dr. M. Mitman: 
Value of Radiology in Diseases of the Ear. 

Laryngology. 5 P.M. (Cases at 4 P.M.) Mr. Maxwell 
EUis: The Mechanisin of Bropchjal Movements and 
the Naso-pulmonary Reflex. 

al neesthetics, 8.30 P.M. Dr. I. W. Magill: Anmsthetics 
in Thoracic Surgery, with Special Reference to Lobec- 
tomy. 

WEST LONDON MEDICO-CHIRURGICAL SOCIETY. 
FrRipay, Feb, 7th.—8.30 P.M. (De Vere Hotel, Kensington), 

Dr. Geoffrey Evans and Mr. Hamblen Thomas: 
Epistaxis. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 


ROYAL COLLEGE OF SURGEONS OF ENGLAND, Lincoln’s 
Inn-tields, W.C. 

MONDAY, Feb. 3rd.—5 P.M., Mr. A. M. Boyd: The Investi- 
gation of Peripheral Vascular Disease. 

WEDNESDAY.—5 P.M., Mr. H. Osmonde Clarke: 
of the Carpal Bones. 

FrRIDAY.—5 P.M., Mr. F. IT. Bentley: Wound Healing in 
vitro. The Interrelation of Epithelial and Fibrous 
Tissue Growth. (Hunterian lectures.) 

GRESHAM COLLEGE, Basinghall-street, E.C. 

Tuerspvay, Feb. 4th, and th, 6th, and Ttb.—6 r.m., Dr. J. 
Alison Glover: Some Aspects of Exercise, Physical 
Education and Swimming. 

UNIVERSITY OF LONDON. 
WEDNESDAY, Feb. 5th.—3 P.M. (London School of Hygiene, 


Keppel-street, W.C.), Col. L. W. Harrison: Venereal 
Disease. 
FRIDAY.—11 A.M., Mr. H. E. Magee, D.Sc.: Nutrition. 


ERTES POSTGRADUATE MEDICAL SCHOOL, Ducane- 
road, A ; 
Fripay, Feb. 7th.—2.30 P.M., Prof. Hey Groves: Fractures 
(first of six lectures). 
HAMPSTEAD GENERAL AND 
HOSPITAL. 
WEDNESDAY, Feb. 5th.—4 P.M., Mr. W. H. Ogilvie: Carci- 
noma of the Tongue. 
NATIONAL HOSPITAL FOR DISEASES OF THE HEART, 
Westmoreland-street, W. 
Tuespay, Feb. 4th.—5.30 p.m., Dr. T. F. Cotton: Rheu- 
4 matic Carditis. 
LONDON SCHOOL OF DERMATOLOGY, 5, Lisle-street. W.C. 
Tuesvay, Feb. 4th.—s P.M., Dr. J. E. M. Wigley : Tuber- 
culosis Cutis. 
THURSDAY.—5 P.M., Dr. G. B. M. Heggs: Some Affections 
of the Skin of the Foot. 
ROSPITAL FOR SICK CHILDREN, Great Omunond-street, 
nC. 


WEDNESDAY, Feb. th.—?2 P.M., Mr. Denis Browne: 
Empyema. 3 P.M.. Dr. W. W. Payne: Vitamin 
Deficiency as a Predisposing Factor in Infection. 

Out-patient clinics daily at 10 A.M. and ward visits at 
2 P.M. 


NORTH-WEST LONDON 


Injuries 


NATIONAL HOSPITAL, Queen-square, W.C. 
MONDAY, Feb. 3rd.—3.30 P.M., Dr. Hinds Howell: Neuro- 
syphiljs (II.). . 
TUESDAY.—3.30 P.M., Dr. Critchley: Cerebral Vascular 
Disease (II.). 


WEDNESDAY.—3.30 P.M., Dr. Kinnier Wilson: Clinical 
Demonstration. 

THURSDAY.—3.30 P.M., Dr. Carmichael: Myopathic 
Diseases. 


FRIDAY.—3.30 P.M., Mr. Elmquist: 
Re-educational Methods. 
Out-patient clinic daily at 2 P.M. 


WEST LONDON HOSPITAL POST-GRADUATE COLLEGE, 
‘Hammersmith, W. 

MONDAY, Feb. 3rd.—10 A.M., Medical wards and skin 
clinic. 11 A.M., Surgical wards. 1.30 P.M., Gyneeco- 
logical wards. 2 P.M., Surgical wards, gynecological 
and eye clinics. 

TUESDAY.—10 A.M., Medical wards. 11 A.M., Surgical 
wards. 2 P.M., Throat clinic. 4.15 P.M., Mr. Woodd 
Walker: Derangements of Kneec-joint. 

WEDNESDAY.—10 A.M., Children’s ward and clinic. 11 A.M., 
Medical wards. 2 P.M., Eye clinic. 4.15 P.M., Lecture 
on anesthesia. 

THURSDAY.—10 A.M., Neurological and gynecological 
clinics. 2 P.M., Eye and genito-urinary clinics. 

FRIDAY.—10 A.M., Skin clinic. Noon, Lecture on treat- 
ment. 2 P.M., Throat clinic. 

SATURDAY.—10 A.M., Surgical children’s 
medical wards. 

Operations, medical and surgical clinics daily at 2 P.M. 

The lectures at 4.15 P.M. are open to all medical practi- 
tioners without fee. 

ST. JOHN CLINIC, Ranelagh-road, S.W. 

FRIDAY, Feb. 7th.—4.30 P.M., Mr. L. Attkins: Oral Sepsis 
in Relation to Physical Disease. 

FELLOWSHIP OF MEDICINE AND POST-GRADUATE 
MEDICAL ASSOCIATION, 1, Wimpole-street, W. 

MONDAY, Feb. 3rd, to SUNDAY, Feb. 9th.—ST. JOHN’S 
HosPITAL, 5, Lisle-street, Leicester-square, - W.C. 
Afternoon course in dermatology (open to non-mem- 
bers).—ST. Marks’ HOSPITAL, City-road, E.C. All- 
day course in proctology.—WEST END HOSPITAL FOR 
NERVOUS DISEASES, Welbeck-street, W. All-day 
course in necurology.—ST. JOHN CLINIC AND INSTITUTB 
OF PHYSICAL MEDICINE, Ranelagh-road, S.W. Sat. 
and Sun. course in physical medicine.—NaTIONAL 
TEMPERANCE HOSPITAL, Hampstead-road, N.W. Tues., 
8.30 P.M., Mr. A. J. Cokkinis: Intestinal Obstruction. 
Thurs., 8.30 P.M., Mr. T. Holmes Sellors: Thorax.— 
Courses are open only to members and associates of 
the Fellowship. 

SOUTH-WEST LONDON POST-GRADUATE ASSOCIATION. 

WEDNESDAY, Feb. 5th.—4 P.M. (St. James’ Hospital, 
Ouseley-road, S.W.), Dr. C. E. Lakin : Demonstration 
of Medical Cases. 

LEEDS GENERAL INFIRMARY. 

TUESDAY, Feb. 4th.—3.30 P.M., Mr. Flint: Demonstration 

of Cases, ; 
LEEDS PUBLIC DISPENSARY. 

WEDNESDAY, Feb. 5th.—4 P.M., Dr. H. H. Moll: 

Allergic Diseases—Hay-fever, Urticaria. 
UNIVERSITY OF DURHAM. 

SUNDAY, Feb. 9th.—10.30 A.M. (Newcastle General Hos- 

pital), Dr. F. J. Nattrass: Medical Ward Visit. 
GLASGOW POST-GRADUATE MEDICAL ASSOCLATION. 

WEDNESDAY, Feb. dth.—4.15 P.M. (Royal Hospital for 
Sick Children), Mr. Alexander MacLennan: Ortho- 
peedic Cases. 


Demonstration of 


and clinics, 


Minor 


Appointments 


BLAIR, L. G., M.R.C.S. Eng., D.M.R.E., has been appointed 
Specialist Radiologist at the Dagenham Sanatorium. 

KELLNER, ANDREW, M.D. Leipzig, L.M.S.S.A., Hon. Assistant 
Physician to the London Homceopathic Hospital. 

LYon, D. Murray, M.D., F.R.C.P. Edin., Principal Medical 
Otticer of the Scottish Widows’ Fund and Life Assurance 
Society. 

MacLEoD, DONALD, F.R.C.S. Edin., Clinical Assistant at 
All Saint’s Hospital for Genito-urinary Diseases, London. 

SLATER, EFFIE, M.B. Lond., D.O.M.S., Assistant Medical Officer 
to the Education Committee of Wolverhampton. 


Medical Referee under the Worknen’s Compensation Act, 
1925: PERCIVAL JOHN Hay, M.D., of Shetlield, for all 
County Court Districts at present comprised in Circuits 
Nos. 13 and 18, with a view to his dealing with ophthalnic 
cases. 

Certifying Surgeons under the Factory and Workshop Acts: 
Dr. OLIVE G. COLDICOTT (Abergavenny, Monmouth) ; 
Dr. W. E. FAULKNER (Alva, Clackmannan); and Dr. J. H. 
ALLAN (Chorley, Lancs). 


Dr. J. B. Albury has been appointed a member of 
the legislative council of the Bahama Islands. 


Dr. D. C. Norris (Inner Temple) and Dr. F. Collar 
(Middle Temple) have been called to the Bar. 


290 THE LANCET] 


[FEB. 1, 1936 


NOTES, COMMENTS. AND ABSTRACTS 


THE PSYCHOLOGY OF 
INTERNATIONAL RELATIONS * 


By WILLIAM Brown, D.M. Oxon., D.Sc., 
F.R.C.P. Lond. 


WILDE READER IN MENTAL PHILOSOPHY, UNIVERSITY OF OXFORD ; 
LATE MAJOR, R.A.M.C., AND NEUROLOGIST TO THE 
FOURTH ARMY, B.E.F., FRANCE 


THE psychology of international relations, other- 
wise the psychology of peace and war, can be 
adequately discussed only on the basis of a scientific 
knowledge of the structure and working of the human 
mind. A number of questions open out: how war is 
possible ; how it can be carried on at all by civilised 
people ; how peace can be achieved, this last only 
by a positive policy, never by laissez-faire. 

Hobbes said that peace was merely an interval 
between wars, the wars being the real—meaning 
the normal—activity, and peace a breathing-space, 
a time when people are tired, disillusioned, and a 
little penitent. Those who take part in war customarily 
declare that when they have finished this business they 
will fight no more. The protestation has much the 
same value as that of the drunkard who exclaims as he 
lifts the glass to his lips that it is the last time. 

Speaking as a psychologist, not as a politician, 
I am convinced that the latest war is not the last. 
In saying this I do not mean to be pessimistic, I 
am merely speaking as I would about a manic- 
depressive patient who, after a state of deep depression, 
passes into one of exaltation and feels that never again 
will his old symptoms return. With a patient like 
that we know that he will have another relapse 
sooner or later, and that no amount of suggestion or 
encouragement will make any difference. It is of 
no use telling him or his relatives that ‘‘ All’s well 
with the world ’’; a relapse is as certain as anything 
can be. In cases of manic-depressive insanity or 
the milder cyclothymia, as in other forms of psychoses 
as distinct from psychoneuroses, a radical cure has 
not been found. No psychotic has ever yet been 
cured by psychotherapy as such, although psycho- 
therapy and psychology in general have enabled 
us to gain a deeper insight into the psychotic’s 
stafe of mind, and sometimes to ameliorate the 
condition. We may cure or improve the hysteric, 
the psychoneurotic, but the psychotic still escapes 
us—although improvement, and sometimes spon- 
taneous recovery, may occur. 

So it is with war and peace. We cannot pretend 
as psychologists that a solution has been discovered 
at present. All we can do is to go on and disentangle 
the various forces which are at work to produce 
war. The causes of war are numerous, and many of 
them seem to have little to do directly with human 
nature. The economic causes of war spring at once 
to the mind. According to some systems of practical 
economics wars are inevitable and must occur from 
time to time. Conflicts of interests exist between 
nations and may become so severe that an appeal 
is at last made to the ultima ratio, the final court 
of trial by brute strength. 

Again it is necessary to make the psychologist’s 
position clear. Asa psychologist I am not advocating 
any particular system of economies as distinct from 
others. We psychologists feel some sympathy with 
the economists, for we are in the same boat. Psycho- 
logy and economics are the two sciences about which 
the man in the street thinks he knows as much as the 
expert. lle is not going to be informed about his 
own mind, for who should know his own mind better 
than himself? He knows all about economics too, 


*A paper read at the inaugural session of the Fourth 
Biennial Conference on Mental Health held in the Central Hall, 
Westminster, on Jan. 23rd, 1936, 


OO n 


for does he not have to deal continually with credit 
balances and deficits? That is one reason why 
progress in these sciences is so slow. 


Man’s Reactions to His Mind 


Deep down in the mind—in our “ heart of hearts,” 
as we say—we are aware of the struggle for existence, 
the desperate fight between man and man, family 
and family, nation and nation, for security, position, 
and power, a fight variously disguised, halted by 
compromise and mutual adjustment, but at times 
flaming into open war. Schopenhauer in one of his 
“ Occasional Essays’’ likened human society to a 
number of hedgehogs that found themselves getting 
chilly in the winter and so got closer and closer 
together to keep one another warm, but as they 
drew closer their prickles hurt one another, and so 
they moved away and got cold again, and eventually 
by trial and error found an optimum distance from 
one another at which they could keep fairly warm and 
at the same time escape hurt. So it is with man 
in society. He finds it difficult to harmonise with 
others, and yet if he went ‘‘ on his own ”’ his life would 
be “ nasty, brutish, and short,’’ to quote Hobbes’s 
phrase, and so coöperation to a certain extent is 
forced upon him. 

That, of course, is not a very close analogy, because 
society is not a matter of deliberate social contract, 
but has grown in relation to the needs of individuals, 
and individuals have never existed by themselves, 
but always within some system or family, and thus 
their social instincts and their ego instincts have 
developed pari passu. We cannot deduce the social 
behaviour of man from his purely individual behaviour, 
and, in fact, there is no such thing as purely individual 
behaviour because man is always acting as a member 
of some group and generally as a member of a number 
of groups simultaneously. It is not that psychology 
deals with the individual man while sociology and 
anthropology and other sciences deal with his social 
relations. At every point the individual is reacting 
to the society to which he belongs. 

A purely economic theory of the cause of war 
might have a corresponding psychological theory. 
very simple, and therefore inadequate—namiely, that 
man gets annoyed when his interests are threatened, 
irritated when his will to live is thwarted, economic 
difficulties make him angry, and when his misfortunes 
and the reason for them are declared to him by 
some demagogue he may in his irritated state become 
pugnacious and ready to fight. That theory is 
simple, as I have said, but very inadequate, because 
it takes practically no account of the structure of 
the mind. The individual mind has developed 
through countless generations from the most primitive 
condition with reference to a very real struggle for 
existence. We must accept in its general outline 
the Darwinian theory of natural selection and the 
survival of the fittest, for the mind as for the body. 
But although the mind has developed to a certain 
degree and it is possible for coöperation to supplement 
competition, and for man to become more and more 
codperative and less and less competitive, never- 
theless he still carries with him tendencies towards 
more primitive forms of mental reaction such as 
were appropriate to the early stages of national 
and social evolution, but are not so obviously 
appropriate now. 


Primitive Urges 


We observe this very clearly in criminal behaviour. 
A great deal of such behaviour is a relapse or a 
regression to a more primitive reaction of the 
organism, The murderer is not always someone whose 
reactions to life have been perverted, but often someone 
who, through disease of the nervous system or 
developmental degeneration, perhaps transmitted 
from parent to child, resulting in weakness of mental 
and nervous control, reacts as his primitive ancestors 


THE LANCET] 


NOTES, COMMENTS, AND ABSTRACTS 


(FEB. 1, 1936 291 


ages ago reacted in an environment where such 
reactions would be accounted normal. He wants a 
man’s watch, and the most direct method is to kill 
the owner. He yearns for the taste of roast pig, 
and so he burns down the house. Many of these 
severe cases of criminality resist every type of treat- 
ment, punitive or reformatory, because they are 
themselves primitive in this particular direction. In 
some ways they are a reversion to type, a ‘“ throw 
back ” to a much earlier level of evolution. 

All this means that civilised man, the modern 
Homo sapiens, carries with him possibilities of 
behaviour that are appropriate to the earlier stages 
of mental development, but are customarily held in 
check or superseded by more developed methods of 
reaction. On analysis one finds that most people 
who are regarded as normal still retain far down in 
their unconscious mind—that is, on the primitive 
levels of mentality—tendencies that were appropriate 
in the early stages of human development but are 
no longer allowed to be dominant. 

One of these primitive tendencies is that of self- 
preservation, present in all of us, but held in check 
by higher considerations; in part such urges have 
been not destroyed or neutralised, but directed in 
the course of evolution to higher social and cultural 
ends. But a good deal of the old urge remains at 
its most primitive levels, even in the most highly 
developed man, so that in certain conditions of great 
danger, especially when accompanied by ignorance 
of what exactly is happening, the urge for self- 
preservation may leap forward with overwhelming 
force, and he may take refuge in panic-stricken 
flight, to his own great disgust afterwards. It is the 
same with the urge not only to preserve our lives 
but to assert ourselves, to extend and enlarge our 
powers. This again may be held in check by various 
mental mechanisms of later development, by the 
grace of modesty, by self-criticism, by consideration 
for others, by a regard for what is decent, even by 

a sense of proportion in things, and, which follows 
from it, a sense of humour; yet nevertheless, deep 
down in the mind, some of this self-assertive tendency 
remains, and given the occasion may blaze out very 
much in its original form. This, again, can happen 
in the most highly developed of men. 

One of the many occasions when these primitive 
tendencies can show themselves uncensored and 
unreproved is in a great mass movement where the 
individual feels the safety and security of the crowd 
around him, all thinking in the same way, and his 
sense of responsibility to himself is greatly lightened. 
He does not deliberately give way to more primitive 
tendencies, but those primitive tendencies are always 
ready to come forward and manifest themselves 
through more complicated civilised behaviour. They 
are like a charge of electricity suddenly short- 
ircuiting a delicate installation, overcoming all 
esistances, and lighting the landscape with a lurid 
lame. Thus a crowd may fall into a panic and in 
uch a state take the slightest occasion for action 
itterly out of proportion to the circumstances. It 
nay when aroused spring savagely like a tiger 
rithout reck or consideration even for its own 
afety. Yet in that crowd, moved by the same 
mpulses and intent on the same wild course, may 
e men who individually would never dream of 
cting in that way. That situation was recognised 
ong before any analytic work had been done upon 
he mind. ‘The crowds of the French Revolution, 
or example, and the excesses which they committed 
‘ere the subject long ago of psychological study. 


Mass Psychology 


The possibility of mass mental reactions or mass 
sychoses has an obvious bearing upon the problem 
f war and peace, buf the deeper analysis of the 
ind in recent times inaugurated by Sigmund Freud 
as shown to how great an extent mental forces can 
mntinue to manifest themselves in an unconscious 
rm, even while the conscious mind is fully alert 
1d apparently in full control. All these forces that 


come up so obviously in mass movements are working 
also in the individual mind and showing themselves 
in distorted forms. Even mental reactions that the 
majority of people would recognise as perfectly 
normal and appropriate to the circumstances can by 
analysis be traced back to still more primitive 
tendencies from which they derive their energy. Itis — 
as if a person who belonged to a wealthy family used 
the leisure that his inherited wealth made possible 
to become highly cultured, deeply read, artistically 
appreciative, while yet the money which enabled him 
to do this came from the labour of many of his own 
species, hewing minerals from the bowels of the 
earth at great toil and risk and with little reward. 
The example that springs to the mind is that of 
Greek culture during the golden age in Athens, a 
culture which was, of. course, founded upon slavery. 
Slavery was justified even by Aristotle. The argu- 
ments are familiar, they are biased, and can be 
used in different ways to point to different con- 
clusions. I am using it here only as an analogy, and 
indeed as an analogy it does not completely hold, 
because the forces in the unconscious in our highly 
developed cultural life are not in themselves good or 


. bad, they just represent biological or mental energy. 


Among them are these primitive forces of self- 
preservation and self-assertion. Both in their measure 
are needed. Unless we are able to preserve our lives 
we shall do no good to anyone. Self-assertion, too, 
is obviously good in a general sense, though it can 
be directed in such a way as to be a curse to everyone 
concerned. It is all a matter of direction, and in 
the cultured life it is directed adequately. With that 
cultured outlook on life these fundamental forces 
have to be kept at bay, under control, used as the 
powers of nature are used in an industrial civilisation. 
Used in a different way they may result in institutions 
and forms of thought which are irreconcilable with 
ultimate peace between individuals or between 
nations. It comes to this, that he who wills the 
means wills the end. <A certain outlook on life, a 
certain direction or misdirection of the internal forces 
may involve ultimately such a conflict as can only 
be settled by an appeal to force. 


The Rule of Law 


It is often said that war could be prevented in the 
same way as duelling has been prevented, by legal 
process. Might not the appeal to force as between 
nation and nation be brought to an end if it were 
declared illegal? But it must be remembered that 
a law, although ultimately it may be in harmony 
with the moral outlook of the great majority of 
individuals, needs force to sustain it. In separate 
communities it is sustained by police. An inter- 
national law binding the nations would need to be 
supported by force at the present stage of human 
evolution. From a psychological point of view it 
seems to me an obvious implication that we need a 
supernational institution with adequate force at its 
disposal to support the decisions of international 
law. That is not within the bounds of practical 
politics at the present time. No nation would 
surrender its sovereignty to a super-state. Such 
quixotism is not to be found now upon the earth. 
The only alternative to this—I do not want to lecture 
on the subject, but to consider it only in relation to 
psychology—is a pis aller or second best, a system 
of collective security through the League of Nations. 

For that to be really successful it should be 
universal. The League of Nations must include the 
whole world, because peace is a matter which affects 
the whole world, especially in view of the rapidly 
extending lines of communication and the physical, 
economic, and cultural contacts of all countries. 
A true League of Nations must include every nation, 
and then the principle of collective security may be 
capable of being maintained. and the primitive 
passions of separate nations held in leash. But as 
things are at present there is no immediate prospect 
of a complete League, and to the extent to which 
it is incomplete, psychologically speaking—and again 


292 THE LANCET] 


I am not speaking as a politician—its prospects of 
success are greatly diminished. It is even a question 
whether, in such a situation, it is not better to 
recognise the difficulties, and seeing that there is 
not an adequate force at the disposal of the League 
to impose its decisions, to keep those decisions as 
expressions of moral opinion, otherwise the League 
may involve more fighting and not less. But the 
more courageous way is to organise economic (as 
distinct from military) sanctions to the utmost of 
which the nations now members of the League are 
capable, and thus to bring forcibly home to an 
aggressor the collective moral disapprobation of his 
aggression. 


Mobilisation of the Unconscious 


It may be asked how it is possible for any indi- 
vidual who has enjoyed the benefits of modern culture 
and has acquired self-control to be brought to such 
a state of mind that he can kill another with whom 
he has no personal quarrel. In the quiet and even 
friendly atmosphere of the laboratory a man may, 
in his scientific enthusiasm, concern himself with 
aeroplanes and armament of various kinds, forgetting 
the use to which they are to be put; but how is it 
possible for him to fire the guns, explode the munitions, 
drop the bombs, release the poison gas, knowing 
that the result will be the killing and maiming of 
his fellow-creatures? In other words, how is it 
possible for anyone to take part in war? That is a 
psychological problem which each of us must put to 
himself. In the last war there were a number of 
people who refused to have anything to do with it. 
They were all classed together as conscientious 
objectors, though in fact the motives behind their 
refusal differed along a wide range. In fact, they 
had only this in common, a strongly individualistic 
turn of mind, and indeed it needed to be strong to 
withstand the tremendous mass suggestion which 
was surging around them. 

But the great majority of people were swept along 
on the wave of popular feeling, and, I suppose, in 
the circumstances of 1914 as they presented them- 
selves to the normal mind at that time, with all 
that people learned or were told of the events 
preceding the outbreak and those of the first months 
of the war, active participation in or support of the 
war seemed to be called for by the reason and 
conscience of the individual as well as by the 
authorities of the State. The unconscious was being 
mobilised at the same time as the mobilisation of 
the army and navy. 

Nevertheless, I think it may be stated that if the 
individual man was fully aware of all the unconscious 
forces at work his participation in war would at any 
rate be more hesitating, his mind more a prey to 
misgiving. liere let me say I am not approaching 
the subject of participation or non-participation from 
the point of view of ethics or religious conviction. 
Those are the ultimate court of appeal, but we are 
not dealing with them at the moment. It is purely 
a question of the facts at our disposal and appro- 
priate action on them. My contention is that we 
have not all the psychological facts at our disposal 
when we endeavour to sum up this question of our 
duty. If the psychological panorama were cleared of 
the smoke screen we should not at all events have 
that terrible contradiction whereby opposing peoples 
take up arms against one another to the glory of 
God, each appealing to Him for victory. 


Forces on Leash 


All this, I know, is a platitude, but it has to be 
mentioned in order that we may face up to the 
psychological problem. The unconscious urges which 
are demanding satisfaction have to be remembered. 
These are not just skeletons in the cupboard, they 
are very live and potent forces, The tiger is there, 
and the wolf, and the jackal, and the snake, and we 
must not forget the donkey. These are at all 
ordinary times held in check by our conscious aims 
and purposes, and in general by our culture, our 


NOTES, COMMENTS, AND ABSTRACTS 


[FEB. 1, 1936 


sense of what is due to others and admirable in 
ourselves. But the working of these unconscious 
forces can distort our moral judgment, so that for 
example during the last war we had quite kindly 
and well-educated people uttering such sentiments 
as that ‘‘ the only good German is a dead German,”’ 
though this became less pronounced as the war went 
on and weariness and disillusionment developed. 
We have to ask ourselves the question, what strange 
mentality settled upon them that they could deny 
all that culture and social contacts had brought them 
and be as bloodthirsty as their primeval ancestors ? 
It is true that the Germans had invaded Belgium ; 
that and other things were fuel for the eager fire. 
Behind it all was the deep conviction that a man 
must be ready to fight for his king and country and 
to preserve the life and honour of his own. 

Those were the motives on the surface, and it is 
true that once war had begun there was a certain 
responsibility upon the shoulders of everyone to see 
that it was prosecuted with the utmost efficiency. 


‘‘ Theirs not to reason why, 
Theirs but to do and die ”— 


and this they did, acting according to whatever plans 
were devised by the higher command. The whole 
nation was working as a nation on the principle of 
self-preservation. The individual was drawn up into 
the national life in a way which certainly that 
generation had never known before. His unconscious 
had the texture of the unconscious of all the other 
members of the nation. 

The same thing happens in times of revolution. 
The leader, so called, at such times is really the man 
who stands for the unconscious of all the people 
whom he leads. People have the leaders they deserve 
or demand. ‘The Jeader is the man who satisfies not 
only their conscious demands but their unconscious 
urges. But that is a thing which is always over- 
looked and will continue to be overlooked by the 
mass of educated people for a long time to come. 


Propaganda and Proper Geese 


It is seen fairly clearly now that if peace is 
eventually to be achieved economic science must 
give of its best, and what it gives must be acted 
upon; but it is not seen with equal clearness that 
psychological science must also give of its best, and 
that what it gives must be acted upon. Up to now 
there has been a good deal of perverted use of 
psychology in relation to war and peace—I refer to 
its use in connexion with propaganda, As soon as 
war breaks out no doubt it is morally right to use 
propaganda on each side to the utmost extent. It is 
the propaganda that takes place before war that is 
so devilish. By propaganda I mean here, fo use a 
simple word, lying, the distortion of facts. Such 
propaganda is successful enough, given the proper 
geese, the people ready to accept the lies or the 
false emphasis. Propaganda for ulterior motives 
makes it difficult even for the best educated indi- 
vidual to arrive at the facts. Ile seeks for them and 
does not get them, whatever newspaper he takes. 
One of the great needs of the world is for complete 
truthfulness, but lying and chicanery are part of the 
very art of war. 

As an illustration of how psychological motives in 
war may work, in another country it was said that 
in the last war they had been brought in to support. 
financial interests, the interests of people who had 
invested heavily and risked a great deal of wealth in 
support of other nations engaged in that war. I am 
not saying that that was true, but only that if it 
were true we should have a primitive motive— 
namely, the desire for gain, or the desire to escape 
financial ruin—supporting and energising more lofty 
moral considerations. 

But if it is possible, as indeed it is, on the fully 
conscious plane to have deliberate mis-statements 
and misdirection and deception and appeal to 
prejudice, and fixed ideas about the duty to fight, 
and the slogan “ My country right or wrong,’’— if 


THE LANCET] 


that is possible on the purely conscious level, how 
much more danger must there be in appeals directed 
to unconscious forces in the mind I have spoken 
already of the instinct of self-assertion. The desire 
for power and prestige goes hand in hand with the 
sense of the importance of one’s family, or college, or 
country, and so from the depths of the unconscious 
there is a continuous line or channel of energetic 
mental development. Such self-assertion can be very 
rigid and intractable. It can be distorted in all 
sorts of ways and disguised in scarcely recognised 
forms. One of the most overwhelmingly successful 
ways of disguising it from ourselves is to moralise it, 
to say that we have a duty to this, that, or the 
other, and to let that sense of duty reinforce what 
is when uncovered, the working instinct of self- 
assertion or desire for power of a ruthless kind— 
ruthless, I say, because it arises from some primitive 
state where the individual neither knew nor received 
pity. 

Aggression pure and simple in the unconscious is 
a primeval factor, the kind of thing that enables 
the soldier to kill his enemy when he “sees red.” 
The word ‘‘ sheep ” has sometimes been applied to 
the soldier type of mind, but there is something much 
more positive than that about it. I am well aware. 
of course, that what I am saying is incomplete. On 
the other side there is the desire, equally funda- 
mental, for fellowship, for love. It is from the refusal 
of love that a great deal of aggression springs. The 
little child wants to be loved and is ready to love, 
but if it does not receive love from its parents it is 
likely to become an intractable child, hostile and 
aggressive. Such aggressiveness is not primitive, it 
is secondary to the denial of love. | 

I feel that it is the same between nations. One 
nation wishes the friendship of another; it would 
rather be the ally of the other than its enemy. But 
if its overtures are rejected a revulsion of feeling 
may take place such as that which overwhelms the 
scorned lover. There is thus a primary aggressive- 
ness which comes out in battle and murder, but 
there is also a secondary aggressiveness which is 
very much more widespread and can manifest itself in 
its own way. There is the further danger in the 
situation that the primitive tendency to self-sacrifice, 
to injure oneself, may, when linked up with the 
ideal of national duty, supply a new fund of energy, 
and thus bring about war or keep a war going after 
it has broken out, and the cunning propagandist 
realises this and appeals to that very sentiment. 

All these are factors which provoke and sustain 
war. I hope I have made it clear in the compass of 
a short address how much dangerous and explosive 
material there is which will have to be dealt with 
and cleared out of the way before peace can be 
ensured. It is rightly said that moral disarmament 
must precede material disarmament, but even before 
moral disarmament there must be a psychological 
assessment not only of those ‘“‘inward parts” which, 
on the highest of all authority, may be ‘“ full of 
ravening and wickedness,’”’ but also of still more 
deep-seated or primitive mental tendencies that in 
themselves are neither moral nor immoral. 


NEW PREPARATIONS 


MULTIVITE PELLETS.—In presenting their new 
chocolate-covered pellets, containing vitamins A, 
B, B., C, and D, the British Drug Houses Ltd. 
(London, N.1) quote a statement that ‘‘ the interest 
which vitamins hold for the physician is not alone 
in their relation to certain well defined diseases . . . 
but rather in the fact that chronic vitamin deficiency 
produces numerous vague, borderline states of ill- 
health which often puzzle the physician and disable 
the patient.” It is impossible, they say, to ensure 
that the normal daily dietary under modern condi- 
tions is rich in the necessary vitamins, and they 
mention anorexia, gastric distension, constipation, 
nervous: disorders, dental decay, certain forms of 


NOTES, COMMENTS, AND ABSTRACTS 


[FEB. 1,1936 293 


anemia, and a feeling of being ‘‘ out of sorts” as 
possible consequences of slight but general vitamin 
deficiency. Multivite Pellets have been made in 
response to a demand for a well-balanced vitamin 
concentrate which would be acceptable to adults 
and convenient for use in private practice and among 
hospital patients and out-patients. Each contains 
vitamin A 3000 international units, vitamin C 
100, and vitamin D 600, with vitamin-B complex 
equivalent to 2°0 grammes of distillers’ yeast. The 
suggested dose is for children 1-2 pellets daily and 
for adults 2—4. Samples are obtainable on application. 


HEwso. is described as a non-poisonous, non- 
corrosive germicide consisting of a pine oil treated by 
a special process and combined with a neutral soap 
so as to give a perfect emulsion when mixed with 
tapswater in the proportions recommended. It 
may be used undiluted on dressings applied to wounds, 
but as a general lotion 5-8 per cent. solutions are 
suitable. Apart from abrasions and cuts it may be 
used for douches, baths, and disinfectant sprays and 
for washing contaminated linen; its destructive 
action on cultures of Bacillus typhosus (Rideal- 
Walker coefficient) is stated to be five times that 
of carbolic acid. The proprietors, Messrs. C. J. 
Hewlett and Son, Ltd. (35, Charlotte-street, London, 
E.C.2), claim in addition that Hewsol is non-staining, 
non-irritating, free from cresol and xylenol deriva- 
tives, and economical in use. It has a pleasant 
smell. 


UsEs of ACRIFLAVINE.—The Boots Pure Drug 
Company Ltd. (Nottingham) have issued an interest- 
ing booklet describing the properties and many uses 
of the acridine antiseptics, with special reference to 
the Boots preparations of acriflavine, neutral acri- 
flavine (euflavine), Acriflavine Emulsion, Burnol 
Acriflavine Cream, and proflavine. An enclosure 
is devoted to the use of acriflavine derivatives in 
gonorrhoea, where they are not only employed for 
local irrigation but also—with reservations— 
administered by mouth or by injection. Acriflavine 
Emulsion is recommended particularly as a dressing 
for wounds, septic conditions. burns and scalds, and 
ophthalmic inflammation or injuries. 


SALICIN.—This drug, a glucoside obtained from 
willows and poplars, introduced as an anti-rheumatic 
in 1874, has suffered partial eclipse by sodium 
salicylate and allied compounds. To show that this 
eclipse is undeserved the three manufacturers in 
Great Britain (J. F. Macfarlan and Co., 32, Bethnal 
Green-road, London, E.l; T. and H. Smith Ltd.; 
and Whiffen and Sons, Ltd.) have prepared a state- 
ment of the value of salicin in medical practice and 
offer to supply samples of powder or tablets. They 
claim that it has none of the depressing or irritant 
effects of salicylates and that clinical experience 
has proved its usefulness in the treatment of influenza 
and rheumatism, and also of psoriasis and other 
skin diseases. 


THE ALFRED EICHHOLZ CLINIC 


THE Alfred Eichholz Clinic, 204/206, Great Port- 
land-street, London, W.1, has issued a further edition 
of its handy scribbling pads, on the covers of which 
are depicted scenes from medical history. The 
latest is a reproduction from the well-known picture 
in Barber Surgeons-Hall, of Sir Charles Scarborough, 
first physician to Charles II., James II., and William 
III., and Edward Arris, serjeant-surgeon to Charles IT. 


NORTH HERTFORDSHIRE AND SOUTH BEDFORDSHIRE 
HosritaL, Hircuty.—The Duchess of Gloucester opened 
a new men’s ward and a new children’s ward at this 
institution on Jan. 17th. The extensions cost £15,000 and 
are the first completed part of a £35,000 scheme. Nearly 
£900 in purses was presented to the Duchess. The 
children’s ward is to be known as the Gloucester ward. 


294 THE LANCET] 


V acancies 


For further information refer to the advertisement columns 
Aldrich Blake Travelling Scholarship.—200 guineas. 
Ashton-under-Lyne District Infirmary.—H.S. At tate of £150. 
Barbados General Hospital.—Sen. Res. Surg. 


£45 
At rate of "8150. 


Bath, Royal United Hosptal.—H.S Also 
Hon. Med. Reg. 
Beckenham, Bethlem Royal Hospital, Monks Orchard.—Jun. 


Asst. Phys. £350. 
Bexley Urban District Council,—M.O.H. £800. 
Birmingham City, Maternity and Child Welfare Dept.—Temp. 


M.O. £10 per week. 
Birmingham Maternity Hospital.—Res. M.O. and Reg. £200. 
Birmingham, Queen’s  Hospital.—Bacteriologist and Clin, 
Pathologist. £600. Also Res. Surg. Reg. £100. 
Ble ee Loyal Infirmary. —Res. Surg. O. £250. 


Also H.S. 


Prato. ‘Royal Infirmary.—H.S. At rate of £135. 

Buxton Clinic for Rheumatism and Allied Diseases,—H.P. At 
rate of £200. 

Cambridge, Papworth Village Settlement —H. P. £200, 

Cancer Hospital, Fulham-road, S.W.—H.S. At rate of £100. 

Cana teri Kent and Canterbury Ilospital. —H.P. At rate of 


Defective. —Asst. M.O 

Coventry and Warwickshire Hospital.—Res. Cas. O. £125. 

Dewsbury and District General Infirmary.—sen. H.S. £200. 

Doncaster Loyal Infirmary.—H.S, to Eye and Ear, Nose, and 
Throat Depts. £175. 

Downpatrick, Down Mental Hospital.—Jun. Asst. M.O. £300. 

Dulwich Hospital, S.k.—H.P. At rate of £120 

East Ham Memorial Hospital, Shrewsbury- road, E.—H.P. At 
rate of £150. 

Edmonton, North Middlesex County Hospital.—Jun. Res. Asst. 
M.O. At rate of £250. 

Egyptian Government,—Director of Lunacy Division in P.H. 
Dept. L.E. 1020 to L.E. 1200 

Hull, City e i for Infectious Diseases, Cottingham.— Res. 

50 

Hull Royal Infirmary.—Second Cas. O. At rate of £150. 

Infants Hospital, Vincent- «square, Westminster. —Res. 
£300. Also two Physicians to Out-Patient Dept. 

Lambeth Hospital, Brook-street, S.E.—Asst. M.O. £350. 

Leeds General Infirmaryu.—iton. Asst. Phys 

Leeds University.—Chair of Physiology. +E 1000. 

Liverpool Hospital i Consumption and Diseases of the Chest.— 
Res. M.O. a 

i £300. 


Reg. to Dean- 


Colchester, Royal Eastern Maree Institution for the Mentally 
50 


M.O. 


London Lock Hospital, Harrow-road, W .—Surg. 
street Male Lock Hospital. £100. 

Middlesbrough County Borough.—M.O.H. £1100. 

Mies Hospital, W.—Fracture and Orthopedic Registrar. 


Mile End Hospital, Bancroft-road, E.—Asst. M.O. £350. 
Nee UROL yne, Hospital for Sick Children.—Res. Surg. O. 


N eran Coun Mental Hospital, Berrywwood.—Second Asst. 


aN 
Nottingham Children's Hospital.—Res. H.S. At rate of £150. 
O. At rate of £150. 


Nottingham General Hospital.—Cas. 


Paddington Hospital, Harrow-road, W.—Asst. M.O. £350. 
Perth hoyal Infirmary.—sen. H.S. £250. 

Portsmouth City.—Visiting Consultant Obstetrician, £200. 
Preston, Sharoe Green HMospital.—Sen. Asst. Res. M.O. Also 


Jun. Asst. Res. M.O. At rate of £200 and £100 respectively. 
Queen Charlottes Maternity Hospital, Marylebone-road, N.W. 
Res. Aneesthetist. At rate of £100. Res. Anesthetist and 
Dist. Res. M.O. At rate of £90. Also. Asst. Res. M.O. 

At rate of £80. 
E.—Res. M.O. 


Queen’s Hospital for Children, Iackney-road, 
Also H.S. and Cas. O. Each at rate of 


At rate of £200. 
£100 


Romford, Oldchurch Hospital.—Asst. Res. Radiologist and 
we He. rig Each £250. Also General Consulting 
Vs. 


Royal National Orthopedic Hospital, 234, Great Portland-street, 
IV.—Asst. Res. Surg. for Country Branch, £250. 
Royal Naval Medical Service.—Kight vacancics. me 
SO 


Royal. Northern ILospital, Holloway. N.—H.P. 
Vanbrugh Hill, S.lé.—Asst. M.O. £350. 


H.S. Each at rate of £70. 

St, Alfege’s | Hospital, 

Sl, Andreu At rate of £120. 

St. George-in- -the- East Hospital, Raine-strect.—Asst. M.O. £350. 

St, John’s Hospital, Lewisham, S.i.—Med. Reg. to Out-patients. 
50 guineas, 

St, Leonards-on-Sea, Buchanan Hospital.—Hon. Surgeon. 

Sl. Peler’s Hospital, Vallance-road, .— Asst. M.O. £350. 

Sheffield Children’s Jlospital.—H S. At rate of £100. 

Shefjleld Royal Hospital—Clin. Asst. to Ophthalmic Dept. 
Also Clin. Asst. to Kar, Nose, and Throat Dept. Each £300. 

Shrewsbury, koyal Salop 1 nfirmary.— Res., H.S. At rate of £160. 

Shrewsbury, Salop Mental Hospilal—Asst. M.O. £350. 

Slockport Infirmary.—H.s. and Cas, O. £150. 


Stoke-on-Trent, North Staffordshire Royal Infirmary.—l1.S. At 
rate of £150. 
Tee Abbey, Board’s Isolation Iospital,—Res. M.O. £650. 


Vest London Hospital, rae: road, W.—Half-time 

Pathologist. At rate of £300 

West Riding of Yorkshire County Council.—School Medical 
Inspector. £500. 

Winchester, Royal Hampshire County Hospital.— Asst. Mon. 
Clin. Pathologist. 

Windsor, King Edward VLI. Hospital.—Hon. Asst. Surg. 

Woolwich and District War Memorial Hospital, Shooters Ilill, 
S.L.—H.P. At rate of £100. 


VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS 


Obstet. 


[FEB. 1, 1936 


Births, Marriages, and Deaths 


BIRTHS 


BRADE-BIRKS.—On Jan. 26th, at the City of London Maternity 
Hospital, Hilda Kathleen’ Brade-Birks, M.Sc., M.B. Manch., 
wife of the Rev. S. Graham Brade-Birks, D. Sc., of God- 
mersham, Canterbury, of a daughter. 


DUFFETT.—On Jan. 20th, at Plymouth, the wife of Edward C. 
Dutfett, M.R.C.S. Eng. ., of a son. 


GARLAND.—On Jan, 23rd, at Leeds, wife of Dr. Hugh Garland, 
of a daughter. 


HADLEY.—On Jan. 16th, the wife of John A. Hadley, F.R.C.S. 
Edin., of Lincoln, of a son. 


MORRISON On Jan. 17th, at Leeds, the wife of Dr. J. Morrison, 
Halifax, of a son. 


RowLANDS.—On Jan. 26th, at Wimpole-street, W., the wife of 
Dr. John Rowlands, of a son, 

SANDELL.—On Jan. 23rd, at W ilbraham- place, S.W., the wife 
of David H. Sandell, M.D., F.R.C.S S. Eng., of a daughter. 

WHITTLE.—On Jan. 23rd, 1936, at Brookfield, Cambridge, 
to Phyllis (née Fricker), wife of Dr. C. Howard Whittle— 


a son. 
MARRIAGES 


DALRYMPLE SMITH—RILEY.—On Jan. 
Richmond, Yorkshire, Angus Dalrymple Smith, : 
F.R.C.S. Edin., to Rowena, younger daughter of Mr. 
Herbert Riley, of Richmond, Yorks. 

PASMORE—CALMAN.—On Jan. 22nd, at Kingston Vale, Dr. 
Stephen Pasmore to Dr. Jean Calman, daughter of W. T. 
Calman, C.B., D.Sc., F.R.S., and Mrs. Calman, M.B. 

SANDEMAN—CUNNINGHAM. —On Jan: 22nd, at Perth, Charles 
Stewart Sandeman, M.B., Ch.B. Edin., to Eva Margaret, 


daughter of the late J ames Cunningham and Mrs. Cunning- 
ham, St. Andrews. 


23rd, at St. Joseph's. 
M.B.. 


DEATHS 
BLAIR-BELL.—On Jan. 25th, Prof. William Blair-Bell, M.D. 
Lond., F.R.C.s. Eng., F.C.0.G., West Felton, Shrop- 


shire, ‘aged 64. 


BROOKE.—On Jan. 15th, at Singapore, Gilbert Edward Brooke, 
L.R.C.P. Edin 

COLQUHOUN.—On J an. 23rd, at a nursing-home, Wiliam Brooks 
Colquhoun, M.R.C.S S. Eng. , aged 76. 

Gwynn.—On Jan. 20th, at Brighton, Edward Betton Gwynn, 
M.B. Edin., eldest son of the late Samuel Betton Gwyrnp, 
F.R.C.S. Eng., L.R.C.P., of Wem, Shropshire. 

HARRISON.—On Jan. 241th, suddenly, at Worthing, 
Leeds Harrison, M.B. Cainb. 

JONES.—On Jan. 20th, at St. Clears, South Wales, Valentine 
Llewellyn Watson Jones, M.R.C.S. Eng., in his 83rd year. 

MAXWELL.—On Jan. 24th, at Yeomans, Wrington, Somerset, 
Herbert Bowen Maxwell, M.R.C.S. Eng. 

Morris.—On Jan. 23rd, at Harrogate, Richard John Morris 
C.B.E., M.D. Durh, . aged 75. 

SHEPPARD.—On Jan. 22nd, at Crockham Hill, near Edenbridge, 


Kent, Amy Sheppard, O.B.E., M.B. Lond., D.P.H. Camb., 
late of Harley-strect, W. 


N.B.—4A fee of ts. 6d. is charged for the insertion of Notices of 
Births, Marriages, and Deaths. 


Henry 


me memene meaane aa a 


THE FOTHERGILL TESTIMONIAL FUND 


THE following is the first list of subscriptions 
received in response to the letter published in 
the British Medical Journal and The Lancet of 
Jan. 18th 


Helen Boyle (Hove), £50; Alfred Cox (London) and Donald 
Hall (Hove), each £20; A. C. Gemmell (Hove), £5; Donald 
Hall (llove), seeond subscription, £10 10s.; Sir Ewen Maclean 
(Cardit¥), ©. E. 5. Flemming (Bradford- -on-Avon), A . H. Bureess 
(Manchester), W. McAdam Kecles (London), and J. W. Bone 
(Luton), each £5 5s.; H. G. Dain (Birmingham), £3 38.3; J. 
D’Ewart (Manchester), £1; C. Saunders (Kew), £1 1s.; W.E. 
Thomas (Ystrad Rhondda), £5 5s. R. Whittington (Hove), 
10s. Gd.:; Sir Henry Brackenbury (Hendon), £5 5s.: P. Mac 
donald (© ork), £5; F, C. B. Gittings (Southsea), £1 1s.; E.M. 
Glynn Whittle (Liverpool), £2 2s.; H. M. Galt (Jersey), q G. 
Greenfield (Rushden), A. T. Ross (Mevagissey), and F. 
Waterfield (Great Bookham), each £1 1s.; F. Radclitře N ped: 
ham), A. Forbes (Sheeld), and J. Hudson (Newcastle-upon- 
Tyne), each £2 2s, >, B. Spurgin (London), £1 Ls. ; H. N. 
Fietcber (Hove), £10 10s, >; G. C. Anderson (London), £3 3s. ; 
Sir Farquhar Buzzard (Oxford), £5; R.C. Buist (Dundee), #5 Ss.5 
A. Lyndon (Hindhead), and EK. A. Starling (Tunbridge), each 
£1 13.; ; Prof. J. W. Biggar (Dublin), £3 3s.: C. Gibson (Worthing). 
£1 1s.: Lancashire Local Medical and Panel Committee, £52 108; 
N. Bishop Harman (London), £5 5s.; 5. A. W instanler 
(Urmston), a ls.; and N. G. Horner (London), £3 3s. Total 
£262 lds. 6 


Cheques should be made payable to the Fothergill 
Testimonial Fund, and addressed to the Treasurer, 
Forthergill Testimonial Fund, British Medical Associa- 
tion, B.M.A. House, AAAS E SURAN London, W’.C.1. 


THE LANCET] 


[FEB. 8, 1936 


ADDRESSES AND ORIGINAL ARTICLES 


MATERNAL MORTALITY IN HOSPITAL 


A REVIEW OF 999 FATAL CASES IN THE GLASGOW 
ROYAL MATERNITY AND WOMEN’S HOSPITAL 
DURING TEN YEARS, 1925-34 * 


By Ducatp Bam, B.Sc., M.D. Glasg., F.C.0.G. 


VISITING OBSTETRIC SURGEON, GLASGOW ROYAL 
MATERNITY HOSPITAL 


THIS investigation has been undertaken to test the 
impression that, although the maternal mortality 
for Scotland generally continues to rise, the death- 
rate in hospital is steadily falling. In 1930 big changes 
were made in the organisation of the Glasgow Royal 
Maternity Hospital and the staff was greatly increased. 
The results recorded in the five-year periods before 
and after these changes are here compared. 

During the first five-year period, 19,134 cases 
were admitted with 542 deaths (28 per 1000), while 
during the second five-year period, 22,425 cases 
were admitted with 457 deaths (20 per 1000). There 
has therefore been a considerable fall in the death- 
rate during the last five years, despite the fact that 
the percentage of abnormal cases has risen from 
62 to 65. Table I. contrasts the numbers and death- 
rates of some of the complications dealt with during 
the two periods. 


TABLE I 
Numbers and Death-rates of Complications during the 
Two Periods 
First Second 

five years. five years. Difference 

Conditi edb 
on on rst an 

° Mor- Mor 

A N second 

Ery f tality five years. 

cent. | C888. | cent. 
Arperemesia 12'1 382 4'4 +127 
Albuminuria.. 2°7 1397 1°5 +235 
Eclampsia 18°0 330 | 17:6 — 65 
Forceps, &c.. ; 4'3 | 1810 3'3 +550 
Cæsarean section for 
contracted pelvis.. 3°0 699 2°0 +275 
Failed forceps outside 16:3 236 | 13°'1 + 46 
Craniotomy . 11°0 147 1'5 — 79 
Abortion ` 1'2 3219 0°6 — 71 
Placenta preevia ee 13°0 487 75 + 81 
Accidental nemor: 

. rhage 4'5 633 50 +106 
Cardiac disease 10°4 606 6'4 +261 


\ 


For further analysis the fatal cases have been 
grouped according to the condition for which the 


: patient was admitted to hospital—unless she was 
" admitted in labour or for some complication of labour, 


in which case they have been classified according to 


` the cause of death. 
TABLE II 
Analysis of Fatal Cases 
1925-29. 1930-34. 
Toxæemia.. 159 118 
Sepsis is. 139 98 
Shock a one te 58 Leia 56 
Hæmorrbage 104 107 
Intercurrent disease z 82 TE 78 


5 The comparison shows a notable fall in the number 
: of deaths from toxemia and sepsis in the second 


es 


> 


*The substance of this paper was read before the Glasgow 


:’ Obstetrical Society on Jan. 22nd. 


5867 


- were being treated in the antenatal war 


five years, and this is in direct contrast to the finding 
of the Department of Health for Scotland, in their 
1935 report, that the death-rate from those two 
causes is on the increase. Each group will now be 
dealt with in detail. 


TOXAMIA 


ficlampsia.—During the first five years there were 
395 cases of eclampsia with 71 deaths (18 per cent. 
mortality), and in the second five years 330 cases 
with 58 deaths (17°6 per cent. mortality). Hence 
there has been no striking improvement in the 
results of treatment of eclampsia, and we must lo 


incidence. 
is known about the antenatal care received b 
fatal cases. We do know, however, that 8 


antenatal care, and in most of the othere\4 
natal supervision was poor. There were no ‘deaths 
from eclampsia in this second period among ‘women. 
being treated in the antenatal wards of the “hospital, 
but 7 of the fatal cases attended the out-patient 
department of the hospital and were later admitted 
with eclampsia. These 7 cases all occurred before 
the end of 1932, since when the antenatal supervision 
has been stricter and the importance of the fact 
that raised blood pressure may be the only pre- 
monitory symptom of toxemia has been realised. 
In the years 1933 and 1934 there have been no fatal 
cases of eclampsia in patients under hospital super- 
vision. This suggests that death from eclampsia 
can be avoided by intensive antenatal care. The 
following figures show, however, that eclamptic 
seizures still occur in patients under hospital treat- 
ment. During the years 1934 and 1935, 46 cases of 
eclampsia were admitted to one unit of the hospital, 
7 of which were under hospital supervision. There 
were 6 deaths among 35 patients who had poor 
antenatal care or none (17:1 per cent. mortality), 
none in the hospital cases, and none in 4 who had 
good antenatal care outside. One of the hospital 
cases may be quoted. | 

Mrs. A., aged 22; first pregnancy, last menstrual 
period March 24th, 1934. On Dec. 24th she was sent to 
the out-patient department of the Maternity Hospital 
from a local authority clinic because of slight edema and 
headache of two weeks’ duration. Blood pressure 
160/108; urine clear. Hospital treatment was refused, 
but on Dec. 3lst she was admitted to hospital after 
persuasion ; B.P. 168/110. Jan. 3rd, 1935: urine clear ; 
very slight edema; B.P. 154/108; urinary output good. 
As patient was at term castor oil and quinine given. 
Jan. 4th: labour pains began at 7 P.M.; urine clear at 
8 P.M.; eclamptic seizure at 11 r.M., with B.P. 156/82 
and a cloud of albumin in the urine. Jan. 5th, 11 a.m.: 
14 fits to date; forceps delivery under local anesthesia ; 
child 7 lb. stillborn. Uninterrupted recovery ; urine clear 
on the third day. 


This case is a striking demonstration of the fact 
that raised blood pressure is one of the most reliable 
pre-eclamptic signs, and may be present long before 
there is any albumin in the urine. There was no 
albuminuria in this case three hours before the onset 
of eclampsia. 

In conclusion, it would appear that strict ante- 
natal care can reduce the incidence of eclampsia and 
also its severity; for when eclampsia develops, 
despite good antenatal care, it seems to take the 

F 


hospital for albuminuria. We know thp 
second five years 40 per cent. of the c 


996 THE LANCET] 


form of seizures brought on by the stress of labour, 
with rapid recovery in the puerperium. 


Albuminuria.—In 1162 patients treated in the 
antenatal wards for albuminuria during the first 
five-year period there were 40 deaths: (3°4 per cent.), 
and in 1397 patients during the second period 22 
deaths (1°5 per cent.). This includes the 8 deaths 
from eclampsia which occurred in the first five-year 
period, already dealt with above. The improvement 
in the death-rate in the second five years is not due 
to any striking advance in treatment but to earlier 
admission to hospital and earlier termination of the 
pregnancy with improved methods of induction of 
labour. During the first five years valuable time 
was frequently lost by attempting medical induction, 
which was often unsuccessful and necessitated the 
use of bougies which often had to be reinserted several 
times before labour began. Bougies are now seldom 
used and have been replaced by rupture of the 
membranes, which has many advantages. 
labour more quickly, does not require a general 
anesthetic, and is less liable to be followed by sepsis. 
Although surgical induction was practised 268 times 
in the second five years and only 130 times in the 
first, there were only 3 deaths from sepsis in the 
second period as compared with 10 in the first. Of 
these 13 deaths 8 occurred after the use of bougies 
and 1 after rupture of the membranes. The gross 
liver damage demonstrable histologically in many 
of those toxxmic cases emphasises the unsuitability 
of a general anesthetic, and especially chloroform, 
which was the anesthetic used for the insertion of 
bougies. In 10 of the 54 cases with fatal albuminuria, 
the obstetric history showed quite clearly that the 
patient was quite unfit for pregnancy, which should 
have been prevented. 


Hyperemesis (vomiting in the early months of 
pregnancy).—The number of cases of hyperemesis 
admitted to hospital has increased from 255 in the 
first five-year period to 382 in the second, while the 
death-rate has fallen from 12:1 per cent. to 4°4 per 
cent. As with albuminuria, there has been no strik- 
ing improvement in the method of treatment in 
hospital, and the improvement in the death-rate is 
due to earlier termination of the pregnancy by better 
methods. There should be almost no deaths from 
hyperemesis, and this could be achieved by earlier 
admission to hospital. In the second five years, 
11 of the 17 deaths from hyperemesis were in patients 
so ill on admission that they died within four days. 
The improved technique for termination of pregnancy 
in cases of hyperemesis, reflected in the fall in the 
number of deaths from shock from 13 to 3, consists 
of the substitution of spinal anesthesia or gas- 
and-oxygen for chloroform, and of abdominal 
hysterotomy in many cases for curettage, preceded 
by dilatation of the cervix by laminaria tents or 
forcibly with I[egar’s dilators. 


Toxic vomiting in the later months.—This category 
includes cases of toxæmia in the later months where there 
is no rise of blood pressure, oedema, or albuminuria, the 
chief symptom being vomiting. In the first five years 
there were 15 deaths, 10 occurring soon after admission 
in severely ill patients, and in the second five years 
9 deaths, all soon after admission in severely ill patients. 
Apparently, therefore, the mortality could be reduced by 
earlier admission to hospital. 

Pyelitis of pregnancy is included with the toxemias for 
convenience. In the first five years there were 10 deaths 
and in the second five years 11. As microscopic examina- 
tion of a catheter specimen of urine was not a routine 
practice in all pationts admitted to the antenatal wards 
during the first five years, the exact number of cases of 


DR. D. BAIRD: MATERNAL MORTALITY IN HOSPITAL 


It induces. 


[FEB. 8, 1936 


pyelitis admitted during this period is unknown and the 
mortality-rates for the two five-year periods cannot be 
compared. As in the toxzemias already considered, earlier 
admission to hospital and better methods of termimating 
pregnancy would reduce the mortality. 


SEPSIS 


This heading covers all cases in which the patient 
died in another hospital after being transferred 
because of sepsis. It does not cover deaths from 
sepsis following the toxæmias and hemorrhages of 
the later months, for these are dealt with in each 
separate group. The number of deaths from sepsis 
has fallen from 139 in the first five years to 98 in 
the second. 


Sepsis following normal delivery—There has been 
a striking fall in the number of deaths from sepsis 
after spontaneous delivery, for although over 1000 
more normal cases were admitted to the hospital 
in the second five years, there were only 15 deaths 
as compared with 30 in the first. Those 15 deaths 
include 2 cases which were already infected on 
admission, delivery having occurred outside. The 
improvement is probably due to recognition of the 
fact that the commonest source of the hemolytic 
streptococcus is the nasopharynx, the practical 
application of which includes the wearing of masks 
and the exclusion of all persons harbouring strepto- 
cocci from contact with the patient during labour 
or the puerperium. For the second five-year period, 


the death-rate from sepsis following spontaneous 


delivery in the group under consideration is approxi- 
mately 1:3 per 1000, which demonstrates that the 
risk of sepsis in hospital is no greater than elsewhere. 


Sepsis following complicated delivery (excluding 
Cwsarean section and “failed forceps outside ”’).— 
The deaths from sepsis in this group have fallen from 
42 in the first five years to 27 in the second. For 
the purpose of analysis cases have been divided into 
emergency and hospital cases, the latter including 
those admitted so early in labour that the hospital 
was really responsible for the conduct of the labour. 
The number of deaths in hospital cases remains the 
same, but there is a striking fallin the deaths in 
emergency cases, from 28 in the first five years to 
13 in the second. The improvement in antenatal 
care has resulted in fewer cases being admitted as 
emergencies after prolonged labour and more before 
the onset of labour or in the early stages of labour. 
This is shown by the greater number of cases of 
contracted pelvis dealt with by the hospital (2335 
in the second five years as compared with 1370 in 
the first) and by the greater number of forceps 
deliveries in hospital (1810 compared with 1260). 
The mortality in hospital cases has therefore dimi- 
nished, since the number of deaths has remained the 
same in the two periods. 

The results in this group show a great all-round 
improvement in the treatment of difficult labour, 
although there are still about 25 per cent. of these 
fatal cases which are probably avoidable. More 
than half of the rest of the fatal cases, which were 
probably unavoidable, were cases of uterine inertia, 
resulting in prolonged labour, repeated vaginal 
examination, and instrumental delivery. The fact 
that the cause of death in 4 cases was chloroform 
poisoning emphasises the unsuitability of this anws- 
thetic in cases of difficult labour. 


Sepsis following ‘‘ failed forceps outside.’’>—The 
number of deaths from sepsis in this category has 
risen from 19 in the first five years to 22 in the second, 


THE LANCET] 


DR. D. BAIRD: MATERNAL MORTALITY IN HOSPITAL 


[FEB. 8, 1936 297 


and the number of such cases admitted to hospital 
has risen from 190 to 236. ‘The increase in this group 
is disquieting. In all the fatal cases the head was 
still high in the pelvis on admission, under which 
circumstances forceps delivery is rarely the correct 
procedure and is so difficult that it should be attempted 
only under the best conditions. Where there is a 
definite contracted pelvis in a primigravida, or a 
history of difficult delivery in a multipara, difficulty 
should be anticipated. Of the fatal cases, however, 
9 were in multipare in whom the previous labours 
had been easy and where appreciation of the high 
position of the head in the pelvis was the only warn- 
ing of probable difficulty. Hospital treatment can 
have very little influence on the mortality in this 
group. 

Sepsis following Cesarean section.—There were 
424 Cesarean sections performed for contracted 
pelvis in the first five years with 13 deaths from 
sepsis (3 per cent.), and 699 in the second five years 
with 14 deaths from sepsis (2 per cent.). The fact 
that the death-rate from sepsis after Cesarean 
section has fallen from 3 to 2 per cent. is probably 
due to the more frequent use of the lower uterine 
segment operation in the second five years. In 
the first five years 410 classical Cesarean sections 
were performed with 13 deaths (3 per cent.)—12 of 
which were due to generalised peritonitis—and 14 
lower uterine segment sections with no deaths. In 
the second five years 449 classical Czesarean sections 
were performed with 11 deaths (2°6 per cent.)—6 from 
generalised peritonitis—and‘ 250 lower uterine seg- 
ment operations with 3 deaths (1°2 per cent.), none 
from generalised peritonitis. This difference in the 
mortality from the two operations is all the more 
striking because a bigger proportion of the cases 
which had the lower uterine segment operation were 
“suspect ’’—i.e., cases where the risk of sepsis was 
greater because the patients had been many hours 
in labour. In the ‘suspect’? cases in this group 
the notifiable pyrexia-rate was 18 per cent. in those 
who had the lower uterine segment operation and 
45 per cent. in those who had the classical Caesarean 
section. The risk of peritonitis is less after the 
lower uterine segment operation than after the 
classical Csesarean section. The lower uterine segment 
operation might be employed more often in cases 
of minor disproportion, after unsuccessful trial labour, 
which in these cases may be the only means of 
deciding whether delivery from below is possible or 
not. It is certainly safer than the difficult forceps 
delivery or craniotomy which is the alternative in 
these cases. 


Sepsis following manual removal of the placenta.—In the 
first five years there were 9 deaths from sepsis after manual 
removal of the placenta, 7 in hospital cases and 2 in patients 
delivered outside; and in the second five years 7 deaths, 
3 in hospital cases and 4 in patients delivered outside. 
Numbers are too small to draw any conclusions. 

Sepsis following abortion.—In the first five years there 
were 3290 cases of abortion admitted with 26 deaths 
(08 per cent.), and in the second five years 3219 cases 
with 11 deaths (0°3 per cent.). The reduction in the 
mortality-rate may be attributable to more strict enforce- 
ment of refusal to admit septic abortion cases. The only 
change in hospital technique is that packing of the vagina 
has been practically given up. 


SHOCK 


There were 58 deaths from shock in the first five 
years and 56 in the second. Deaths under anesthesia 
have been included in this group for convenience. 


Deaths under anesthesia include 5 cases of delayed 
chloroform poisoning. In the fatal cases the operations 
were curettage for abortion (7), Caesarean section for con- 
tracted pelvis (3), insertion of bougies (2), and forceps 
delivery after long labour (11), in 5 of which the cause of 
death was delayed chloroform poisoning. Chloroform was 
the anesthetic in all cases except one, in which spinal 
anesthesia was used. l 


The fact that delayed chloroform poisoning was the 
sole cause of death in 5 cases emphasises the danger 
of chloroform in obstetrics. 


Deaths from shock, excluding those under anæsthesia.— 
In the first five years there were 48 fatal cases 
and in the second five years 42. There have been 
fewer deaths in emergency cases but just as many 
in hospital cases. As in the sepsis group, this is 
due to better antenatal care resulting in fewer cases 
of disproportion being admitted as emergencies and 
more being admitted before the onset of labour. 
But there is still room for improvement in antenatal 
care outside, for in the second five years 24 of the 
42 fatal cases were emergencies. Of the other 18 
which occurred in hospital cases death might have 
been avoided in several but was probably unavoid- 
able in most. 


Of the fatal cases in this group in the ten-year 
period 26 had rupture of the uterus, 4 in hospital 
cases and 22 in emergency cases. Eleven died 
undelivered. The average parity was seven, and 
there were only 2 primigravidæ. Of the 24 multi- 
pare 10 had had no previous difficulty. The increas- 
ing danger of rupture of the uterus with increasing 
parity should always be borne in mind, even where 
the labour is easy. 


HÆMORRHAGE 


In the first five years there were 104 deaths from 
antepartum and postpartum hæmorrhage and in 
the second five years 107. There is a diminished 
number of fatal cases of placenta prævia and an 
increased number of deaths from accidental hæmor- 
rhage and postpartum hæmorrhage in the second 
five years. 


Placenta prævia.—During the first five years 
there were 406 cases of placenta prævia with 53 deaths 
(13 per cent.), and during the second five years 
487 cases with 37 deaths (7:5 per cent.). The imme- 
diate cause of death was hæmorrhage and shock in 
56 and sepsis in 34. In 55 of the 90 fatal cases 
the patient arrived in good condition and in 12 
she might have done so but for neglect of warning 
hæmorrhage. The fall in the death-rate in the 
second five years must be largely due to improved 
technique in hospital, but that this could be further 
improved is demonstrated by the fact that 22 of 
the 37 fatal cases in the second five years arrived in 
hospital in good condition. In many of those there 
was delay in emptying the uterus, either because 
the bleeding had ceased temporarily or the cervix 
was closed, making exact diagnosis difficult. One 
unit of the hospital has gradually in the last five 
years adopted the policy of emptying the uterus at 
once by Cesarean section if the placenta is felt to 
reach down to within half an inch of or to cover the 
internal os, even although there may be no bleeding 
at the time. Blood transfusion is used extensively. 
During the second five-year period 174 cases of placenta 
previa were admitted to this unit with 7 deaths (4 per 
cent.); and 3 of them were admitted moribund. 

I see no reason: why the death-rate from placenta 
previa should be more than 3 per cent.—less than 


‘4 


298 |. THE LANCET] 


half the present rate for the whole hospital. Some 
lives would be saved by earlier transfer to hospital 
on the first hemorrhage. Most of the deaths would 
be avoided by improvement in hospital technique— 
that is, prompt emptying of the uterus after admis- 
sion to hospital, the avoidance as far as possible of 
vaginal manipulation, and the extensive use of blood 
transfusion. This last has been employed far too little 
in the past: it was used in only 3 of the 56 fatal 
cases where hemorrhage was the cause of death, 
and in only 7 of the 34 where sepsis was the cause 
of death. It should not be regarded as a desperate 
remedy but should be given as quickly as possible 
after the blood loss. — 


Accidental hemorrhage.—During the first five 
years there were 527 cases with 24 deaths (4°5 per 
cent.) and in the second five years 633 cases with 
32 deaths (5 per cent.). In 42 of the fatal cases the 
patient was so ill on admission that she died within 
afew hours. In 4 cases there was excessive bleeding, 
and the patient’s life might have been saved by 
blood transfusion; but on the whole there seems 
little scope for improvement in the results of treat- 
ment along the usual lines. The question arises 
whether these catastrophes could be avoided by 
adequate antenatal care, since they are commonly 
believed to be the result of toxemia; but an analysis 
of the more complete antenatal records of the second 
five years fails to show evidence of toxemia in many 
of the cases. Even where there was toxemia it 
was usually mild, hemorrhage occurring suddenly 
without warning, so that antenatal care can do little 
in the prevention of accidental hemorrhage. In 
30 of the 56 fatal cases in the whole ten years the 
patient had had seven or more children, often in 
rapid succession. Better spacing of the children 
would probably diminish the risk of this compli- 
cation. 


Postpartum hemorrhage.—During the first five years 
there were 16 deaths from postpartum hemorrhage and 
27 during the second period. Blood transfusion was given 
in only 2 of the 43 cases, although in 29 of these (14 hospital 
and 15 emergency cases) there was time available. 
Organisation of donors on a large scale should make it 
possible for these patients to have blood transfusion 
within a short time of the hemorrhage. 


Abortion.—In the first five years there were 3290 cases. 


of abortion with 8 deaths from hæmorrhage (0°24 per 
cent.), and in the second five years 3219 cases with 
10 deaths (0°31 per cent.). In 4 of the fatal cases the 
patient was moribund on admission, and in the remaining 
14, although the patients did not die until after periods 
varying from several hours to several days after admission, 
blood transfusion was given in only 2. While the death- 
rate in this group is low, it could be further reduced by 
earlier admission to hospital and more frequent use of 
blood transfusion, which would also minimise the incidence 
of sepsis by improving the patient’s resistance. 


INTERCURRENT DISEASE ) 


During the first five years there were 82 deaths 
from intercurrent disease and in the second five 
years 77. This group includes such conditions as 
pneumonia, tuberculosis, meningitis, cancer, and 
cardiac disease. Only the deaths from cardiac 
disease will be considered in detail. 

In the first five years there were 345 cases of 
cardiac disease complicated by pregnancy with 
36 deaths (10:4 per cent.), and in the second five 
years 606 cases with 39 deaths (6'4 per cent.). The 
reason for the fall in the death-rate is that women 
with severe cardiac disease are being admitted to 
hospital earlier and are being kept in hospital longer. 


` 


K 


DR. D. BAIRD : MATERNAL MORTALITY IN HOSPITAL 


[FEB. 8, 1936 


Here again, however, there is room for improvement, 
for in the last five years 27 patients were admitted 
very seriously ill and 8 of them died before the 
pregnancy could be terminated. The best mode of 
delivery varies with each case but is not the most 
important factor in deciding the outcome. The 
decision must be made early in pregnancy whether 
it is safe to allow the pregnancy to proceed. Where 
it is decided that the cardiac reserve is sufficient, 
the greatest care to preserve it should be taken by 
adequate rest in bed. In 15 of the fatal cases in the 
first five years, and 5 in the second, the cardiac 
lesion was so severe that pregnancy should have 
been prevented, preferably by sterilisation. 


CONCLUSIONS 


The maternal death-rate in the Glasgow Royal 
Maternity Hospital is falling—partly because of an 
all-round improvement in technique and partly 
because the more abnormal cases, which were: for- 
merly sent in as emergencies, are now being sent to 
hospital before labour or in the early stages of 
labour. 

There is room for improvement both inside and 
outside the hospital. The chief faults inside the 
hospital are (1) the lack of proper organisation for 
immediate blood transfusion in cases of hemorrhage, 
and (2) the fact that many urgent cases, which present 
most dithicult obstetric problems, have to be dealt 
with by junior members of the staff because their 
seniors are non-resident. The faults outside the 
hospital are the lack of adequate antenatal super- 
vision, particularly in the toxemias, and unjusti- 
fiable attempts to perform major obstetric pro- 
cedures under adverse conditions. The problem 
outside the hospital, however, is more difficult, 
owing to ignorance and lack of coöperation on the 
part of the patient. Moreover in Glasgow rickets 
in childhood (causing a high incidence of contracted 
pelvis), multiparity, poor housing, and poverty are 
all very important factors. As the class from which 
our hospital patients come cannot afford even a 
small fee to a family doctor, an extension of ante- 
natal supervision by the local authority—possibly 
with compulsory notification of pregnancy—is urgently 
required. More hospital accommodation, especially 
for antenatal cases, is also a pressing need. 


It is clear that in some 9 per cent. of the fatal 
cases pregnancy was a grave risk which the patient 
should not have been allowed to undertake. Sterilisa- 
tion or contraception was indicated. Experience at 
the voluntary birth control clinic shows that most 
of the patients cannot pay the sum necessary for 
the purchase of contraceptive materials, and as 
there are no birth control clinics under the local 
authority in Glasgow, this matter deserves their 
immediate attention. 


NEw HOSPITAL FOR MELKSHAM.—Plans for this 
hospital, to be erected with the Ludlow-Bruges legacy 
of £200,000, have been prepared. They provide for a 
cottage hospital with accommodation for about forty 
pationts. The wards and the administrative block will 
be of one and two storeys respectively. 


WALSALL GENERAL HOsPITAL.—Two members of 
the Hale family have promised to provide the money 
for a children’s ward at this hospital. The present 
ward has room for 10 children only, and those 
above eight years old have to be accommodated 
in adult wards. The cost will be between £4000 
and £5000. l 


THE LANCET] 


DRS. BARBOUR & STOKES: CHRONIC CICATRISING ENTERITIS 


[FEB.'8, 1936 299 


CHRONIC CICATRISING ENTERITIS 


A PHASE OF BENIGN NON-SPECIFIC GRANULOMA 
‘OF THE SMALL INTESTINE 


By R. F. BARBOUR, M.A. Camb., M.B. Edin., 
M.R.C.P. Lond. 
AND 
A. B. Stoxess, B.M. Oxon., M.R.C.P. Lond. 


ASSISTANT MEDICAL OFFICERS, THE MAUDSLEY HOSPITAL, 
' LONDON 


GRANULOMATA of the intestine were formerly 
considered neoplastic, but later a ‘“‘specific”’ group 


was isolated, leaving a non-specific residuum. To 


begin with, the granulomata of the large bowel 
received attention, and it is only in the last ten 
years that similar lesions in the small intestine have 
been adequately investigated. 

Before 1895 most circumscribed chronic lesions of 
the intestine appear to have been regarded as neo- 
plastic, but in that year Senn °° distinguished between 
infective granuloma and carcinoma, while in 1907 
Moynihan ë¢ reported six cases in which the original 
diagnosis of malignant disease of the large bowel was 
replaced by that of granuloma of the intestine. Two 
years afterwards Braun ® gave a survey of the con- 
dition and explained so-called cured cases of malignant 
disease as benign granulomata that had undergone 
resolution. Proust, Robson,®? and Lejars‘ ® reported 
similar lesions. In 1913 Dalziel 2? described cases in 
which the small, as well as the large, intestine was 
involved, and in one of these two-feet of jejunum 
was removed at operation for partial obstruction. 


Tietze £? reviewed the condition in 1920. In some 
cases the cause of the granuloma was held to be 
tuberculous infection or syphilis, but in the majority 
no definite cause could be found. The non-specific 
origin of the granulomata of the intestine was 
emphasised by Moschcowitz and Wilensky °° in 1923, 
while Mock 5! in 1931 concluded that the benign 
non-specific granulomata did in fact form a definite 
pathological entity. He described their possible 
wtiology and symptoms, and believed them to be 
similar to tumours occurring elsewhere in the body. 
Since that time, although specific granulomata 
(e.g., tuberculous, 12 1? 23 32) of the intestine have 
been reported, there is an increased tendency to 
regard many as of non-specific origin.® 59 

The importance of the benign non-specific granu- 
lomata affecting the small intestine was brought out 
by Crohn, Ginzberg, and Oppenheimer.!® Among 
52 cases of non-specific granuloma of the intestine 
these authors isolated 13 in which the terminal 
ileum was involved.**? To this localised condition 
the name of regional ileitis was given, although in 
America it also became known as Crohn’s disease. 
Following this work numerous cases of granuloma of 
the lower ileum were reported under such titles as 
Crohn’s disease, regional ileitis,!3 regional enteritis," 
chronic cicatrising enteritis,® 24 #4 and localised chronic 
ulcerative ileitis.? In some of them parts of the 
small intestine other than the terminal ileum were 
involved and lesions were found in the jejunum and 
in the duodenum. This more widespread involve- 
ment of the small intestine led Crohn ?® to enlarge 
and amend his original concept. 

It is interesting to note that almost all the recorded 
cases of non-specific granuloma of the small intestine 
are in the American literature; only a few are to be 
found in British and continental journals. In 1933 


‘Molesworth 52 in this country reported a single case 


of granuloma of the intestine with stenosis of the 
ileocæcal valve and likened it to cases described by 
Mock. In 1934 Jackman *® described two cases 
under the heading of localised hypertrophic enteritis, 
while Dickson Wright 8 demonstrated two cases of 
Crohn’s disease at the Medical Society of London in - 
January, 1935. Owing to the recent interest in this 


condition the following case is recorded. 


CASE-HISTORY ` 


The patient, a man of 63, was of: good family ante- 
cedents, and for thirty years had lived abroad as a medical 
missionary. In 1927 he was not allowed to return to 
China because of poor health. This however did not 
prevent him from holding several medical appointments 
in this country, and at the time of the onset of illness he 
was engaged in private practice in London. From 1927 
he had suffered from indigestion and from “chills” 
which were liable to lead to vomiting. He also com- 
plained of indefinite pains in the back and chest which 
were attributed to ‘“‘ rheumatism and lumbago.” He was 
seen by several doctors but no definite diagnosis was 
made, and he found that by following a simple diet he 
was able to overcome any temporary discomfort. For 
one year he had been losing weight and had seemed to be 
in poorer health. 


Previous Illnesses.—Paratyphoid in 1906; sunstroke 
in 1907; typhoid in 1923; septic finger with cellulitis 
and axillary abscess in 1926, with amoebic dysentery in 
the same year. i. 

History of Present Iliness.—Early in September, 1934, 
the patient took his annual holiday and returned home 
seemingly fit. On Sept. 27th he felt ‘‘ queer ” and was 
unable to attend to his practice. Next day he complained 
of acute abdominal discomfort, and he was admitted the 
same evening to a London general hospital. On admis- 
sion his temperature was 99°4° F. The liver was said to 
be enlarged and coarse friction was heard over the liver 
in the sixth right intercostal space. In view of the history 
of ameebic dysentery a tentative diagnosis of amcbic 
hepatitis was made and emetine gr. 4 was given intra- 
muscularly. Examination of the stools failed to show 
entamcebe or cysts. On three evenings the temperature 
rose to 99°4° but at all other times it was subnormal. 
On the third day he became difficult to manage, demand- 
ing food in the middle of the night and insisting that he 
was quite well. He rapidly developed a delirious condi- 
tion in which he tried to get into bed without taking off 
his shoes and trousers, and on the sixth day he discharged 
himself from hospital. 

During the next fortnight he was staying with rela- 
tives, and in the first week his physical condition showed 
little change. He was placed on a light diet, and to begin 
with took his food well. There was an occasional rise of 
temperature but no record was kept. During the second 
week he developed a thrombosis of the right calf and 
was admitted to the Hospital for Tropical Diseases, 
London. On the previous night his temperature rose to 
101°4°, and he is said to have. been making rambling 
remarks. On admission he was noted as appearing 
dehydrated and toxic, and during his stay his diet had 
to be supplemented by intravenous glucose-saline. Physi- 
cally his condition remained unchanged; he had neither 
diarrhoea nor vomiting, and there was a slight rise of 
temperature on only two occasions. His mental state 
showed variation : at times drowsy, he was also at times 
violent. Sometimes he would refuse food by day, only 
to eat it at night. As the patient’s uncodperative attitude 
was dominating the clinical picture he was transferred 
to the Maudsley Hospital on Nov. 13th. 

The physical examination on admission showed a middle- 
aged man, cachectic, and dehvdrated, with sunken eyes 
and prominent cheek-bones. He lay in bed with his eyes 
closed and took no evident interest in his surroundings. 
He appeared to understand what was said to him, but 
would only answer by a nod of the head or a shrug of the 
shoulders. He would sit up or lie down, but would not 
coéperate in the finer tests. His breath was offensive, 


300 THE LANCET] 


DRS. BARBOUR & STOKES: CHRONIC CICATRISING ENTERITIS 


(FEB. 8, 1936 


the tongue was dry-coated, and the teeth showed pyorrhea. 
Examination of the abdomen was difficult owing to the 
patient’s failure to relax; the upper abdomen was held 
more tensely than the lower, which could be palpated 
satisfactorily. The patient indicated that he had had 
pain in the right iliac fossa but that it was no longer 
present. There was no visible peristalsis; no tumour 
or masses were found. The liver and spleen were not 
enlarged, the kidneys could not be palpated. Borborygmi 
were noted; the patient was incontinent of fæces, no 
blood or slime was present. No abnormalities were 
detected in the respiratory, musculo-skeletal, and central 
nervous systems. The heart sounds were weak but no 
murmurs were detected. The vessels were not unduly 
thickened. Blood pressure 110/70. The patient had 
glandular hypospadias. 

Progress in Hospital_—The mental state continued 
negativistic; he resisted attention, but did not help 
himself. He showed little interest in his surroundings, 
and he occasionally made remarks, but no natural con- 
versation was 
ever possible. 
Shortly after 
admission tube- 
feeding was 
started, and had 
to be continued 
at intervals. The 
patient vomited 
most days, and 
was also doubly incontinent. The vomiting was of two 
kinds—one immediately after being tube-fed, the other two 
hours later. It was never offensive or projectile. At one 


MALL AL (Ak “MM, Yi 
td 


JUHILE 1A DUH LLL ALLL) 


1 inch. 


time the vomiting was so constant that for three days: 


nothing but intravenous glucose-saline was given, and 
even then the patient tried to remove the needles. During 
December the vomiting became less frequent and he 
was able to take convalescent diet, at a few meals even 
feeding himself. Throughout he remained stuporous, and 
he never complained of pain or tenderness. The physical 
condition showed little change except that he appeared 
to be losing ground. The systolic blood pressure dropped 
to 78—the diastolic could not be detected. Four days 
before his death his temperature rose, on one occasion 
to 99°8°, but no cause for this could be found. Finally on 
Feb. 2nd he died quietly in his sleep. 


CLINICAL AND LABORATORY DATA 


The following data include tests carried out both at 
the Hospital for Tropical Diseases and at the Maudsley 
Hospital. 

Temperature: Sept. 27th, 28th, 29th, daily swing from 
97°6-99°4° F. No definite records are available for the 
period Oct. 2nd-16th. Oct. 16th, 101°; 17th, 100°; 
19th, 99°. Thereafter subnormal till Nov. 12th, when 
99° was again recorded; it continued at an average of 
97° till four days before his death when 99°8° was reported, 
but it fell again to 97°. 

Pulse: The rate remained between 70-80 till December 
when it rose to an average of 100 and remained at that 
level with little variation till within a few days of his 
death. 

Weight: Sept. 30th, 7 st. 4} lb.; Nov. llth, 6 st. 6 lb. ; 
Jan. 29th, 5 st. 12 Ib. 

Laboratory tests: The blood counts showed a pro- 
gressive anemia: 4,200,000-3,230,000 red cells per c.mm. ; 
hemoglobin, 80-58 per cent. The white count on 
admission was 12,000 ; thereafter no count above 4000 was 
obtained. The polymorphonuclear leucocyte percentage 
remained about 70 per cent. No abnormal red or white 
cells were scen. Neither vomit nor gastric analysis showed 
abnormal findings. Free acid was present in the fasting 

uice. 
Feces: The patient was incontinent of fæces on most 
days, but had diarrhea only twice. Examinations for 
blood and slime were always negative. Culture of the 
stools showed B. coli, enterococci; no organisms of the 
typhoid group or entamosbe wore detected. Giardia 
lamblia cysts were found on several occasions. 

Urine: A trace of albumin was present. 

Other examinations of the blood including blood 
culture; urea and cholesterol estimation; and Wasser- 


FIG. 1.— Diagrammatic scheme of the small intestine from the pylorus to the ileo- 
cecal valve, showing 13 places of thickening and 7 of thinning. 


mann, Kahn, and Van den Bergh tests all gave 
negative or normal findings. The sedimentation-rate was 
increased ; the blood-serum agglutinated typhoid 1 : 250, 
A levulose-tolerance test and examination of the cerebro. 
spinal fluid failed to show any abnormalities. Several of 
these examinations were repeated more than once. Radio. 
graphy was unfortunately impossible owing to the patient's 
lack of coöperation and his poor physical state. 


AUTOPSY 


The body showed extreme emaciation, but apart from the 
glandular hypospadias, the external appearance was 
otherwise normal. There was no evidence of an abdominal 
operation having been performed. 

On opening the abdomen the great omentum was seen 
to be firmly bound down to the right iliac fossa. There 
was a generalised early peritonitis, non-hzemorrthagic, 
with very little free fluid. There was surface glazing of 
the peritoneum, with lymph flaking more conspicuous in 
the neighbour- 
hood of the 
lower ileum and 
other portions 
of the small 
intestine. 

At varying 
points along its 
length the 
small intestine 
showed evidence of an inflammatory process in its walls. 
There were thirteen such portions as shown diagram. 
matically in Fig. 1, varying in length from } in. to 2 in. 
These portions were widely separated, as seen inside the 
abdomen, and in their neighbourhood the peritonitis was 
most evident. The first as measured in the formalinised 
specimen was 21 in. from the pylorus, the last 4} in. 
from the ileocecal valve. In the fresh state these portions 
showed a relatively sharply defined area of congestive 
lividity. The adjacent mesentery was thickened and 
congested, but the mesenteric lymph nodes were not 
enlarged. The vessels in the mesentery appeared normal. 
These portions felt firm and hard, and on opening the 
gut the lumen of the intestine in these parts was narrowed 
and the wall greatly thickened. The degree of con- 
striction varied but in the narrowest part the lumen was 
0°5 cm. in diameter, and the thickest wall measured 
0°9 cm. The thickness was associated with the presence 
of fibrous tissue and was greatest on the mesenteric side 
(Fig. 2). The mucous membrane had lost its normal 
rug, was thickened, more congested, and more spongy. 
There were one or two areas of ulceration. 

There were also lengths of intestine which were ballooned 
out, with very thin walls, and no rugæ. Seven such 
portions were present, bearing no constant relation to 
the constricted parts. Sometimes they preceded or fol- 
lowed a constricted part (Fig. 3); sometimes normal gut 
intervened. The diagram explains the relation. 

The inflammatory process did not show the same degree 
of activity in each of the thirteen portions. The more 
active lesions were in the neighbourhood of the lower 
ileum, and there the peritonitis was most marked, and 
there the omentum was bound down. The large intestine 
appeared normal saving for a small area of doubtful 
thickening in the ewcum. The appendix was normal. 

The liver was slightly smaller than normal and showed 
slight back-pressure effect. No evidence of amebic 
hepatitis or abscess was found. The bilary tract was 
normal. The spleen was a toxic spleen. The kidneys 
were small with thinned, ill-defined cortices and slightly 
granular surfaces. The other abdominal organs were 
normal. In the thorax the lungs showed terminal 
bilateral broncho-pneumonia. There was no evidence of 
active tubercle in the pleure, lungs, or mediastinum. 
There was gross atheroma of the descending aorta. The 
heart and brain were normal. 


Scale 1 mm. = 


MICROSCOPICAL EXAMINATION 


Transverse sections of the localised lesions of the small 
intestine showed variations corresponding to the situation 
of the lesion. In general those nearer the ileocæcal valve 


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DRS. BARBOUR & STOKES: CHRONIC CICATRISING ENTERITIS 


[FeEB. 8,1936 301 


showed evidence of a more acute pathological process 
than those further removed. 

In the parts of more acute reaction there was much 
congestion and cedema of all portions of the bowel wall, 
and in these parts the mesentery was also involved. 
The reaction was a fibroblastic reaction with an infiltra- 
tion of polymorphonuclear leucocytes, round cells, and 
plasma cells. In parts the reaction had gone on to a 
definite laying-down of fibrous tissue. The mucous 
membrane showed ulceration, and the submucosa was 
much thickened by congestion and cellular infiltration 
(Fig. 4). There were in parts accumulations of poly- 
morphonuclear leucocytes with formation of small 
abscesses. The lymphoid tissue was not hypertrophied. 
The muscle coats showed most markedly the laying down 
of fibrous tissue, but there was also an infiltration with 
leucocytes. This infiltration was most evident in the 
tissue plane between the longitudinal and circular muscle 
coats. The serosa showed thickening with fibrinous 
exudate in which leucocytes were enmeshed. 

In the parts of less acute reaction there was more 
fibrosis and less leucocytic infiltration. The mucous 
membrane was more intact. The striking feature of these 
portions was the presence of giant cells of foreign-body 
type in the tissue plane between the longitudinal and 
circular muscle coats. These giant cells were numerous 
and were found onlyin this plane. They were in close 
relationship to ganglion cells of Auerbach’s plexus which 
appeared to be particularly prominent in these sections 
(Fig. 5). The giant cells contained hard-looking 
crystalline bodies of variable shape and size. In their 
neighbourhood the round-cell infiltration was more intense. 

Everywhere the reaction was attended by great thicken- 
ing of the bowel wall, with encroachment on the lumen. 
There was no pathological evidence of tubercle. The 
sections appeared to be those of non-specific granulomata 
of the small intestine. Sections of the ballooned portion 
showed a marked attenuation but without inflammatory 
reaction. 

Sections of the liver showed a good deal of fatty degenera- 
tion particularly affecting the portal zone, but without 
' inflammatory reaction. In the kidneys there was chronic 
glomerulo-tubular nephritis with acute exacerbation. 


DISCUSSION 


Symptoms and Signs.—This case, although present- 
ing the pathological features of chronic cicatrising 


FIG. 2.— Photograph of a cross-section of the ileum showing 
thickening of its walls and mesentery. 


enteritis, had an abnormal symptomatology owing to 
the patient’s mental state. 

Crohn 19 divided his cases into four clinical types 
which have been adhered to by subsequent authors. 
_ l. Acute intra-abdominal 
uTitation. 

2. Ulcerative enteritis. 

3. Chronic obstruction of the small intestine. 

4. Persistent intractable fistule in the right lower 
quadrant. 


Each of these types has its characteristic symptoms. 
In the first type acute appendicitis is simulated and 


disease with peritoneal 


in this connexion it is noteworthy that appendi- 
cectomy has been performed for the relief of symp- 
toms #5 56; other cases of “acute abdomen” may 
represent the acute stage of this condition.2® 4° In 
the second type the patient complains of colic and 


FIG. 3.—Photograph of a portion of 
constricted and ballodned parts. . 


frequency of bowel movements, and there is usually 
a low-grade constant fever. In the third type 
incomplete obstruction is encountered with violent 
cramps, borborygmi, and occasional attacks of 
vomiting and constipation ; a palpable mass may be 
felt 34 and the obstruction may be complete.? In 
the fourth type intractable fistule follow the operative 
drainage of a supposed appendix abscess.®° 42 It is 
probable that these types represent phases of one 
progressive lesion 1 and that therefore an overlap 
in the symptomatology is to be expected. 

The age-period is worthy of note. Crohn?® 
originally described the condition as chiefly affecting 
young adolescents, but cases have since been reported 
involving all age-groups, even the sixth and seventh 
decade.!° 50 Our patient was aged 63. Rockey 8 
reported four cases in children operated on for 
appendicitis of ages 5, 9, 11, and 19 in which there 
was a hypertrophy of the terminal ileum with 
mesenteric adenitis and in which tuberculosis seemed 
to be excluded. The possibility of a familial incidence 
has been suggested by Crohn,'® who records two 
cases in children of the same parents. 


Diagnosis.—Almost all of the reported cases seem 
to belong to the third group described by Crohn and 
therefore have been reported under the heading of 
chronic cicatrising enteritis. The cicatrisation does 
not usually give rise to a gross form of obstruction, 
and in the absence of a palpable mass the clinical 
picture is often indefinite and the diagnosis difficult 1° ; 
in our case, complicated by a severe mental illness, 
the diagnosis was not made during life. In these 
circumstances the diagnosis is often one by exclusion 
but Galambos and Mittelmann,*! Kantor,4! and 
Weber °4 have described X ray appearances which 
they believe to be typical and diagnostic when the 
terminal ileum is involved. 

The differential diagnosis is usually from neoplasms, 
malignant and benign 4%; the specific granulomata, 
including hyperplastic tuberculosis, lymphadenoma, 
actinomycosis, and syphilis; and the localised 
inflammatory masses associated with chronic infection 
of the appendix and Meckel’s diverticulum.?® 33 


he ileum showing adjacent 


302 THE LANCET] 


DRS. BARBOUR & STOKES: CHRONIC CICATRISING ENTERITIS 


(FEB. 8,.1936 


Chronic’ intussusception!® and twisted ovarian 
pedicle 2° have been simulated. 
/Etiology.—Chronic cicatrising enteritis is not the 


result of any single wtiological factor. It is a par- 
ticular clinical example of granuloma of the intestine 


showing submucosa 
thickened with cellular intiltration and congestion. 


FIG. 4.—Low-power photomicrograph 


of non-specific origin. It is believed that in every 
case an initial factor impairs the vitality of the gut 
wall and allows bacterial invasion from the lumen 
of the gut. The bacterial invaders are probably 
numerous in kind, but all produce a similar type of 
granulomatous reaction. In that sense all the lesions 
are non-specific.’ 

Mock classifies fully all the possible factors pro- 
ducing the local lessening of resistance which is 
followed by the production of these granulomata in 
the alimentary tract. Of these factors some are more 
or less theoretical, others more substantiated by the 
facts of the recorded cases. In the substantiated 
cases foreign bodies and infections appear to be 
outstanding. The former include fishbones, cherry 
pips, fruit cake, sponges in the abdomen, and par- 
ticularly ligatures and sutures from a preceding 
operation. The latter include specific bacterial 
infection (e.g., bacillary dysentery), protozoal infec- 
tions (e.g., amaebic dysentery), and metazoal infections 
(e.g., worms). Diverticulitis and ulcerative colitis 
sometimes precede a localised granuloma. 

In the small intestine the foreign-body factor was 
at first thought to predominate ; preceding operations 
were stressed in the case-histories and suture material 
was incriminated. More recently this factor has been 
found inadequate and suggestions have been made 
that mechanical factors operate either directly on the 
gut or on its blood-supply. Chronic recurrent self- 
reducing intussusception at the ileocacal valve, or an 
upset of local circulatory conditions by an appendi- 
citis, might account for a terminal ileitis, but they 
would not account for lesions higher up in the 
intestine. 

The case recorded here had a history of alimentary 
infection by Entamæba histolytica, BP.  typhosus, 
B. paratyphosus, and Giardia lamblia. There was no 
evidence of foreign body and no abdominal operation 
had been performed. The other possible primary 
factors suggested by Mock and others,’ 534 © such 
as trauma, mechanical interference with the blood- 
supply, and extension of infection from extra- 
alimentary sources, were not found. The involvement 
of small intestine alone would appear to exclude 


Entameba histolytica: the widespread involvement 
of the small intestine is against B. typhosus and 
B. paratyphosus. The giardia infection was present 
up to the time of death and giardia cysts were 
frequently and easily found in the stools. G. lamblia 
is a recognised invader of the small intestine,*® 6 
and attention has recently been directed to the 
widespread lesions caused by this organism in the 
small intestine by Little,47 Lyon and Swalm,‘® and 
Paula e Silva.55 In view of this work it is suggested 
that the giardia infection was the primary cause of 
the granulomata found in this case. 


Pathology.—The pathological lesion in chronic 
cicatrising enteritis tends to be localised and may 
particularly affect the terminal ileum. Its localisa- 
tion may be anywhere in the small intestine and a 
similar condition has been noted in the stomach.® 
The lesion may be multiple. 


The lesion is a chronic inflammation of the wall of 
the gut with considerable stricture of the lumen. 
The inflammation involves the mesentery and the 
lymph glands may be enlarged.?1124 In the case 
reported no lymph nodes were involved. Ulceration 
of the mucous membrane may occur. Ballooning of 
portions of the gut has infrequently been observed.*® 
It was present in this case. 


Microscopically the lesions show a fibroblastic 
reaction with infiltration of polymorphonuclear leuco- 
cytes, round cells, and plasma cells.14 15 24 26 33 35 32 
The inflammation involves all layers of the wall and 
is attended by fibrosis. Giant cells have been 
recorded,}® 11 15 1619243439 sometimes incorporating 
hard crystalline bodies of variable shape and indeter- 
minate origin,® 26 33 53.65 66 although regarded by 
some as of lipoid nature.°® Their restriction to the 
intermuscular plane and juxtaposition to Auerbach’s 
plexus is an outstanding feature of this present case. 
It is suggested that the involvement of Auerbach’s 


Kea 


FIG. 5.—High-power photomicrograph showing the inter- 
muscular plane. Giant cells with crystalline bodies are seen 
adjacent to Auerbach’s nerve ganglion. 


plexus by the inflammatory process accounts for the 
ballooning of portions of the gut. 

The lesions do not appear to have any anatomical 
arrangement and show none of the features of tuber- 
culosis.37 5 Hyperplastic tuberculous lesions of the 
ileum are rare and it is probable that some of the 
reported cases are really non-specific granulomata., 53 65 
In the present case the lesions reach as high as the 


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DRS. BARBOUR & STOKES: CHRONIC CICATRISING ENTERITIS 


[reB. 8, 1936 303 


upper jejunum and a primary tuberculous lesion in 
this situation would be extremely rare. 


The occurrence of metaplasia in the epithelium of 
the inflamed gut has been suggested by Donchess 
and Warren,*‘ and a possibility of early carcinomatous 
change. This would be a further example of malignant 
change occurring at a focus of chronic infection.?? 


Treatment.—Treatment at present consists of excision 
of the affected areas,}! 26343538 with or without a 
short-circuiting operation. The fact that so many 
of the reported cases had been operated on previously 
for appendicitis 15 18 19 21 33 89 53 66 seams to indicate 
the advisability of exploring the terminal and lower 
ileum in all cases of chronic appendicitis that come 
to operation. 


SUMMARY 


(1) A short historical survey of granulomata of the 
intestine is given, with special reference to a group 
involving the small intestine, isolated by Crohn. 
(2) The present case is one of chronic cicatrising 
enteritis and its symptomatology is discussed with 
reference to four clinical types. (3) Diagnosis is 
usually by exclusion. Typical X ray appearances 
have been described when the terminal ileum is 
involved. (4) Aitiologically many primary factors 
may. operate, all producing an infective granuloma 
of non-specific type. It is suggested that the giardia 
infection was the primary factor in the present case. 
(5) Pathologically strictures and dilatations of the 


gut are met with. Microscopically giant cells incor- 


porating foreign bodies of indeterminate origin are 
seen in a picture of chronic inflammation. In the 
present case they are in juxtaposition to the nerve- 
cells of Auerbach’s plexus. (6) Treatment consists in 
excision of the affected parts. : 


Thanks are due to Dr. Edward Mapother for per- 
mission to publish this case; to Dr. P. H. Manson-Bahr 
and Dr. E. ff. Creed for their valuable help; and to Mr. 
Geary for preparing the specimens. The photographs 
-were obtained by the aid of Dr. H. A. Ash. We are 
responsible for the opinions offered. 


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Intestine, Jour. Roy. Army Med. Cor ie 1934, lxiii., 43. 

Fischer, A. W., and Lurmann: ber eine tumor- 
, bildende ulcerése stenosierende und perforierende Ent- 
' giindung a unteren Ileum, Arch. f. klin. Chir., 1933, 

' elxxvii 

Galambos, re eer Mittelmann, W.: Typical and Atypical 
Terminal Lleitis, Amer. Jour. Dig. Dis. and Nut., 1935, 
ll., 


Ileocolitis, Surg., Gyn., 


. Garvin, J `D.: Hyperplastic Tuberculosis of the Duodenum 


and Terminal Ileum, Jour. Amer. Med. Assoc., 1930, 
XCV., 1418. 


L., and Oppenheimer, G. D. Non-specific 
Eamets of the Intestine, Ann. of Surg., 1933, xeviii., 


Infectious Granulomata, Med. Jour. and Rec., 
32, CXXXV. , 390 


. Gordon, D.: Non- -specific Granulomata of the Ileum, Ann. 


of Surg., "1933, xcevii., 130 
Ameebic Granulomas of the 


Jour. Amer. Med. Assoc., 1931, xcvii., 


Unspezifische Entzündung des Ilco- 
coecums, Münch. med. Woch., 1934, lxxxi., 479. 

Bell, G. H., and Brunn, H.: Chronic Cica- 
trising Enteritis, Surg., Gyn., and Obst., 1933, lvii., 637. 
Regional Ileitis, Clinical and 
Pathological Entity, New Eng. Jour. Med., 1933, ccix., 


Large "Bowel, 
166 


. Jackman, W. A.: ee at Hypertrophic Enteritis, Brit. 


Jour. Surg., 1934, xxii i 
Regional Ileitis—Its X Ray Diagnosis, 
Jour. Amer. Med. Assoc., 1934, ciii., 2016. 


. Kapel, O. : Ulceröse stenosierende Pnrzunaung Aes unteren 


Ileum, Deut. Zeits. f. Chir., 1934, cexliii. 
King, E. L.: Benign Tumours of. the ea: Surg., 
Gyn., and Obst., 1917, xxv., 54. 
Über einfach entzündliche Stricturen des Dick- 
darmes, Arch. f. klin. Chir., 1903, lxx., 876. 
Infective Granuloma of the Stomach, Ann. 
of Surg., 1935, cii., 30. 
~ Des tumeurs inflammatoires paraintestinales, 
Bull. et mém. Soc. Chir. de Paris, 1908, xxxiv., 9. 
Little, A. H.: sanblan, New Orleans Med. and Surg. 
Jour., 1935, Ixxxvii., 
Giardiasis, Amer. 


Lyon, B. B. Y., and EN W. A.: 
Jour. Med. Sci., 1925, clxx., 348. 
Manson-Bahr, P. H. : Manson’s Tropical Diseases, London, 
Regional Ileitis, Ann. of Surg., 1935, cii., 
. E.: Infective Granulomata, Surg., Gyn., and 
Obst., 1931, lii., 672. 
Molesworth, H. W. "Le: ‘Granuloma of Intestine with Stenosis 
of the Ileocæcal Valve, Brit. Jour. Surg., 1933, xxi., 370. 


Moschcowitz, E., and Wilensky, A. 0.: Ni on-specific 
Granuloma of the Intestine, Amer. Jour. Med. Sci., 1923, 


clxvi. 

: Mimicry of Malignant Disease in the 
Large Bowel, Edin. Med. Jour., 1907, xxi., 228. 

Paula e Silva: Giardiasis, Amer. Jour. Dig. Dis. 
Nut., 1935, ii., 350. 

Regional Tleitis, New Eng. Jour. Med., 


Robson, A. W. M.: Abdominal Tumours Simulating 
Malignant Disease, ‘Brit. Med. Jour., 1908, i., 425 

Rockey, E. W.: Thickening of the Terminal Ileum with 
Mesenteric Adenitis in Children, Northwest Med., 1933, 


xxxii., 145 
Hypertrophic Jejuno- -lleitis—Tuberculous or 


and 


1934, ccxi., 457. 


Non-specific, Jour. Mount Sinai Hospital, 1934, i 
Senn, N.: Principles of Surgery, Philadelphia, 1895. 
J. M., and Russum, B. C.: Non-specific Granu- 
lomata of the Gastro-intestinal Tract, Nebraska State 
Med. Jour., 1935, xXx., 296. 

: Tropical Diseases, London, 1929, p. 176. 
Über entzündliche Dickdarmgeschwülste, 
Ergeb. der Chir. u. Orth., 1920, xiii., 211. 

Regional Ileitis—Its Roentgen Diagnosis 
(Discussion), Jour. Amer. Med. Assoc., 1934, ciii., 2020. 
Non-specific Granuloma of the Intestine, 
Med. Jour. and Rec., 1932, CXXXV., 445. 

and Moschcow itz, E.: Non-specific 

Granuloma of the Intestines, Amer. Jour. Med. Sci., 

1927, clxxiii., 374. 

Wiliams, C. Inflammatory Tumours of the Small Intes- 
. tine, V irginia Med. Monthly, 1933-34, 1x., 728. 
Wright, A. D.: Trans. London Med. Soc., 1935, lviii., 94. 


304 THE LANCET] 


ACRIFLAVINE AS A URINARY 
ANTISEPTIC 


By Eric W. ASSINDER, M.D. Birm. 


DIRECTOR OF THE VENEREAL DISEASES DEPARTMENT, 
THE GENERAL HOSPITAL, BIRMINGHAM 


ACRIFLAVINE has been used as a general and urinary 
antiseptic for some years; its action is directly anti- 
septic, not depending upon excessive acidity or 
alkalinity of the urine, although higher antiseptic 
values are obtained undoubtedly in alkaline than in 
acid urine. In the venereal diseases department of 
the General Hospital, Birmingham, it has’ been used 
intravenously in the routine treatment of acute 
gonorrhoea in 4985 cases. Numerous other so-called 
urinary antiseptics have also been used but in none 
has the improvement been so great as with acriflavine. 

The application of this drug has not been confined 
to gonococcal infection ; many cases of Bacillus coli 
infection of the urinary tract have also been treated 
successfully. 

Similar reports have been made from time to time 
by other observers. In 1921 Davis! stated that 
“by a study of 204 aniline dyes, with only two 
(proflavine and acriflavine) was it possible to demon- 
strate the secretion of antiseptic urine following 
intravenous injection.” In 1926 Jausion and Vaucel ? 
claimed very successful treatment of gonorrhaa with 
intravenous acriflavine alone. Further, in 1932 
Davis and Sharpe? said that “‘acriflavine exerts an 
antiseptic action in normal urine which is uniform 
and consistent to a surprising degree.” They also 
found that alkalinity is ‘‘ quite essential for consistent 
and dependable results.” 

It should be stated that acriflavine as a urinary 
antiseptic must not be looked upon as the sole weapon 
in treatment; one must realise that the urinary 
tract is not a simple tube, but one into which there 
are many glandular openings, especially the ducts 
of the prostate and urethral glands. Obviously it is 
sometimes impossible to reach the real site of infec- 
tion with a urinary antiseptic, although one may 
cleanse the surface of the tract temporarily, and it 
seems desirable, therefore, in all cases of urinary 
infection to attempt to increase a patient’s resistance 
to a particular organism by, for example, vaccine 
treatment. 


GONORRHG@A 


As a routine all cases of acute gonorrhea in the 
male have had intravenous injections of 2—4 c.cm. 
of a 2 per cent. solution of acriflavine in sterile dis- 
tilled water. Ten such injections have been the 
standard course (one injection being given every 
second or third day). The patient has been instructed 
not to take large amounts of fluid, so that a higher 
concentration of acriflavine shall be obtained in the 
urine. The necessity for this precaution is well 
brought out by the experiments of Miller and Chu.4 
(In accordance with what has been stated above, 
supplementary treatment, such as vaccine, irrigation, 
and potassium citrate grs. 60 t.d.s. to ensure an 
alkaline urine, has also been given.) 

The intravenous route has always been chosen in 
order to get the immediate and maximum effect 
upon the urinary tract. In my opinion, one does 
not get such good results with acriflavine by mouth, 
and it seems more than probable that a large part 
of the acriflavine given by mouth will not be excreted 
through the kidneys at all. 


DR. E. W. ASSINDER: ACRIFLAVINE AS A URINARY ANTISEPTIC 


[FEB. 8, 1936 


Results—In the 4985 cases of acute gonorrhea 
which have been given acriflavine, perhaps the most 
noticeable feature has been the short duration of 
the urethral discharge ; as a rule the discharge ceases 
in 7-10 days, which is very much less than is usual 
in the average case treated by irrigation alone. If 
the posterior urethra is already affected, acriflavine, 
which is being continuously excreted into the bladder, 
helps to clear the cystitis; while if the posterior 
urethra is not affected, the acriflavine apparently 
protects it. 

It is obviously not possible with such a large 
number of cases to give accurate percentages of cure 
within a particular time; for many of the patients 
will not attend for tests of cure. But the very 
decided impression has been that the duration of the 
actual infection, like the duration of the initial dis- 
charge, has been much shortened by acriflavine. 


B. COLI INFECTIONS OF THE URINARY TRACT 


It is quite common for cases of B. coli infection to 
reach a venereal diseases clinic, sent up as possible 
gonococcal infections, perhaps because of epididy- 
mitis or frequency of micturition. Table I. shows 
the results in consecutive cases of bacilluria treated 
with acriflavine and also with an autogenous vaccine. 


TABLE I 
B. coli Bacilluria treated with Acriflavine and Autogenous 
Vaccine 
Duration 
a i Number of ; 
Case. | “trouble” | injections of | Clinical | Pathological 
before cot cent, result, (cultural). 
treatment. IRS IOGs 
1 2 months. 8 x 4c¢c.cm Cured Cured. 
2 4 9 10 x 4 9 | 99 »> 
3 10 days. 8x3 55 ee a5 
4* 3 months. 8x4 ,, ee B. coli still 
present. 
3 3 29 10x 2 ,, ,» Cured 
6 1 year. 10x 4 ,, os i oe 
i? 5months.; 20x 4 ,, ss Mi 
8 3 weeks. 30x 4 ,, No symp- B. coli still 
toms. present 
9 2 days. 8x4 ,, |! Cured. Cured. 
10* 7 years. 28x 4 ,, ' Failure. B. coli still 
f present. 
11 3 weeks. $Sx4 ,, Cured. Cured. 
12 4 days. 6x1 ,, RA Se 


+ Case 4 developed jaundice; no more acriflavine given. 

* Case 7.—b. colt still present after first course of ten 
injections. 

* Case 10.—Patient relapsed after being clear of B. coli in 
urine and clinically well. 


These results are very strong evidence of the 
value of acriflavine, and compare favourably with 
those obtained by the use of a ketogenic diet ë or 
mandelic acid.® 

EXPERIMENTAL 


Acriflavine can be showed to have an extra- 
ordinarily high antiseptic value in regard to the 
gonococcus. I find that a dilution of l in 20,000 
will kill the gonococcus in fifteen minutes. Its 
action upon such organisms as B. coli is, as one 
would expect, much less; some strains are only 
killed in thirty minutes in a dilution of 1 in 200. 

It seems reasonable to expect that the urine of a 
patient who is receiving an antiseptic for a urinary 
infection should show definite antiseptic properties. 
In order to test this property, the urine of two 
patients was examined :— 


(a) A patient who was given 3c.cm. of acriflavine (2 per 
cent.) intravenously and passed urine within half an hour. 
(b) A patient who had been on hexamine grs. 10 and 
ammonium chloride grs. 15 t.d.s. for a week. 


. 


THE LANCET] 


DR. PARKES WEBER: HEPATIC CIRRHOSIS 


[FEB. 8, 1936 305 


Four cubic centimetres of each of these urines were 
added to 24-hour cultures of gonococci; the sus- 
pensions of these gonococci in the urines to be tested 
were then put in the incubator at 37° C., and to each 
was added three drops of serum to ensure growth if 
antiseptic action had not taken place. Subcultures 
were then made at intervals of one, two, three, and 
four hours. The results are seen in Table II. 


TABLE II 


Growth of Organisms in Urine of Patients receiving (a) Acri- 
flavine and (b) Hexamine and Ammonium Chloride 


Urine A ; PA + — = y 
Urine B—pH 5'4 (after 
addition of serum) te + + + + 


after 48 hours’ 


+ = Growth of gonococci 
- = incubation. 


No growth of gonococci 


The tests were repeated on other patients with the 
same results and appear to confirm the clinical 
findings of the value of acriflavine as a urinary 
antiseptic. 


PREPARATION OF ACRIFLAVINE 


For nearly five years the acriflavine used in the 
above series was very satisfactory from a tolerance 
standpoint. There were a few cases of dermatitis on 
parts exposed to sunlight, such as face and hands, 
and also an occasional case of toxic jaundice; this 
was in accord with the findings of Jausion and Vaucel ? 
and many others. In 1932-33, however, jaundice 
began to occur with great frequency, and it was 
quite obvious that it would not be possible to con- 
tinue with the drug, at any rate in the same dosage 
as previously, although it seemed to be of great value 
in the treatment of urinary infections. Other observers 
were obviously troubled in a similar way, and Hughes 
and Birch 7 in 1933 stated that they had abandoned 
flavine therapy owing to toxic effects. Correspon- 
dence in THE LANCET in 19318 suggested that the 
acriflavines which were being used were not chemically 
identical. 

Such contradictory experiences forced us to the 
conclusion that the acriflavine used in 1928 differed 
in some important way from that used in 1933, and 
in 1933-34 the products of different firms were tried. 
The prevalence of jaundice nevertheless continued. 

In February, 1935, Imperial Chemical Industries 
Ltd., Dyestuffs Group, were asked to investigate 
the matter, and they have succeeded in supplying an 
acriflavine which is apparently non-toxic.* Since 
June, 1935, 300 patients have been given this new 
product intravenously according to the method 
described above, and in only 2 cases has there been 
any evidence of liver damage: in these there was 
transient jaundice for 48 hours only, and this may 
have been due to other causes. Every case has been 
investigated for signs of hepatic damage, and before 
each injection the urine has been ‘examined for 
urobilinogen ; this has been conspicuously absent 
whereas in 1933 it was found with great regularity. 

In my opinion, patients who are receiving acri- 
flavine should always be tested for the presence of 
urobilinogen in the urine and use of the drug should 
be discontinued if it is found. 


* This preparation, Acriflavine (Intravenous), may be obtained 
from The British Drug Houses Ltd. 


(References at foot of next column) 


INBORN AND FAMILIAL TENDENCY 
TO THE DEVELOPMENT OF 


HEPATIC CIRRHOSIS * 
By F. PARKES WEBER, M.D. Camb., F.R.C.P. Lond. 


SENIOR PHYSICIAN TO THE GERMAN HOSPITAL, LONDON 


CASES of hepatic cirrhosis in children, not due to 
alcohol or congenital syphilis or any known cause of 
cirrhosis, are usually regarded as the manifestation 
or one of the manifestations of a congenital- 
developmental disease, and the occasional familial 
incidence of cirrhosis has often been adduced in 
support of this view. In this paper I shall shortly 
discuss the data in favour of there being an inborn 
tendency to hepatic cirrhosis (a congenital tissue or 
organ inferiority of the liver, as Prof. Brouwer would 
say, destined to manifest itself by obvious changes in 
postnatal life, with or without known exciting causes), 
and shall arrange my remarks under two headings : 
(I.) examples of the familial incidence of hepatic 
cirrhosis, in which the cirrhosis has not been due to 
any known exciting cause, such as alcohol or syphilis, 
or in which an inborn familial tendency to the disease 
may be presumed because an exciting cause such as 
alcohol, though present in one of the affected members 
of the family, was absent in others; (II.) examples 
of hepatic cirrhosis accompanying and probably con- 
stituting a part of acknowledged diseases of the 
congenital-developmental class. 

But first I must explain what I mean by diseases 
of the congenital-developmental class. Under con- 
genital-developmental diseases and abnormalities 
I include all truly inborn abnormalities and consti- 
tutional diseases, whether obvious at birth or 
manifesting themselves later at various ages. Amongst 
the more easily recognised ones are: hemophilia ; 
hemolytic (acholuric) jaundice, and some other 
familial abnormalities of the blood (and hemopoietic 
system); alkaptonuria, congenital porphyrinuria, and 
other inborn abnormalities of metabolism, such as 
Gaucher’s disease, the Niemann-Pick disease, amau- 
rotic family idiocy, familial cutaneous xanthomatosis, 
the Hand-Schiler-Christian lpoid-granulomatosis, 
von Gierke’s hepatomegalic glycogen-storage disease, 
&c.; renal glycosuria (apparently harmless in itself) ; 
familial optic nerve atrophy and other diseases, dys- 
plasias and dysbiotrophic conditions in which the eyes 
are affected ; numerous hereditary diseases and dys- 
plasias of the skeletal (bone and cartilage), muscular, 
vascular, and nervous systems; and many minor 
conditions, including inherited abnormalities of the 
skin and its appendages; food-idiosyncrasies and 
allergic peculiarities. It is almost certain that many 


*Some remarks on this subject, which are here amplified, 
were made by Dr. Parkes Weber in the discussion on Prof. 
B. Brouwer’s paper on the Spleen, the Liver, and the Brain, 
at the meeting of the section of neurology of the Royal Society 
of Medicine on Jan. 16th, 1936. 


(Continued from previous column) 


DR. ASSINDER: REFERENCES 


. Davis, E.: Amer. Jour. Med. Sci., 1921, clxi., 25 
: a H., and Vaucel, M.: Presse méd., Feb. Tah 1926, 


z Jour. Amer. Med. Assoc., 1932, 
97 

F., and Chu, C. C.: Amer. Jour. Surg., 1934, 
xxiii., 


457. 
Clark, A. L.: Proc. Staff Meet. Mayo Clin., 1931, vi., 605. 
‘ Rosenheim, M. L.: THE LANCET, 1935, i., 1032. 
Hughes, E., and Birch, C. A.: Ibid., 1933, ii., 633. 
. Correspondence, Ibid., 1931, oe 218, 269, and 323. 
F 


ONNA Ae V Ne 
ad 
j 
peo 
ET, 
oO 
od 


306 THE LANCET] 


DR. 


diseases, which are rarely obviously inherited—such 
as hypertrophic pyloric stenosis (which may occur 
occasionally in twins or recurrently in more than one 
child of the same parents) and Hirschsprung’s megalo- 
colon congenitum and aortic isthmus stenosis—also 
really belong to the group under consideration.? All 
inborn constitutional diseases belong to the congenital- 
developmental group, even when their manifestations 
are delayed till long after birth, till puberty, middle 
age, or even later. It is because the manifestations 
are often delayed till long after birth that I prefer 
to speak of this group of diseases as the congenital- 
developmental group, and not as the congenital group. 

Known hereditary or familial incidence may often 
be absent in diseases and abnormalities of the 
congenital-developmental class, but its occasional 
presence is sufficient to stamp the disease or 
abnormality as belonging to the class. Thus, the 
puzzling disease “lipodystrophia progressiva ”’ appar- 
ently belongs to the class and seems to be a “ dysbio- 
trophy ”? (if I may use the term, instead of “ abio- 
trophy ’’ of Gowers) of the subcutaneous fat over the 
head and upper part of the body, chiefly affecting 
females. L. Barraquer-Ferré ? has lately narrated 
the case of a female whose mother and maternal 
grandmother were likewise affected. The disease, 
though potentially present at birth, may be “ delayed ” 
in its appearance long enough to allow of a female 
not being prevented by her shrunken death’s-head-like 
face from finding a mate. Some would probably 
prefer to express themselves by saying that the 
lipodystrophia was potentially present at birth as a 
congenital tissue inferiority (Gewebsminderwerdigkeit), 


I.— EXAMPLES OF THE FAMILIAL INCIDENCE OF HEPATIC 
CIRRHOSIS, NOT DUE TO ANY KNOWN EXCITING 
AGENT OF TIIE DISEASE 


Various cases of familial hepatic cirrhosis have 
been published. 

At the Royal Society of Medicine (section for the 
study of disease in children) in February, 1934, Prof. 
F. Langmead? demonstrated cirrhosis of the liver 
with splenomegaly in three brothers, aged 9, 11, 
and 13 years respectively. In the boy, aged 11 years, 
the diagnosis was subsequently confirmed by micro- 
scopic examination (‘‘ biopsy ”’), which showed typical 
multilobular cirrhosis of the liver. Langmead referred 
to Byrom Bramwell’s account (1910) of a family with 
hepatic cirrhosis.4 Byrom Bramwell's patient, a boy, 
aged 9 years, had ascites, oedema, jaundice, fever, 
and a large liver, and the necropsy showed typical 
“ hob-nailed ” cirrhosis. Three other members (girls) 
of the family of seven apparently died from hepatic 
cirrhosis. Langmead also mentioned J. Szanto’s > 
three cases of multilobular cirrhosis of unknown 
origin, with splenomegaly, in a family of ten. In 
one of these cases the diagnosis of hepatic cirrhosis 
was confirmed by necropsy (a boy, aged 15 years) 
who likewise had genital hypoplasia. 

F. J. Poynton and W. G. Wyllie ê in 1926 described 
two cases of congenital familial hepatic cirrhosis of 
unknown etiology in a brother and sister, aged 9 years 
and 4 years respectively, but the diagnosis of von 
Gierke’s hepatomegaly (hepatomegalia glycogenica) 
was subsequently suggested.? 

In 1903 I recorded the necropsy on a girl, aged 
14 years, with biliary cirrhosis (‘‘ Tanot’s disease ”) 
of the liver.8 Ier sister was said to have died at the 
age of 19 years with similar symptoms. J. Dreschfeld® 
met with hypertrophic hepatic cirrhosis in two 
brothers, one of them was a drinker and the other 
temperate. Sir William Osler!® mentioned two 


PARKES WEBER: HEPATIC CIRRHOSIS 


[FEB. 8, 1936 


brothers in America affected with Hanot’s cirrhosis. 
Boinet !! wrote of a family in which the father and 
two children had biliary cirrhosis (Hanot’s type) and 
three other children had enlarged spleens. J. Finlay- 
son !2 spoke of three brothers and a sister, two of 
whom had cirrhosis of Hanot’s type; another had 
enlargement of the liver and spleen, with icterus, 
and the remaining one had slight jaundice. Hasen- 
clever ?3 recorded an instance of three members of 
one family, a boy and two of his sisters, having 
typical hypertrophic biliary cirrhosis. 


II.—EXAMPLES OF HEPATIC CIRRHOSIS ACCOMPANYING 
AND PROBABLY CONSTITUTING A PART OF 
ACKNOWLEDGED DISEASES OF THE CON- 
GENITAL DEVELOPMENTAL CLASS 


Progressive lenticular degeneration (Kinnier Wilson's 
disease).—W ilson’s disease is a chronic progressive 
degeneration of the lenticular nuclei of the brain 
combined with a cirrhosis of the liver, which has 
been usually latent during life and first discovered 
at the post-mortem examination. Familial incidence 
in this rare disease has been emphasised by Wilson 
himself, as well as by later authors. The evidence 
seems to me to point to the disease being most pro- 
bably a combined *‘dysbiotrophy ” of the lenticular 
nuclei and the liver, and the hepatic constituent of 
the combined condition in some cases does give rise 
to obvious clinical symptoms so as to be recognised 
as a form of familial cirrhosis even during life.!4 In 
some cases the lenticular nuclei or the liver may be 
only slightly affected, but it seems very unlikely that 
any of the above-mentioned cases of familial hepatic 
cirrhosis in children were of the nature of incomplete 


-Wilson’s disease with the liver only affected. 


IITwamochromatosis.—The occurrence of hepatic cir- 
rhosis (‘‘ pigmentary cirrhosis of the liver”) as a part 
of hemochromatosis or “‘ bronzed diabetes” is too 
well known to need insistence. The site of the 
greatest visceral changes varies in different cases, 
and the characteristic liver changes may occur even 
without very marked cutaneous pigmentation. The 
occasional familial incidence of the disease has been 
pointed out by J. II. Sheldon,?> R. D. Lawrence,!® 
and others, so that hemochromatosis must be classed 
amongst the rare inborn abnormalities of meta- 
bolism, such as alkaptonuria, pentosuria, cystinuria, 
congenital porphyrinuria, the inborn abnor- 
malities of lipoid metabolism, &c., which I have 
above referred to. Indeed, a special analogy may be 
pointed out in regard to von Gierke’s hepatomegale 
glycogen-storage abnormality, in as much as in the 
latter disease different viscera (e.g., the heart) may 
be specially involved in different cases. 

Erythremia.—Though I think that erythremia of 
the Vaquez-Osler type is, like the leukemias, due to 
a neoplastic change in the bone-marrow, a familial 
incidence of the disease has been reported in quite a 
number of cases.17 It may be presumed to develop 
(under the action of unknown agents) in individuals 
having an inborn constitutional predisposition. 
Hepatic cirrhosis is a recognised though only ocea- 
sional complication of erythremia, and seems in 
some cases to occur independently of any special 
agent such as phenylhydrazine, which may have been 
used in the treatment.!8 

Telangiectasia of the Osler type —Very many valu- 
able papers have been written on this disease, includ- 
ing regular monographs with copious bibliographies, 
by If. I. Goldstein, who was, I believe, the first to 
call it the ‘* Rendu-Osler disease,” by which name 
it is now known in France. In many cases, though 


THE LANCET] 


in far from all, there has been striking hereditary . 


incidence. I was fortunate enough to be able to 
describe a typical familial example in 19071°®; and 
in 192429 I alluded to the possible analogy and 
association of the telangiectatic condition of the 
skin and mucous membrane of the nose and mouth 
with certain hzemorrhagic telangiectatic conditions 
in the stomach, intestines, kidneys, or lungs. In 
fact, it is quite possible that in rare cases the typical 
cutaneous telangiectases may be altogether absent. 
Very few complete post-mortem examinations have 
been published, but recently Ludo van Bogaert and 
J. H. Scherer?! found hepatic cirrhosis present in a 
typical familial case of the Rendu-Osler type of 
telangiectasia. From what I remember of the pro- 
gress of the patient I described in 1907 there may 
well have been visceral disease and perhaps hepatic 
cirrhosis present at the end. I have been told of an 
as yet unpublished case in which hepatic cirrhosis 
was found at the post-mortem examination; so it 
was also in a remarkably atypical case, the liver and 
spleen from which were recently (Jan. 13th, 1936) 
demonstrated by Mr. R. Davies-Colley at the Medical 
Society in London. The telangiectasia in this 
disease must be regarded as due to a congenital- 
‘developmental dysplasia of the small blood-vessels, 


potentially present at birth, though often not mani-. 


festing itself by obvious changes till after puberty. 
What is the relationship of the hepatic cirrhosis, 
when present? Is it the result of an associated 
developmental dysbiotrophy of the liver—i.e., a 
congenital tissue or organ inferiority in the sense 
intended by Prof. B. Brouwer and others? The 
subject is complicated by the well-known fact that 
in advanced or active hepatic cirrhosis there is a 
tendency for the patient to develop cutaneous telan- 
giectases on the face and hands, notably those of the 
spider-like type, as I have had occasion to observe. 


REFERENCES 


1. Large parictal foramina in the skull may certainly be 
hereditary, if rarcly so. ‘Cf. Greig. D. M.: Edin. Med. 
Jour., 1927, n.s., xxiv., 629; Weber, Fi P., and 
Schwarz, E.: Proc. Roy. Soc. Med., 1935—36, XXİX., 122; 
Goldsmith, W. M.: Jour. of Heredity, 1922, xiii., 69. 

. Barraquer-Ferré, L.: Presse méd., 1935, xliii., 1672. 

. Langmead, F.: Proc. Roy. Soc. Med., 1934, xxvii., 939. 

. Bramwell, B.: Clin. Studies, 1910, viii., 347. See also 
later paper by Byrom Bramwell (Edin. Med. Jour., 1916. 
n.s., xvii., 90) where he suggests that such cases of 
familia] cirrhosis of the liver may be allied to Wilson’s 
progressive lenticular degeneration. 

5. Szauto, J.: Monats. f. Kinderheilk., 1927, xxxvi., 393. 

6. PONT F. J., and Wyllie, W. G.: Arch. Dis. Childhood, 

, l. 
1180. 


He es DO 


T. Ellis, R. W. ‘B.: Proc. Roy. Soc. Med., 
8. Weber, F. P.: Edin. Med. Jour., 
9. Precor id; J.: 


1935, xxviii., 
1903, n.s., Xiv., 114. 


Principles and Practice of Medicine, London, 
1905, 6th cd., p. 561. 

11. Boinet: Arch. gén. de méd., Paris, 1898, clxxxi., 385. 

12. Finlayson, J.: Glasgow Hosp. Rep., 1899, ii., 39. 

13. Hasenclever: Berlin klin. Woch., 1898, xxxv., 997. 

14. Cf. The cases described by Stanley Barnes (Proc. Roy. Soc. 
Med., 1924, xviii., Sect. Neurol., p. 34), in one of which 
(Case 3) the hepatic atYection seems to have preceded the 
lenticular affection. Cf. also Lhermitte and Muncie: 
La Cirrhose familiale splénomegalique: forme hépatique 
de la dégéneration hépato-lenticulaire, Presse méd., 
1929, xxxvii., 1495. Compare, however, Lithy, F.: 
Deut. Zeits. f. Nervenheilk., 1932. exxiii., 101; and 
Siemerling, E., and Jakob, A.: Ibid., p. 182. 

15. Sheldon, J. Quart. Jour. Med., 1927, xxi., 1233; and 
THE LANCET, 1934, ii., 1031. 

16. Lawrence, R. D.: THE LANCET, 1935, ii., 1055. 

17. Regarding literature on familial incidence of erythremia, 
see Weber, F. P.: Med. Press and Circ., 1927. cixxv., 

Curschmann, H.: Act. Med. Scand., 1923, lvii., 
228; Naegeli, O.: Jahreskurse für drztl. Fortbildung, 
1934, p. 50; Hirschfeld,.H.: Neue Deutsche Klinik, 
Klin. Fortbildung, 1935, Ergiinzungsband III., p. 514. 

18. Weber, F. P.: Case of Erythremia, with Jauudice, Hepatic 
Cirrhosis, and Hwmatemesis, THE LANCET, 1933, i., 800. 

19. Weber, F. P.: Ibid., 1907, ii., "160, 

20, Weber, F. P.: Brit. ‘Jour. Child. Dis. , 1924, xxi., 198. Sir 
William Osler’s first paper was published in the Johns 
Hopkins Hosp. Bull., 1901, xii., 333. 

21. van Bogaert, L., and Scherer, J. H.: Ann. de méd., 1935, 
xXx3xviii., 290. 


DR. PAUL NIEHANS : HYPERTROPHY OF THE PROSTATE 


Med. Chronicle (Manchester), 1896, n.8., 


[FEB. 8, 1936 307 


MODERN VIEWS ON HYPERTROPHY 
OF THE PROSTATE 


By PauL Nrenans, M.D. Zürich 


SURGEON AND UROLOGIST (SWISS MEDICAL FEDERATION), 
CLARENS-MONTREUX, SWITZERLAND 


THE prostate is a complex gland situated beneath 
the orifice from which the bladder is emptied and 
including the prostatic sinus (uterus masculinus). 
It is composed of tubular-gland tissue embedded 
in a stroma of connective tissue and unstriped muscle- 
fibres. The prostate increases in size with age, and 
may hinder the evacuation of the bladder and even 
lead to retention of urine. 

In adenoma there is an increase in the glandular 
tissue and the prostate is enlarged and soft. In 
myoma, muscular tissue predominates. In fibrous 
degeneration the prostate is of a firm consistence 
and not always enlarged. In hypertrophy these 
three tissue elements are met with in varying 
proportions. 

According to the latest statistics, about a third 
of men aged 60 years and upwards suffer from the 
prostate and for a long time treatment has been 
sought to cure or relieve them, 


Historical 


The first description of hypertrophy of the prostate 
dates from the sixteenth century. On the ground 
that hypertrophy of the prostate is a manifestation 
of old age closely related to the sexual function, 
surgeons have long endeavoured to cope with it 
through the medium of the genital system. In 
1884 Lannois, in France, suggested castration, 
but although the clinical results were satisfactory 
(Burkhard claimed success in 69-2 per cent., Cabot 
83-6 per cent., and White 87-2 per cent.) the psycho- 
logical reaction and ensuing cachexia were so alarming 
that the succeeding generations of surgeons abandoned 
this method of treatment. Only in veterinary 
surgery is hypertrophy of the prostate dealt with 
by means of castration. Unilateral castration 
(Albarran, Motz, Pavone) does not lead to any 
improvement. Harrison in 1893 substituted for 
castration section of the vasa deferentia, but without 
obtaining any results. Later Bier, also unsuccess- 
fully, igatured the vessels leading to the testicle. 

As a result of advances in surgical technique, 
prostatectomy became at the beginning of the present 
century the routine treatment of prostatic obstruction, 
and for a time interest in other methods of treatment 
was lost. It was revived when Romeis reported a 
marked reduction in the size of the prostate of a 
man of 68 following the implantation of the testicle 
of a young man of 22. Since then the close connexion 
between prostatic hypertrophy of old age and 
diminution in the internal secretion of the testicle 
has been confirmed by many observations on animals. 

Experimentally, Steinach succeeded in greatly 
increasing the internal secretion of the testis by. 
blocking “the external secretion, but when bilateral 
ligature of the vas deferens was applied to prostatic 
enlargement the results were negative. In 1927 I 
endeavoured to influence prostatic hypertrophy 
by ligature of the efferent ducts where they emerge 
from the testis at the level of the head of the 
epididymis. This produces the maximum increase 
in the internal secretion of the testis (Steinach). 
The attempt was more successful, the size of the 
prostate being diminished in the majority of cases. 


308 THE LANCET] 


DR. PAUL NIEHANS: HYPERTROPHY OF THE PROSTATE 


[FEB. 8, 1936 


In 1933 Landau discovered in cats a constant 
sympathetic ganglion situated in the connecting 
capsule surrounding the efferent ducts in the head of 
the epididymis. This corresponds to the point where 
the vasa deferentia penetrate the posterior surface 


of the testis and is the site of my ligature. Nicod 
found a ganglion in man at the same point. Landau 


and Heitz-Boyer are both of the opinion that the 
action of the ligature on the prostate is of a reflex 
nature, while I} believe it to act through the 
endocrine system. 

In 1933 Laqueur and van Cappellen published the 
results obtained in hypertrophy of the prostate by 
daily injections of 4-20 units of testicular hormone 
(IIombreol). In the same year Lacassagne adminis- 
tered 500 units a week of the hormone of the female 
sex gland (cstrin) to male mice for a period of 
five months and observed a considerable development 
of the posterior lobe of the prostate, retention of 
urine, and secondary hydronephrosis. His observa- 
tions were confirmed in 1934 by Burrows and 
Kennaway. Lacassagne and de Jongh also made the 
interesting observation in 1933 that injections of 
benzoate of folliculin (cestrin) in young mice, in normal 
adult mice, and castrated adult mice produced a 
eanceroid epithelial proliferation of: the posterior 
lobe of the. prostate, which proved fatal in about 
six weeks. In 1934 Courrier and Gros asserted that 
they found marked enlargement of the prostate and 
seminal vesicles in monkeys treated with folliculin 
and at the same time an extraordinary development 
of the unstriped muscle of these organs. In the 
following year there appeared very interesting 
articles on the enlargement and alteration of the 
prostate and seminal vesicles obtained by injecting 
cestrin into monkeys (Parkes and Zuckerman) and 
into rats (Laqueur and de Jongh). 


Experimental Work on Animals 


The fact that hypertrophy of the prostate has 
been observed in monkeys, dogs, and rats has made 
it possible to throw light on the subject by means 
of animal experiments. Long ago John Hunter 
proved that when castration was carried out in young 
animals the prostate did not develop, and that 
after the operation in adult animals it atrophied. 
Subsequent work has shown that the prostatic secre- 
tion stops 53 days after removal of the testicle (Gley, 
Pézard), Tho same occurs after a severe lesion of the 
testicles produced by radium or X rays. When 
Lower caused anæmia of the testicles by ligature of 
the arteries he obtained not only a pronounced 
degeneration of the tubular elements and the inter- 
stitial cells, but also a secondary atrophy and sclerosis 
of the prostate. 

All these experiments show that the prostate 
atrophies and degenerates as soon as the influence 
of the testicles is removed by castration, by the action 
of radium and X rays,or by the cutting off of the blood- 
supply. Lower found that when he subjected tho 
sex glands of rats or dogs to the influence of small 
doses of radium or X rays the testicles underwent 
a 50 per cent. reduction in size and weight, the 
tubules being completely destroyed, but the interstitial 
cells of Leydig which are more resistant to radiation 
increased in number. Associated with these changes 
there occurred an enlargement of the prostate and 
seminal vesicles. Exactly the same results could 
be obtained from bilateral operative cryptorchism, 
that is to say, returning the testicles into the animal's 
abdomen. 


1 Schweiz. med. Woch., 1934, lxiv., 557. 


These two experiments prove that destruction of 
the germinal epithelium and proliferation of Leydig’s 
cells lead to hypertrophy of the prostate. After the 
vasa deferentia of rats and dogs had been ligatured 
without damaging the blood-vessels Lower reported 
that the testicles, prostate, and seminal vesicles 
showed no change after several months’ observation. 
He therefore concludes that occlusion of the vas 
deferens does not have any influence on the testicles 
or prostate. 

Steinach, on the other hand, claimed that vaso- 
ligature enabled an old animal which had previously 
micturated with difficulty to empty its bladder, 
and Slotopolsky stated that after Steinach’s ligature II. 
the old germinal epithelium disappears but is replaced 
by a newly formed germinal epithelium. From this 
we can infer that the renewal of the germinal epithelium 
and reabsorption of its secretion by the circulating 
blood are followed by a shrinkage of the hyper- 
trophied prostate. A variety of hormones has been 
used experimentally on animals in order to study their 
action on the prostate. Whilst research on this 
subject is still incomplete, the most important 
results may be summarised as follows :— 


I 


Influence of the Male Hormone on the Development, Preserva- 
tion, and Shrinkage of the Prostate 


It is known that there are many female hormones and 
to-day it is admitted that there are also many male 
hormones. According to McCullagh the male sex gland 
secretes two hormones :— 

(a) A fat-soluble hormone, probably secreted by the 
interstitial cells of Leydig, which stimulates the develop- 
ment and function of the accessory sex glands including 
the prostate. 

(L) A water-soluble hormone, supposed to be produced 
by the germinal epithelium, which exerts an inhibitory 
action on the anterior lobe of the pituitary and the produc- 
tion of prolan which retards the development of the 
prostate. 

Further, there has been found in the urine of men and 
even women a male hormone (androstanediol) which. 
according to Laqueur,is not identical with the hormones 
of the testis (androsterone) and is chiefly responsible for 
the growth of the cock’s comb in fowls. 


il 


Influence of the Female Hormones, in particular the 
Πstrogenic Hormone (Folliculin), on Changes 
in the Prostate 


The female follicular hormone (folliculin, cestrin) is 
normally present just as well in the male as in the female. 
In the mouse, small doses of follicular hormone cause 
typical signs of growth, not only of female organs lke the 
vagina, uterus, tubes, and mamma, but also of the male 
organs—prostate, seminal vesicles, and ampulle of the 
vasa deferentia. By increasing the dose of folliculin 
the quantitative physiological balance between the male- 
and female hormones is upset on the female side and 
pathological tissue proliferations appear in the prostate, 
seminal vesicles, and ampulle of the vasa deferentia. 
There is an extensive increase in the unstriped muscle 
which becomes thickened; at the same time connective 
tissue and proliferations showing keratinisation appear 
in the posterior part of the prostate and hinder micturition, 
so that do Jongh always found the bladder distended in 
the male mouse, and in rats and guinea-pigs treated with 
Menformon the seminal vesicles were ten times as large. 
The proliferation takes place chiefly in the posterior 
region of the prostate, which corresponds exactly to the 
group of glands which develops spontaneously in old men, 
causing hyportrophy of the prostate (de Jongh). If the 
injections of menformon are stopped the prostate shrinks 
completely in mice in three days’ time (de Jongh). 
Substances like benzoylate of menformon or benzoate 
of folliculin are even capable of causing growths similar 


THE LANCET] 


to cancer in the posterior part of the prostate (see results 
obtained by Dodds, Lacassagne, de Jongh). It is therefore 


possible to start a pathological new growth in the prostate | 


with a female hormone. 

All these changes were absent when de Jongh 
administered both male (hombreol) and female (men- 
formon) hormones together. The prostate was unaltered. 


rt 


Influence on the Prostate of the Hormone of the Anterior 
l Pituitary Lobe.: Prolan 


Lower, working with sexually immature rats, succeeded 
in obtaining premature development of the sex glands, 
prostate, and seminal vesicles by administering prolan B, 
the hormone of the basophil cells of the anterior pituitary 
lobo. In adult animals he obtained hypertrophy of the 
prostate (adenoma) and proliferation of the seminal 
vesicles by the same means. Extracts of the anterior 
pituitary lobe were found to be just as active as extracts 
of the urine of pregnant women. 

On the other hand, Engle and Smith found that removal 
of the anterior pituitary lobe in young rats checked the 
development of the gonads, prostate, seminal vesicles, and 
Cowper’s glands. ar 

Free secretion of the sex glands inhibits the effect of 
prolan and for this reason the prostate develops up to 
puberty and again after 50. Decrease in the quantity 
of hormone from the sex glands stimulates the secretion 
of prolan and consequently leads in advancing age to 
hypertrophy of the prostate. 

The loss of the sex glands (castration) is followed by 
hypertrophy of the anterior lobe of the pituitary,? the 
cells of which become rapidly exhausted by the excretion 
of prolan. This secretion though temporarily increased 
loses all action on the prostate, for, according to the 
majority of authors, prolan does not act directly on the 
prostate but indirectly through the medium of the sex 
glands. 

Lower anastomosed the blood-vessels of a rat recently 
castrated with those of a normal rat. Although the 
pituitary of the normal rat showed no alteration, tho sex 
glands, prostate, and seminal vesicles were hypertrophied 
(by the action of the hypertrophied anterior lobe of the 
pituitary of the castratod animal). These changes only 
occurred after ten days. Thirty days later the prostate 
had increased 40 per cent. in size and weight and was 
composed chiefly of gland tissue (adenoma). 

The same results were obtained by injections of the 
hormone secreted by the basophil cells of the anterior 
lobe of the pituitary. 

In old age, which may be regarded as Nature’s method of 
performing a gradual, incomplete, and discreet castration, 
the hormone of the scx glands diminishes imperceptibly 
so that the pituitary has plenty of time to produce its 
prolan and evoke hypertrophy of the prostate. 


The above results may be summarised as follows: 
Male hormone stimulates the normal development 
of the prostate. Female hormone produces the 
formation of fibromyoma of the prostate, and benzoate 
of folliculin a proliferation of the pavement epithelium 
of the prostate. Basophil hormone of the anterior 
lobe of the pituitary (prolan) gives rise to prostatic 
adenoma. 


Prostatic Enlargement in Man 


In man also the hormone of the male sex glands 
regulates the development, preservation, and functions 
of all the accessory glands, including the prostate. 
The human prostate attains its normal size at puberty 
equally with the growth of the testicles and the 
development of the secretion of the interstitial cells 
of Leydig. At the onset.of the activity of the germinal 
epithelium the development of the prostate ceases 
so that the gland remains stationary from puberty 


* This increase in size is explained by considering that after 
castration, the inhibitory action of the sex glands on the 
basophil cells ceases to have effect as soon as the activity of 
tbe anterior lobe of the pituitary becomes increased. 


DR. PAUL NIEHANS : HYPERTROPHY OF THE PROSTATE 


[FEB. 8, 1936 309 


to the sixth decade. From the age of 50 the testes. 
become smaller and softer. While the. number of 
the interstitial cells of Leydig remains unaltered, the 
secretion of the germinal epithelium and with it the 
production of spermatozoa gradually diminishes and 


, perhaps is stopped completely. At the same time the 


prostate renews its development. >- 

If the secretion of the interstitial cells of Leydig is 
normal the prostate is developed by puberty and 
keeps within normal limits as long as the secretion 
of the germinal epithelium is sufficiently plentiful. 
If the secretion of the interstitial cells of Leydig 
is lacking the prostate cannot develop. . This is the 
reason why hypoplasia of the prostate is met with in 
hypoplasia and anomalies of the testicles (Kaufmann) 
and atrophy of the prostate follows loss of the testicles. 
Lower found the prostate atrophied, small, fibrous, 
and hard in ten eunuchs in whom he was not able to 
demonstrate the presence of the male hormone in 
the urine. The relation between the testes and 
prostate is therefore unquestionable. 

The prostate is also under the control of the hormone 
of the basophil cells of the anterior pituitary lobe. 
When with advancing age the secretion of the 
germinal epithelium diminishes and gradually dries 
up the pituitary endocrine centre seeks the aid of 
prolan to re-establish the function of the genital 
glands. .But a powerful and prolonged action of 
prolan takes place indirectly—probably through the 
medium of the cells of Leydig—and promotes the 
formation of prostatic adenoma. The increased 
secretion of prolan begins as soon as it is no longer 
inhibited by an adequate secretion from the germinal 
epithelium, and continues until the basophil cells 
of the pituitary are gradually exhausted and replaced | 
by eosinophil cells. 

The female follicular hormone also influences 
the prostate. The follicular hormone is present 
in the testes and male urine. It stimulates the 
growth and normal development of the generative 
system, within the normal physiological limits of 
its action, together with the male hormone. In the 
male it is balanced by the hormone of the germinal 
epithelium, in the female by the hormone of the 
corpus luteum. Each hormone has its own sphere of 
action; thus according to de Jongh the follicular 
hormone controls: (a) In the female genital system, 
the muscular tissue of the vagina, uterus, and tubes ; 
it induces the growth of pavement epithelium of the 
vagina and cervix uteri and finally the development 
of the breasts, (b) In the male, the plain muscle 
of the prostate, seminal vesicles, and vasa deferentia, 
together with the connective tissue of their ampulla, 
the pavement epithelium 3 of the prostate, and the 
efferent ducts of the seminal vesicles. As de Jongh 
so aptly puts it: the female hormone produces 
“a female rut in the male prostate” ; the prolifera- 
tion of the epithelial, muscular, and connective 
tissue cells of some parts of the prostate leads to its 
hypertrophy. 

In old age the secretion of the sex glands in man 
is reduced by half (Lower),* while the female hormone 
is maintained (Laqueur). In this way the physio- 
logical equilibrium between the testicular and follicular 
hormones is upset and the female hormone increases 
its effect. This accounts for the activity in the 
prostate, with neoplastic formations at the time of the — 
male climacteric. The secretion of the interstitial 


>The columnar epithelium of the prostate is developed under 
the influence of male hormone (Lacassagne). 

+ Normally a man passes 10-24 units of male hormone in tbe 
urine in 24 hours. By noting the elimination of hormone in 
the urine it is possible to tell exactly when an abundant 
secretion of male hormone becomes much diminished. 


THE LANCET] 


310 


DR. PAUL NIEHANS: HYPERTROPH Y OF THE PROSTATE 


[FEB. 8, 1936 


cells of Leydig being no longer balanced by that of the 
germinal epithelium, the prostate enlarges. At the 
same time there is a rise in the prolan circulating 
in the blood, which in turn, by stimulating the 
secretion of the cells of Leydig, leads to hypertrophy 
of the prostate. If there be a predominance of 
follicular hormone over male hormone, the prostate 
hypertrophies and degenerates. 

From a consideration of the rôle which these 
hormones play in the development of the prostate 
we can conclude that :— 

(1) The normal secretion of the interstitial cells of 
Leydig contributes to the normal development of the 
prostate. 

(2) The pituitary prolan as well as the secretion of 
Leydig’s cells if excreted for a considerable time in increased 
amounts produces adenoma of the prostate. 

(3) An excess of follicular over male hormone leads to 
the formation of a fibromyomatous prostate. 


All these typical alterations of the prostate, which 
vary in type and degree, can only occur if there be 
a shortage of hormone from the germinal epithelium. 
Hence de Jongh’s dictum “the testicle protects us 
from pathological changes in the prostate.” 


Treatment 


If in old age we could augment the internal secretion 
of the sex glands, especially that of the germinal 
epithelium, not only would the increased output of 
prolan be stopped but the physiological balance 
between male and female hormones would be 
re-established and the prostatic enlargement reduced. 
With this end in view the following methods of 
treatment have been used :— 

= (1) Injections of male hormone (Laqueur, van Capellen). 

(2) Transplantation of testicles of adults (Romeis). 

(3) Steinach’s ligature Il., diversion into the blood 
stream of all the secretion from the germinal epithelium 
(Niehans). 

Treatment by means of hombreol consists in 
giving injections of 1 c.em. of oil of hombreol once or 
twice daily for three weeks. Laqueur and van 
Capellen claim that by this method improvement 
is maintained in some cases for six months. For 
information on the subject of treatment by means 
of transplantations of the testes the work of Romeis 
should be consulted. 

In 1928, in a prostatic case aged 69, I applied an 
inter-epididymo-testicular ligature such as had been 
advocated by Steinach in order to enhance the 
endocrine function of the sex glands and bring about 
rejuvenation. The result was surprisingly good, 
not only with regard to the general improvement 
in the patient’s condition but also to the effect 
on the prostate. I showed this case in Montreux 
in 1928 at the Swiss Surgical Society. The ligature 
between the testicle and the head of the epididymis 
closes the efferent ducts through which the external 
secretion of the testicle escapes, with the result that 
the hormone of the germinal epithelium as well as 
the hormone of the interstitial cells of Leydig pass 
through the pores of the albuginea into the numerous 
veins which surround the testicle and thus gain the 
general circulation. This brings about a rejuvenation 
of the enfeebled organism in the sense that the old 
cells are reabsorbed and young cells formed. Further 
it inhibits the abnormal development of the prostate 
by reducing the hypersecretion of prolan and by 
re-establishing the physiological balance between 
male and female hormones. 

I described the operative technique in 1930 pointing 
out that the ligature must not be placed level with the 
Superior pole of the testicle but as near as possible 


to the head of the epididymis, so as to avoid putting 
the albuginea of the testicle under tension and thus 
hindering the passage of the hormone of the genital 
glands into the blood stream. Briefly the technique 
is as follows : 


(1) Place a silk ligature in the groove between the 
epididymis and the testicle, not level with the testicle 
but level with and even, if necessary, encroaching on the 
head of the epididymis. If the ligature be placed at the 
level of the testicle, as recommended by M. Chevassu 
and as is possibly the practice of other operators, the 
inelastic cov- 
ering of the 
testicle is put 
under perman- 
ent tension 
whereby the 
internal secre- 
tion is likely 
to be ob- 
structed, for 
the testicular 
hormone 
would no 
longer be able 
to pass 
through the 
fine pores of 
the albuginea 
and reach 
the veins 
which sur- 
round the 
testicle. If 
both means of 
egress for the 
testicular hor- 
mone—the 
vasa defer- 
entia and the 
blood stream 
—are closed, 
an extreme hypertension is produced by stasis and even the 
massive necrosis described by Slotopolskv may occur. The 
testicle becomes swollen and acutely tender, a complication 
which has been wrongly imputed to Steinach’s ligature II. 
instead of to a faulty technique. 

(2) Tie all the efferent ducts of the testicle (15 according 
to Kaufmann), applying the ligatures tightly but without 
dividing them. If the ducts are divided the external 
secretion would persist—which is not desired. 


Symp. Gang. 


Diagram to illustrate the operative technique 
of Steinach’s ligature II, 


From 1927 up to the present I have relieved, 
by this very simple procedure, nearly 400 patients 
suffering from enlargement of the prostate. The 
operation can be done painlessly under a local anws- 
thetic, a fact that is alone suflicient to warrant for 
this simple procedure a wide appreciation. 


RESULTS OBTAINED FROM STEINACIL LIGATURE II 


The general rejuvenating effect has been sufliciently 
observed, both in animals and man, by so many 
prominent men of science as to remove any doubt about 
it. Asa frequent result of the ligature the heart is 
invigorated, the pulse becomes regular, the circulation 
improved, the arterial tension reduced to normal. 
headache and vertigo disappear, the appetite is 
improved, metabolism increased, caleareous deposits 
in arteries and joints are absorbed, musculature 
strengthened, the gait made firm and upright, sleep 
restored by the removal of nocturnal frequency of 
micturition, and clearness of thought and ability 
to undertake intellectual work restored. The effect 
of the ligature on the prostate itself is rapid in its 
action on spasm of the sphincter. It is less rapid in 
its action on the enlargement. 

The painful straining gradually abates, the patient 
once more empties the bladder without effort, the 


f 


| 


THE LANCET] 


CLINICAL AND LABORATORY NOTES 


[FEB. 8, 1936 311 


stream becomes more forcible, and in the majority ` 


of cases the residual urine entirely disappears. This 
result lasts for years and has been checked by a 
great number of cases in which there was no departure, 
either clinical or histological, of the prostate from 
the normal. 

Three of my cases will suffice to show the action 
of Steinach’s ligature II., both on the sphincter 
spasm and on the hypertrophy. 


1. Spasmodic contraction of the bladder sphincter.— 
Man aged 61; dysuria since the end of September and 
unable to pass more than 60 c.cm. urine at a time without 
‘great difficulty. Bladder distended up to the umbilicus. 
Ligature Steinach II. Oct. 13th, 1933. One and a half 
hours after the operation the patient voided 400 c.cm. 
urine and since then on an average 300 c.cm. four times 
a day. This patient had never had a catheter passed as 
he had a narrow and much inflamed phimosis. 

2. Hypertrophy of the prostate—In 1929 I performed a 
Steinach’s ligature II. operation on a colleague aged 57, 
suffering from adenoma of the prostate, who was only able 
with great difficulty to pass a few drops of urine at a time. 
In order to estimate the improvement which followed, 
this patient measured the projection of his stream on the 
ground. This gradually increased from zero up to a metre 
which equals that of a young man. The improvement 
is still maintained after 64 years. 

3. A contractor, 
difficulty of micturition for six months and had twice 
required catheterisation for retention. There was great 
hypertrophy of the prostate. Steinach’s ligature II. 


* The norma! length of the prostatic urethra is 13 mm., but 
in hypertrophy it may attain 5 cm. or more. Heitz-Boyer 
noted after Steinach ligature II. a decrease in the size of the 
prostate and a shortening of the urethra, elongated by 
hypertrophy. 


aged 64, who had suffered from’ 


operation was performed on Jan. 9th, 1928. No indwell- 
ing catheter was necessary. The urine was passed more 
easily each day and after the twenty-third day the bladder 
was completely emptied. Since then he only passes 
urine once at night and has had no mishap or dysuria. 
The prostate is only slightly enlarged. He has now been 
under observation for eight years. 


Conclusions 


In the last few years I have done a very large number 
of ligature operations. They are painless and nearly 
all my patients have assured me that they have felt 
no discomfort either during or after operation. 
In cases without infection the length of treatment is 
12 days and the mortality has been nil. 

Since the operation entails no risk, the doctor can 
advise this treatment at the onset of prostatic trouble 
before there is any indication for prostatectomy. He 
may also advise it as a prophylactic against the changes 
in the interaction of the endocrines due to age and thus 
avoid hypertrophy of the prostate, a condition which 
untreated is always progressive. For the prophy- 
laxis and treatment of senile changes in the prostate 
in the future the resources of endocrinology will be more 
and more utilised and in serious cases the patient will no 
longer have to choose between the use of the catheter 
and prostatectomy, to which operation the famous 
urologist Legeu once referred as “a procedure which 
may prove fatal, but which will cure those it does not 
kill.” Steinach’s ligature II. can relieve a great 
many of the sufferers from prostatic enlargement 
however advanced their age without shock, pain, 
loss of blood, or risk. 


CLINICAL AND LABORATORY NOTES 


EFFECT OF THE HIGH-FREQUENCY FIELD 
ON SOME PHYSIOLOGICAL PREPARATIONS 


By Sır LEONARD HILL, M.B. Lond., LL.D., F.R.S. 
SUPERVISOR, ST. JOHN CLINIC AND INSTITUTE OF 
PHYSICAL MEDICINE; AND 
H. J. TAYLOR, B.Sc., Ph.D. Lond. 


PHYSICIST, ST. JOHN CLINIC AND INSTITUTE OF 
PHYSICAL MEDICINE 


SINCE so-called ultra-short waves are being used 
extensively for medical treatment an explanation 
of their mode of action is required. Various authors 
have claimed that effects can be produced in the 
ultra high-frequency electric field which are not 
explicable on the basis of rise in temperature. A 
good review of the literature is given by Mortimer 
and Osborne.! One of the more important papers 
is by Haase and Schhephake,? who claim that a 
selective lethal action on various organisms is a 
specific action of ultra-short waves. This is denied 
by Hasché and Leunig:? Many of the claims made 
for the specific action of ultra-short waves rest on 
the early work of Schereschewsky,4> who studied 
the effect of the ultra high-frequency field om mouse 
and fowl sarcoma and carcinoma. More recently 
Schereschewsky has published ® a review which 
includes his earlier work and says that no case can 
be made out for ascribing effects as not being directly 
due to heat. Reiter?’ has, however, claimed that 
high-frequency currents of frequency 8°82 x 10° sec.-! 
corresponding to a wave-length of 3°4 m. destroy 
rat tumours by a specific effect distinguishable from 
that of heat. The method of cooling the animal 
employed by Reiter is open to criticism. and Taylor § 
has shown that if a more efficient method of cooling 


be employed no destruction of the tumour and 
surrounding tissues results, when these are exposed in 
the high-frequency field. Moreover, he found that 
a low intensity without cooling of the treated parts 
is as effective as a high intensity with which artificial 
cooling is employed ; further, a frequency correspond- 
ing to 45m. wave-length is just as effective as that 
corresponding to 3°4 m. 


EXPERIMENTAL WORK 

As an additional proof of the fact that the action 
of the 3:4 metre wave-length is due to heat we have 
exposed the excised frog heart in the high-frequency 
field, the heart being immersed in a small quartz 
vessel containing Ringer’s solution. The temperature 
of this solution was taken at times with a thermometer, 
the vessel of course being removed from the field for 
the purpose. Strict accuracy is not claimed for this 
method, but as the heat loss from the quartz vessel 
and contents is slow no great error is introduced. 
It was found that the heart continued to beat normally 
until a temperature above 30°C. was reached. The 
heart then ceased to beat but might be restored by 
cooling until a temperature above 35°C. was reached, 
when the heart failed to recover. As the behaviour 
of the frog’s heart was exactly as it is known to be 
when merely submitted to increasing temperature 
in a bath of Ringer’s solution, we conclude that the 
result of exposure to the high-frequency field is 
wholly due to heat. In case it were argued the 
high-frequency field acted rather on the saline solution 
than on the heart, a preparation was made of the 
thorax of a large frog containing the heart in situ, 
and this was suspended by cotton threads in the 
field with the lower part of the thorax uppermost. 
The heart was covered by the liver and the tempera- 
ture was taken by removing the preparation from the 


312 THE LANCET] 


field and inserting the thermometer between the liver 
and heart. Here again the heart ceased to beat 
when the temperature rose above 30°C. and could 
be restored by cooling until the temperature reached 
5°C. <A preparation was then made of the head 
of the frog after the removal of the lower jaw and 
tongue, so that the ciliated epithelium covering the 
roof of the mouth was exposed. The activity of 
the cilia was tested by placing some granules of iron 
dust upon it and timing the progress of them towards 
the opening of the gullet. This preparation, placed 
in Ringer’s solution in the quartz vessel, was exposed 
in the field and taken out at intervals and tested for 
temperature and for movement of the cilia. The 
cilia continued to show activity up to a temperature 
of. 42°C., stopped at a higher temperature, but 
started again on cooling if they had not been heated 
to a temperature higher than 45° ; above this 
temperature they stopped for good. Similar results 
were obtained when the whole head was suspended 
in the field on a thread, the temperature was taken 
by inserting the thermometer in the mouth, when 
the field was switched off; the activity of the cilia 
was observed after opening the mouth. This result 
also agrees with the known effect of temperature on 
the ciliated epithelium of the frog. Next a nerve- 
muscle preparation was exposed in the field in a 
quartz vessel in the same way. This was taken out 
for testing at intervals. The muscle continued to 
contract vigorously on faradic stimulation of the 
nerve up to a temperature of about 42° C. undergoing 
heat rigor at 45°C. 
| CONCLUSION 


The behaviour of frog heart, cilia, and nerve-muscle 
preparation exposed in the high-frequency field 
corresponding to 3°4m. wave-length is shown to be 
exactly the same as when merely heated in Ringer’s 
solution; the biological effect of the field is thus 
due to heat. 

This research was carried out with the aid of a grant, 
for expenses, from the Medical Research Councii. 


REFERENCES 

1. Mortimer, B., and Osborne, S. L.: Jour. Amer. Med. Assoc., 
1935, civ., 13. 

2; ae W. ae ‘and schliephake, E. Strahlentherapie, 1931, 
X 

3. Haschó, e and Leunig, H,: Ibid., 1934, 1., 351. 

4. Se heresche wsky, W.: Ú, S. Pub. Health Rep., 1928, 
xliii., 927. 

5. Schereschewsky : Ibid., 1926, xli., 1939. 

6. Schereschewsky : Radiology, 1933, xx., 246. 


. Reiter, T.: Deut. med. Woch., 1933, lix., 


7 1497. 
8. Taylor, H. J.: Brit. Jour. Radiol., 


1935, viii., 718. 


POLYCYSTIC DISEASE OF THE KIDNEYS 


By W. E. Cooke, M.D. Liverp., 
r.R.C.P. Lond., D.P.H. 


THE PATHOLOGICAL DEPARTMENT, ROYAL 
INFIRMARY, WIGAN 


DIRECTOR OF 


THE case to he described has many unusual features. 


History.—A. B., then 16 years old, was seen by her 
medical attendant in November, 1933. She complained 
of backache, lassitude, and dyspnoea on exertion. There 
was a considerable degree of anemia. The urine con- 
tained large quantities of blood and pus, and _ bacterio- 
logically Bacillus coli and Staphylococcus albus. There 
was no radiographic evidence of calculus, and the renal 
shadows were reported to be normal in size and shape, 
but after an injection of Uroselectan on Feb. 13th, 1934, 
none of the dye appeared in the renal areas at any time. 
She had appeared a healthy though under- developed girl 
until the onset of the symptoms. In October, 1933, she 
had had a very scanty monstrual period which lasted 
seven days, and was accompanied by a great deal of pain, 
This was the only period she had. 


CLINICAL AND LABORATORY NOTES 


` liver, spleen, and pancreas were normal. 


right (Fig. 1). 


[FEB. 8, 1936 


From November, 1933, to June, 1935, her condition 
fluctuated. The anxmia improved and for long periods 
the urine did not contain blood. She was able to take 
walks and carry on an apparently normal life. 

Firal illness.—On admission to hospital on June 23rd, 
1935, at the age of 18, she was 4 ft. 7 in. in height and 
juvenile in appearance, with lack of development of 
secondary sexual characteristics. The blood pressure 
was 116/70 mm. Hg. The daily output of urine was 
20—40 oz. until July 14th, the day before her death, when 
it was 2 oz. The specific gravity varied between 1004 and 
1014, and the urine contained blood and pus. The blood- 
urea, ten days before death, was 700 mg. per 100 c.cm., 
the serum calcium 6-7 mg., and the creatinine 3-4 mg. 
There was & progressive anemia, the hemoglobin falling 
to 30 per cent., with red cells 2,400,000 per c.mm., colour- 
index 0-6, and the reticulocytes less than 0-1 per cent. 
The average diameter of the red cells was 7-3. Total 
leucocytes were 16,000 per c.mm. with a differential count 
of polymorphs 78 per cent., monocytes 4 per cent., and 
lymphocytes I8 per cent. The polynuclear count was: 
(I.) 6, (II.) 20, (III.) 40, (TV.) 22, (V.) 12. Bleeding from 
the gums was noticed about that time and a pericardial 
rub two days before death, The disease was apyrexial 
throughout. 

POST-MORTEM FINDINGS 


There was a fibrinous pericarditis with 2 oz. of serous 
fluid in the pericardium. The heart weighed 84 oz. The 
The uterus was 
small and the ovaries unscarred. The bladder and 
ureters were normal, the pelves dilated. 

Kidneys.—Both kidneys were cystic. Each was 6 in. 
long, 3 in. wide, and 3 in. thick at the deepest part, and 
each weighed 154 oz. The hilum notch was accentuated. 
The right kidney was translucent, the cysts being filled 
with a pale straw-coloured urine of specific gravity 1004, 
containing 0-5 per cent. of urea and a trace of albumin 
with a few pus cells. Many of the cysts of the left kidney 
were distended with blood-clot, some contained thick 
necrotic material and the remainder pale urine as in the 
No tubercle bacilli were present and 
cultures gave B. coli and Staph, albus. 

The adrenals were flattened and the normal contour 
lost. They were situated postero-internally immediately 
above the hilar notch, the external border becoming, with 
the altered position, anterior, the anterior surface 
postero-internal, and the posterior, antero-external. A 
considerable proportion of the kidneys was above their 
upper borders. They appeared, microscopically, normal. 

Histology.—The small triangular areas at the junctions 
of the cysts presented the usual appearance of dilated 
ducts lined by cuboidal epithelium (Fig. 2). In the 
larger cysts this had become flattened. In the left kidney 
the renal tissue in these positions showed cloudy swell- 
ing of the tubular epithelium, tubules of unequal sizes, 
thickening of Bowman’s capsule, and areas of round-celled 
infiltration (Fig. 3). 

DISCUSSION 

In addition to the abnormal situation of the 
adrenals, the unusual features of the case are :— 
recording 59 cases of 
polycystic kidney gave the following ages when the 
condition was diagnosed :— 


Years. Patients. Years. Patients. 
1- 9 ee . 0 40—49 ee ee 17 
10-1 9 ee ae 0 50-59 ae ee 18 
20—29 ee ee 2 60-69 ee es 8 
30-39 a me 14 
Kiister’s ? figures for 239 cases were :— 
Patients. Patients. 


Stillborn or dying show 30-40 years .. 24 


after birth ; 5! 40-50 ,, is 53 
Died in first, year oie 10 50-60 _,, bs 41 
l- 5 years... site 6 60-70 ,, ice 10 
5-10 so, eat. Yee 1 70-80 og, ih 6 
10—20 ,, = te 4 80-90 sg, PE 3 
20—30 ci 22 


Oppenheimer sellected from the literature 29 cases 
between the ages two and twenty years and suggests 
that these represent the connecting link between the 
new-born and the adult types of the same disease. Until 
we know more about the etiology his contention 


THE LANCET] 


cannot be confirmed nor refuted, but 
his own and Kiuster’s figures are 
remarkable in emphasising the rarity 
of the condition between the ages 
of one and twenty and the greatest | 
incidence in the 30-60 age-group. 

2. Infantilism.—The terms renal 
dwarfism, renal infantilism, and 
renal rickets have been used 
synonymously, but as Ellis and 
Evans? point out, many cases fall 
clearly into one of these groups and 
should be differentiated. The 
present case would be placed into 
the group of renal infantilism. The 
rarity, in fact total absence, of 
dwarfism, rickets, and infantilism 
recorded in connexion with poly- 
cystic kidneys in contrast with their 
frequency in cases of contracted 
kidney and hydronephrosis and 
dilatation of the ureters occurring 
before puberty may be explained 
by the fact that serious diminution in the amount 
of effective renal tissue in the former disease 
does not usually take place until after twenty years 
of age. Although it is difficult to believe on viewing 
cystic kidneys, the two-thirds of renal substance 
necessary to life (reduced now by some workers to 


yellow urine. 


a 


FIG. 2.—Photomicrograph of tissue be- 
tween cysts, showing dilated tubules 
lined with cuboidal epithelium. The 
epithelium lining the larger cysts on 
each side of the triangular piece of tissue 
is flattened. (X 75.) 


tion. 


Photomicrographs by C. F. Hill and W. E. Cooke. 


one-sixth) must have functioned over the period of 
puberty. 

3. Blood analysis—The blood-urea, 700 mg. per 
100 c.cm., was the highest I have seen. The serum 
calcium fell from 10:8 to 6:7 mg. a few days before 
death. The amount of creatinine was unusually high. 

4. Blood count——Brown and Roth?‘ stressed the 


CLINICAL AND LABORATORY NOTES 


right kidney was transparent, the cyst containing a pale yellow urine. 
left shows some of the cysts filled with blood-clot at A, others filled with necrotic 
materia] at B. The cysts that appear empty in the photograph contained pale 
The ureters are seen in the centre of each kidney. (x }.) 


FIG. 3.—Photomicrograph of renal tissue from - 
left kidney, showing thickened Bowman’s 
capsule, variation in size of the tubules, 
and at X an pe of round-celled infiltra- 

(xX 75. 


[FEB.'8, 1936 313 


FIG. 1.—Photograph of the polycystic kidneys, sectioned, described in text. The 


The 


relationship between anzemia and renal insufficiency. 
They attribute the anemia to a disturbance in 
hemopoiesis. This is also suggested by the blood 
in the present case. Two factors may have been 
jointly responsible for the progressive anæmia— 
renal insufficiency and infection of the kidneys. 
But the polynuclear count 
points to some radical dys- 
function either in the pro- 
duction or elimination, or 
alteration in the life-history 
of the polymorphs. The 
right-handed polynuclear 
count—(I.) 6, (II.) 20, 
(III.) 40, (IV.) 22, (V.) 12— 
giving a weighted mean of 
3°14 is remarkable in itself 
in a case with a gross 
infection, still more so with 
a leucocytosis of 16,000 
per c.mm., and is in my 
experience unique. The 
polymorphs generally were 
of normal size, but macro- 
polycytes were not infre- 
quently seen (Fig. 4). The 
lobes of the nuclei were so 
numerous and the fragments so contorted and super- 
imposed as to make the count the most difficult 
I have encountered. Figs. 5, 6, and 7 were taken 
from almost successive fields in a blood film and will 
afford some idea of the task. 

Similar counts are recorded in pernicious anzmia, 
but in that disease the polymorphs tend to be larger 


FIG. 4.—A macropolycyte of type 1 illustrating large size of cell and hypersegmentation of the nucleus. 


the difficulties cncountered in making a polynuclear count. 


(x 1000.) 
FIGS. 5 to 7.—Three almost successive fields in a blood film illustrating polymorphs with hypersegmented nuclei, and 


(x 1000.) 


314 THE LANCET] 


and the basichromatin in the nucleus less in amount 
and therefore less densely staining than in the present 
case, so that the contortions and divisions are more 
easily followed. 
SUMMARY 

(1) The case is one of polycystic kidney associated 
with infantilism. (2) Although gross infection of the 
renal cysts was present, the case was apyrexial 
throughout. (3) The blood-urea reached the high 
figure of 700mg. per 100¢.cm. of blood. (4) The 


ASSOCIATION OF CLINICAL PATHOLOGISTS 


[FEB. 8, 1936 


polynuclear count was right-handed. (5) The 
anatomical position of the adrenals was abnormal. 


REFERENCES 


1. Oppenheimer, G. D.: Ann. of Surg., 1934, ii., 1138. 

2. Küster, E.: Die Chirurgie der Nieren. No. 52 B, of Berg- 
tana and Bruns’s Deutsche Chirurgie, Stuttgart, 1962, 
p. 51: . 

3. Ellis, A., and Evans, H.: Quart. Jour. Med., 1933, ii., 231. 


4. Brown, G. E., and Roth, G. M.: Arch. Internal Med., 1922. . 
XXX., 817. 


5. Cooke, W. E.: The Arneth Count, Glasgow, 1914, p. 18. 


a a nee ee ARTE 
MEDICAL SOCIETIES 


ASSOCIATION OF CLINICAL 
. PATHOLOGISTS 


THE ninth annual meeting of this association was 
held, by the courtesy of Sir Henry Wellcome, at the 
Wellcome Physiological Research Laboratories, 
‘London, on Jan. 25th. Dr. J. G. GREENFIELD 
occupied the chair. 


Dr. I. MuENbE (London) spoke on the 
Clinical Pathology of Skin Diseases 


with particular referencé to parasitic and fungal 
infections. He pointed out that in acarus infection 
of human type the rash might be widespread and the 
manifestations varied but that the characteristic 
burrows would be found between the webs of the 
fingers, on the glans penis, in the axillary folds, and 
in women under the breasts. The parasite could be 
demonstrated by shaving off the skin at the end of 
the burrow and examining under the microscope. In 
infection derived from pet animals type burrows 
might be missing ; the eruption was usually confined 
to the hands and arms and would disappear on 
removal of the infecting pet. In fungal infections 
the speaker laid stress on the identification of the type, 
which was best done by culture; in those acquired 
from cat, dog, or canary, removal of the source of 
infection was essential. Kerion was usually due to 
animal infection. The black dot type of ringworm 
was becoming much more common ; in this type the 
extraction of hairs for examination presented diffi- 
culties which were best met by the use of a comedo 
extractor. Achorion infection might be acquired 
from mice, in which animals it produced a fatal 
encephalitis. Dr. Muende recorded one case which 
had been associated with an epidemic among mice in 
the place of work. Moniliasis was a not infrequent 
cause of paronychia; the fungus could be identified 
by scrapings taken from under the nail bed even in 
the absence of pus; it was particularly prone to 
occur in barmaids, bakers, and pastry cooks. 
Dyshidrosis was due to sensitisation to a fungus 
infection usually by an epidermophyton between the 
toes. A useful guide to the presence of such sensi- 
tisation was the reaction produced by the intradermal 
injection of the soluble products from a culture of 
mixed fungus of the same type. Eczema might be 
due to sensitisation to vast numbers of ‘‘ eczemato- 
gens’; Dr. Muende described the ‘“‘ patch test’ for 
the identification of such sensitisation. 


Dr. C. M. WENYON, F.R.S. (London), spoke on the 
clinical pathology of 


Protozoal Infections 


He said that, though amoebic dysentery was prob- 
ably not so common in this country now as in the 
years immediately succeeding the war, numerous 
carriers of pathogenic amæœbæ still existed. Many of 


these carriers were not aware that they had ever 
had ameebic dysentery and many of them experienced 
very little inconvenience. Amæœæbæ might be found 
in vast numbers in the stools of those with very 
little in the way of symptoms and this had led some 
people to conclude that there were two types of 
histolytic ameeba, one type (called “ dispar ’’) 
being of relatively low pathogenicity. Dr. Wenyon 
discussed the difficulties in the identification of amcebic 
infection and emphasised the necessity of examining 
fresh specimens of fæces; repeated examination 
might be necessary and protozoa were rarely found in 
very liquid fæces. Amæbæ might be found in 
scrapings taken from ulcers through a sigmoidoscope 
when they could not be found in the fæces. All 
intestinal parasites except giardia could be cultivated. 
but this method was only possible in institutions 
dealing with very large numbers of cases. Giardia 
was an inhabitant of the duodenum and could be 
obtained by means of duodenal intubation ; chole- 
cystitis had been ascribed to it but Dr. Wenyon did 
not regard the case as proven. In the diagnosis of 
protozoal blood infeċtions a good stain was the first 
requisite. Except in the case of kala-azar culture 
was of no use as a diagnostic measure. In the 
diagnosis of bilharzia and schistosoma infestation a 
useful aid was the intradermal injection of the 
appropriate antigen. 

Dr. G. W. GoopHart (London) pointed out that, 
while diagnosis of trichomonas infection of the vagina 
could be made from fresh secretion, the parasites 
could not be demonstrated in dried films. 

Dr. R. V. Facey (Bournemouth) stated that he 
came across large numbers of cases of vaginal 
trichomoniasis and that these responded readily to 
treatment with arsenical pessaries. 

Dr. H. P. Himsworrn (London) spoke on the 


Significance of Blood-sugar Levels in 
Diabetics 


He asked why the blood-sugar rises in diabetes $ 
The classical] explanation is failure in carbohydrate 
storage. He however suggested that the rise of 
the blood-sugar was a compensatory phenomenon. 
He showed graphs indicating the course of the blood- 
sugar and of the ketosis in a severe case of diabetic 
coma; when sugar was given in large amount without 
insulin the blood-sugar rose but the ketosis became 
less ; he cited an instance of diabetic coma in which 
the blood-sugar had been forced up by the adminis- 
tration of glucose to over 1000 mg. per cent. with 
decrease in ‘ketosis and corresponding improvement 
in the clinical condition. On giving sugar to the 
diabetic more sugar was excreted than was taken ; 
similarly the establishment of diuresis, though it had 
no effect on the blood-sugar level, would result in 
increased excretion of sugar. He suggested that the 
main factor in diabetes was an incapacity to utilise 
carbohydrate until the blood-sugar had risen to a 


THE LANCET] 


GLASGOW OBSTETRICAL SOCIETY 


[FEB. 8, 1936 315 


certain level above the normal; on this account it 
was harmful to withhold sugar from the diabetic. 
The level of the blood-sugar bore no relation to the 
clinical condition. 

Dr. S. C. DYKE (Wolverhampton) expressed his 
agreement with Dr. Himsworth that more harm was 
done by withholding than by giving excess of sugar 
to the patient in diabetic coma, but pointed out that 
a high blood-sugar encouraged diuresis and therefore 
favoured the further dehydration of the patient ; 
dehydration was the main danger in coma and 
reduction of the blood-sugar was a necessary step in 
combating it. In the established diabetic he asked 
whether continued hyperglycemia might not be one 
of the causes of the vascular degeneration which is 
the main cause of morbidity. © 


Dr. J. A. Boycott (London) described the 
Diagnosis of Teratoma Testis 


by means of the Aschheim-Zondek reaction. The 
method depended upon the fact that sufferers from 
malignant tumours of testis excrete in the urine 
excessive amounts of gonadotropic hormone; this 
was not the case with simple and inflammatory 
tumours. Two sets of mice were used; one series 
received graduated injections of concentrated and 
the other of unconcentrated urine. By means of a 
table it was possible to calculate the amount of 
gonadotropic hormone excreted. The test was useful 
not only in diagnosis but also in controlling the 
results of operation and radiotherapy. 


Dr. DYKE also described a case of accidental 
transmission of malarial infection in the course of 
blood transfusion ; the donor had lived in India but 
had never known that he had had malaria. 

In the course of the afternoon Dr. S. H. Daukes, 
curator of the Wellcome Museum of Medical Science, 
conducted members round the magnificent medical 
museum of the institution. 


GLASGOW OBSTETRICAL SOCIETY 


AT a meeting of this society on Jan. 22nd Dr. 
JoHN GARDNER, the president, took the chair, and 
Dr. DuGatp BAIRD read the paper published on 
p. 295 under the title of 


Maternal Mortality in Hospital: 


In the subsequent discussion Dr. J. DUNLOP said he 
‘did not accept the nasopharyngeal origin of puerperal 
sepsis, and attributed his own improved results in 
general practice to the use of gloves. He thought 
many errors in judgment resulted from overtiredness, 
after a long day in practice. He agreed that spacing 
of births was most desirable, and put in a plea for 
birth control clinics run by the local authority. 

Dr. JaMES Cook thought that uterine inertia was 
often due to over-indulgence in strong tea, He was 
alarmed at the increased number of Cesarean sections 
and asked why induction was not performed more 
often. He was in favour of a‘great extension of ante- 
natal care, and advocated medical examination before 
marriage. | 

Dr. A. S. M. MACGREGOR (M.O.H. for Glasgow) 
was not convinced that there was an increase in 
the maternal mortality for Scotland, the apparent 
rise being due to more accurate certification and 
statistical fallacies. There seemed no doubt that 
technical practice was improving. He thought that 
an analysis such as Dr. Baird’s, where each case 
was assessed individually, was the best method of 


studying the problem. The incidence of sepsis in 
Scotland had not diminished in the last few years, 
especially that of sepsis due to the hamolytic strepto- 
coccus, and he believed that this might be explained 
by the increased virulence of the hemolytic strepto- 
coccus in northern latitudes. He thought the non- 
coöperation of patients themselves was an important 
factor in maternal mortality. He asked if Dr. 
Baird would put greatest emphasis on the provision 
of antenatal beds in a government policy. 

Dr. DouGLas MILLER advocated Caesarean section 
in those cases of uterine inertia with stigmata of 
endocrine deficiency. He said they had been dis- 
appointed with the results of the use of masks in 
Edinburgh, and asked if some of the improvement in 
Glasgow was not due to more careful segregation of 
“ suspect’ cases. 

Prof. SHaw DUNN remarked that antenatal care 
had not altered the incidence of albuminuria, since 
this condition probably depended on intimate physio- 
logical and dietetic causes, occurring early in preg- 
nancy. 

Prof. JAMES HENDRY thought that much of the 
improvement in results at the Royal Maternity 
Hospital was due to the reorganisation of the staff 
which allowed continuous service and team-work, 


_and to better coöperation with the general practi- 


tioner and local authority. The extended use of 
Cesarean section in the treatment of placenta previa 
was a great advance. 


Dr. Bamp replied that he did not attribute the 
fall in the sepsis-rate to better segregation. The 
most striking fall occurred in sepsis following spon- 
taneous delivery, which, as Colebrook had shown, 
was almost always due to the hemolytic strepto- 
coccus, in contrast to sepsis following abnormal 
labour, where the hemolytic streptococcus was the 
causal organism in only 30 per cent. There was 
little evidence of infection being transferred from 
one patient to the other, for the cases of sepsis were 
sporadic and infection seemed to take place at the 
time of labour. He was convinced of the naso- 
pharyngeal source of infection by the hemolytic 
streptococcus. He certainly thought that more ante- 
natal beds should be an important feature of a govern- 
ment plan; but great tact was often necessary to 
persuade the patient to stay in hospital. 


NORTH OF ENGLAND OBSTETRICAL . 
AND GYNECOLOGICAL SOCIETY 


At the annual meeting of this society, held in 
Manchester on Jan. 24th, with Dr. Rutu NICHOLSON, 
the president, in the chair, a paper on 


Extroversion of the Ovaries for Secondary 
Functional Amenorrhea 


was read by Dr. K. V. BatLtey. Recent advances 
in endocrine therapy, he said, had done much to 
simplify the treatment of many uterine disorders, 
and Kaufmann’s work had undoubtedly established 
a rational treatment for functional amenorrhea. 
But even the large doses of hormones used by 
Kaufmann gave irregular results and Dr. Bailey 
thought it desirable to bring forward an operative 
treatment he had adopted in 16 cases during the past 
five years, especially as its results indicated a probable 
cause for the relative failure of endocrine therapy 
in some cases of secondary amenorrhea. In this 
condition uterine junction had once been present, 
and the true failure was probably in ovary or 


316 THE LANCET] NORTH OF ENGLAND OBSTETRICAL AND GYN:COLOGICAL SOCIETY 


pituitary. As a rule, the patient was otherwise 
healthy and well developed, showing no sign of gross 
endocrine imbalance. In the ovaries themselves 
lack of follicular ripening and ovulation might lead 
to multicystic disease or to chronic cirrhosis of the 
tunica with progressive fibrosis of the ovarian stroma 
—findings most readily attributable to a basic 
pituitary deficiency. Once established, these changes 
were permanent; although ovulation might 
occasionally be induced in an ovary showing advanced 
multicystic disease, it could only occur in a small 
area which still functioned and found an outlet to 
the surface. Regeneration was as impossible as in a 
multicystic kidney. The operation he had adopted 
was based on these facts andsought to assist maturation 
and ovulation in the remaining follicles by facilitating 
their approach to the surface. It might seem to 
break the rules of surgery, because a raw surface was 
deliberately produced in the pelvic cavity, but this 
raw surface faced downwards towards the pouch of 
Douglas and was not in contact with any peritoneal 
surface. What he did was to excise a wedge of tissue 
sagittally from the cystic or cirrhotic ovary, with 
its apex at the hilum; then by means of sutures 
the organ was turned almost inside out—or, more 
accurately, the cut halves were flattened outwards. 
In no case had Dr. Bailey seen post-operative adhesions 
or symptoms attributable to them, and he now looked 
on the operation—which he usually preceded by 
dilatation and curettage—as thoroughly safe. Endo- 
crine treatment had been given in addition, including 
Antuitrin S, but judging by control cases the doses 
were too small to have any effect per se, though they 
might stimulate follicular growth, to the stage of 
ovulation, in the extroverted ovary. Of the 16 cases 
treated, the duration of the amenorrhea had been over 
six months in 4, over a year in 4, and over two years 
in 3; there were also 5 cases with a constant 
periodicity of two to six months. Regular menstrua- 
tion had been established and continued in 12 of the 
16 cases, the operations being performed in 1932 
(1 case), 1933 (1), 1934 (4), and 1935 (6). Of the 4 other 
patients, 1 had begun to menstruate three years after 


operation, 2 had had single periods, and 1 had not ' 


yet menstruated at all; in these 4 cases the initial 
amenorrhea had lasted, respectively, one year, seven 
months, six months, and two years. In 2 of the 
successful cases other treatment (including curettage 
and administration of antuitrin S or œstrin or both) 
had been given for three months before operation 
without effect. On one occasion, Dr. Bailey said, 
he had seen at laparotomy an ovary which had been 
resected and repaired a few months previously. 
Surface healing had taken place by the formation of 
a thin red and wide scar—much more delicate at 
that stage than the tunica albuginea itself—and 
it was probable that a similar scar formed on the 
cut surface of the extroverted ovary, which would 
easily allow of ovulation. Though adequate hormone 
therapy should always he attempted where possible, 
and might be successful where amenorrhosa had not 
been too prolonged, he believed that the operation 
described might be helpful in cases which proved 
otherwise resistant. 


Mr. J. E. Stacey said that the late Mr. King had 
performed a' similar operation on a number of cases 
of dysmenorrhea in the presence of cystic ovaries. 
He was inclined to think it would be more useful for 
that condition than’ for secondary amenorrhea. 
Prof. D. Doucat thought the operation very drastic 
if the patient was young and if the amenorrhoa 
was only of six months’. standing. Periods of 


(FEB. 8, 1936 


amenorrhea of this length were by no means 
uncommon in young unmarried women.—Mr. T. N. A. 
JEFFCOATE said there were really three types of 
amenorrhea: (1) where the ovary was not function- 
ing as an endocrine organ; (2) where there was 
persistence of the cestrin phase ; and (3) where there 
was persistence of the lutein phase. A differential 
diagnosis could be obtained by the examination of 
curettings, and the condition might be relieved in 
a number of ways—e.g., by injections of anterior 
pituitary hormone, by mental shock, or perhaps as 
a result of the shock of an operation.—Dr. D. C. 
RACKER considered that a persistently low blood 
cstrin was sometimes a factor in the production 
of amenorrhea of this type.—Dr. BAILEY, in reply, 
agreed that operative treatment was certainly drastic 
but felt that it had a definite place where other 
methods had failed. 


Granulosa-cell Tumour 


Prof. DouGaL said that during the last ten years 
there had been a revival of interest in certain ovarian 
tumours which had a hormonic influence on the 
sexual characters of the host. These tumours were 
derived from undifferentiated cells in the ovarian 
mesenchyme which though not utilised during 
embryonic development still retained their powers 
of growth and later in life were able to proliferate 
and form new growths. If the sexual influence of 
these cells was towards masculinity the tumour was 
known as an arrhenoblastoma ; if towards femininity, 
as a granulosa-cell tumour; and if neutral, as a 
dysgerminoma. He described the case of a married 
woman of 41 who complained of excessiye and too 
frequent menstrual loss, and who had a large solid 
abdominal tumour indistinguishable clinically from 
a uterine fibroid. At operation the tumour was 
found to be ovarian and was removed, the uterus 
and the other ovary being left behind. Microscopi- 
‘ally it proved to be a very large granulosa-cell 
tumour composed of large numbers of alveoli con- 
taining round cells with deeply stained nuclei. Com- 
menting on this case Prof. Dougal pointed out that 
rranulosa-cell tumours are usually unilateral and 


have a very low degree of malignancy, if they are 


not actually benign. They may develop at any period 
of life and their biological influence is due to excessive 
secretion of astrin. Therefore, if the tumours develop 
before puberty sexual precocity is the result; if 
during the reproductive period, excessive and too 
frequent menstrual loss ; 
pause, post-menopausal hemorrhage. 

The discussion which followed centred round the 
distinction between the granulosa-cell tumour and 
the Brenner tumour, which is derived from Wolfhan 
relics in the hilum of the ovary. Mr. JEFFCOATE 
held that their distinction on histological grounds 
must be very fine and that a physiological basis 
would be more satisfactory—Le., if a tumour produced 
cestrin, and consequently a disturbance of the men- 
strual cycle, it was a granulosa-cell tumour, while 
if it did not it must be a Brenner tumour.—Prof. 
DouGaL said he was inclined to agree. 


Dr. J. W. Brive described three cases of hydro- 
peritoneum secondary to ovarian tumours, and 
showed a specimen of malignant Fallopian tubes. 


Corrigendum.—Mr. A. W. Cubitt points out that 
the remarks attributed to him on p. 260 of our last 
issue were made by a subsequent speaker. 


and if after the meno-’ 


THE LANCET] 


[FEB. 8, 1936 317 


- REVIEWS AND NOTICES OF BOOKS 


Outlines of General Psychopathology 


By Wa. Matamoup, M.D., Professor of Psychiatry, 
State University of Iowa. London: Chapman 
and Hall. 1935. Pp. 462. 21s. 


A SYSTEMATIC account of psychopathology, such as 
is here supplied, is greatly needed by the beginner in 
psychiatry. Presentations of the theory of this or 
that school abound, but for an ordered arrangement 
of the known data and the less debatable explanations 
for their occurrence the reader has had to turn to 
the translation of Kretschmer’s text-book of medical 
psychology, itself disproportionate in so far as it 
reflects the personal investigations and interests of 
its author. Prof. Malamud’s book is well balanced 
and non-controversial. Through having worked in 
Heidelberg he is familiar not only with the holistic 
method of von Weizsacker’s earlier phase but also 
with the phenomenology of Jaspers, to whose more 
detailed and formal treatise he is clearly indebted. 
Chief, however, among those whom he mentions as 
his guides, one sees Adolph Meyer whose salutary 


refusal to guess overmuch is a sure guard against the: 


common faults of psychopathologists. 

The book begins with a plain definition of psycho- 
pathology and discussion of its relationships and 
limitations, the fields in which it may be applied and 
the material upon which it draws. The next part 
describes and analyses the phenomena under the 
general heads: behaviour and experience. The 
various determinants in pathogenesis are next 
examined in turn, the structure of personality is 


discussed, and the synthesis of abnormal functions in 


the various types of morbid reaction is illustrated, 
in the last part of the book, by clinical material. In 
spite of its length the work is properly named : it is 
only a framework or outline, in which the experienced 
psychiatrist must not expect to find recondite 
problems or much detail. The difficulties of the 
author’s task have been so well overcome that it 
would be unjust to reproach him for omissions that 
are judicious and doubtless intentional. 


Immunology 


By Nosie PIERCE SHERWOOD, Ph.D., M.D., 
Professor of Bacteriology, University of Kansas, 
and Pathologist to the Lawrence Memorial Hospital, 
Lawrence, Kansas. London: Henry Kimpton. 
1935. Pp. 608. 25s. 


THIs is a laboriously and conscientiously produced 
volume which covers the main ground of immuno- 
logical science. Such subjects as cellular immunity, 
serological tests, blood grouping, the chemistry of 
antigens, and hypersensitiveness are treated in detail 
and the analysis of a large body of immunological 
literature is made available. At times the ‘“‘ scissors 
and paste ° method of compilation is unduly obtrusive, 
but some chapters, notably those on hypersensitive- 
ness, are well done and the author clearly speaks 
from his own experience. Among the less satis- 
factory chapters are those on toxin and antitoxin. 
Here Prof. Sherwood seems to tread with a some- 
what uncertain step, though the subject is a funda- 
mental one in immunology. We were unable for 
example to find any clear description of the present 
unit of diphtheria antitoxin: the accounts given 
on pages 116 and 212 are inadequate not to say 
misleading. The sections on active immunisation 
against diphtheria also seem to have been compiled 


somewhat uncritically. It is surprising to find the 
expressions ‘‘C. diphtheria”? and “Cl. botulinus ” 
repeated in several places in an otherwise carefully 
written book. To the instructed reader the book 
will prove of considerable value as it covers in 
well-expressed summaries a large amount of modern 
immunological literature, particularly that of American 
origin, and provides full references to original sources. 


The Foot . l 
By Norman C. Laxe, M.D., M.S., D.Sc. Lond., 
F.R.C.S. Eng., Senior Surgeon and Lecturer on 


-` Surgery, Charing Cross Hospital. London: 
Baillière, Tindall and Cox. 1935. Pp. 330. 
12s. 6d.. 


D1SORDERS of the feet, which are extremely common, 
have been treated lightly by the medical profession 
until recent years, to the profit and satisfaction of 
unorthodox practitioners and the vendors of patent 
remedies. Painful feet, to which doctors and nurses 
are especially prone, are liable to alter the whole 
outlook of the individual and make work a burden. 
It behoves us therefore to study their causation and 
treatment with minute care. This book is intended 
for the practitioner and general surgeon, perhaps 
for the masseur and chiropodist, and does not 
deal with elaborate orthopedic details, which can 
be studied elsewhere. Enough about the evolution, 
anatomy, and physiology of the foot is presented in 
readable form to make a foundation for the later 
chapters dealing with the etiology and treatment of its 
common disorders. One chapter is devoted to foot- 
wear, and one to the mechanism of walking, in relation 
to the weakness of the modern foot. Needless to 
say, woman’s footwear receives just criticism. 
The commoner operations recommended are briefly 
described in a separate chapter, and methods of 
anesthesia are discussed. The old anatomical 
terminology is used throughout (except for one or 
two mistakes), but it would be to the advantage of 
future generations of students if the terminology 
of the Anatomical Society of Great Britain, now 
used in two or three text-books, could be adopted 
in future editions. It is difficult to understand why 
anatomists and surgeons should speak different 
languages. There are some printer’s errors which 
should also receive attention in a future edition. 

The book can be strongly recommended as an 
excellent exposition of disorders of the feet. 


Experimental Physiology 


By M. B. Visscuer, Ph.D., M.D., Professor of 
Physiology in the University of Illinois, Chicago ; 
and P. W. SmitH, Ph.D., Associate in Physiology 
in the University. London: Henry Kimpton. 
1935. Pp.191. 15s. 


LIKE most practical physiology text-books this is 
based on a course of experiments made by the students 
of a particular medical school. Such courses have 
much in common, and the authors here are careful to 
make no claim for originality in their subject matter 
presented. In this they are modest, for we have not 
seen in other books simple instructions for the 
demonstration of experimental polyneuritis in the 
pigeon, or for the observation of the cestrous cycle 
and the gonadotropic (wrongly called cestrogenic) 
properties of pregnancy urine. Experiments are 
suggested for every ‘‘system”’ of the body, and the 


318 THE LANCET] 


frog muscle experiments are cut down to suitable 
proportions. The only criticism with regard to 
allocation of space is that the nervous system and the 
special senses are perhaps over-represented. The 
instructions are clear and concise, and no teacher 
will read through the book without picking up useful 
technical hints. An unusual feature is that the 
illustrations are nearly all photographs, a road to 
perfection which most authors have abandoned 
as being too full of pitfalls. In this case the experi- 


NEW INVENTIONS 


[FEB. 8, 1936 


ment is justified, the lay-out of the apparatus and 
the photography being excellent. The last chapter 
is an appendix on methods, preparations, apparatus, 
dosage of drugs in animal experiments, and so forth, 
and is of real value. Selected references to original 
papers and reviews are given throughout. 

The general impression left by the book is that of 
a well turned-out and practised piece of work with 
no loose ends, and the publishers as well as the authors 
deserve praise for its production. 


NEW INVENTIONS 


INSTRUMENTS FOR USE IN OPERATIONS 
UPON FRACTURES OF THE NECK 
OF THE FEMUR 
Tue following instruments have been designed for 
use in operating upon fractures of the neck of the 

femur by the lateral approach. 


LLOYD-KING NAILS 
(Modified from Smith-Petersen) 


These stainless steel nails are a modification of the 
Smith-Petersen triradiate nail and are designed for 


Se PP RET EIST Seen, aaa 


ned et Ne Ee ge 


use with Eric Lloyd’s director, though they are 
equally suitable for any other method “of operating 
upon fractured necks of the femur. The nails differ 
from the standard design in the folowing parti- 
culars: 1. The head is twice the usual thickness, 
being 1 cm. deep, and is traversed by a threaded 
hole 6 mm. in diameter. 2. The nails are made in 
seven lengths from 7 cm. to 10 em. with an interval 
of 0°5 cm. between each consecutive pair. 3. The 
length of each nail (excluding the head) is engraved 
on ‘the head and no engraving is permitted on any 
other part of the nail. 4. Each of the three flanges 
is snagged like the edge of a saw for 3 cm. adjacent 
to the head. This is intended to counteract any 
tendency for the nail to come out when it has once 
been inserted. 5. One of the three flanges is made 
3 mm. shorter than the others. This shorter flange 


q a Ty 


— 
SS E 


En i i= 
=. <= 


LG EP Ed 
=> 


Oo o 


Metal case for nails. 


is directed proximally when used with Eric Lloyd’s 
director, 6. The nails are made in two diameters— 


viz., the ordinary standard 13 mm. and a larger one 
of 16 mm. 


STERILISABLE METAL CASE FOR LLOYD-KING NAILS 


‘This is a strongly.made metal cylindrical case 
with a screw- top “lid. It contains a cruet stand 


fitting, which is made to take one set of seven Lloyd- 
King nails of 13 or 16 mm. diameter. The case is 
half filled with water and the lid screwed down half 
a turn before boiling the nails. Thereafter, no 
handling is necessary, ‘and as the length of each nail 
(excluding the head) is engraved on the outside of 
the head it is easy to find the desired length of nail. 
Moreover, the absence of any one of the seven sizes 
of nail is immediately noticed if they are kept in 
this case. 
LLOYD-KING NAIL INTRODUCER 


This is a threaded stainless steel rod which screws 
into the head of the nail. It is used to pick out the 
selected nail from the sterilised case containing the 
set of seven and to start the nail the first few milli- 
metres into the cortex of the great trochanter. All 
temptation to handle the nail is thus removed, and 


the short flange of the nail can be placed in the cor- 
rect orientation during introduction. As soon as the 
nail has started on its course the introducer can be 
unscrewed and an ordinary punch used to complete 
the nailing. 

LLOYD-KING NAIL EXTRACTOR 


The removal of triradiate nails may be extremely 
difficult and some patterns of extractors necessitate 
full exposure of the whole head of the nail and even 
a portion of the shaft before the instruments can be 
engaged. This extractor screws into the head of the 
nail and considerably simplifies removal, inasmuch 
as exposure is minimised. It was described by 
Thomas King, and is here modified in three respects : 
1. The engaging screw is much longer and of larger 


16 mm, | 


Thate, 


13 mm. | SS 


diameter. 2. A single extractor will remove nails 
of either 13 or 16 mm. diameter. 3. A larger and 
more convenient screw handle has been supplied. 


oS x i 
$ A Vs 1 
Da i any 
/ —— Anis e Wo on 
al 


These instruments have all been made for me by 
Messrs. Down Bros., Ltd., St. Thomas’s-street, 
London, S.E.. but the director (described in 
Tus LANCET, 1935, ii., 129) is made by the Medical 
Supply Association. 


Eric I. Luorp, M.B. Camb., F.R.C.S. Eng. 


THE. LANCET] 


SAFETY VERSUS COMFORT IN CHILDBIRTH 


[FEB. 8, 1936 319 


THE LANCET 


LONDON : SATURDAY, FEBRUARY 8, 1936 


SAFETY versus COMFORT IN CHILDBIRTH 


THE large majority of confinements are now 
attended by a midwife and it can hardly be long 
before every expectant mother will require the 
attendance of a woman whose experience and 
responsibilities are legally defined. In 40-50 per 
cent. of the cases she attends the midwife calls in 
a doctor, and in a proportion of confinements 
which varies from 10-70 per cent. in different 
parts of England a doctor has been previously 
retained by the expectant mother ; but this leaves 
many women who cannot expect any alleviation 


of the pains of childbirth except what they can get 


at the hands of a midwife. Fifteen years ago the 
Home Secretary gave every midwife who has 
notified her intention to practise the right to carry 
in her bag Dover’s powder and laudanum as well 
as chloral and bromide; with these the midwife 
working alone has been able to ensure rest and 
relaxation for the anxious and restless patient. 
The injunction of the Central Midwives Board 
that no drug should be used by a midwife unless 
she has been thoroughly trained in its use and is 
familiar with its administration seems to have been 
conscientiously followed. But none of these 
sedatives is effective in the second stage of labour, 
and four years ago Miss E. M. Pye suggested 
and Mr. L. C. Rivett worked out the use of 
chloroform in the form of 20-minim capsules, 
to be crushed and administered by the midwife, 
or by the woman to herself, during brief periods 
of severe pain as they arise. Under the leadership 
of Mrs. STANLEY BALDWIN the proposal was taken 
up warmly by the National Birthday Trust Fund, 
which was then financing the provision of qualified 
anzesthetists in maternity wards, and at a festival 
dinner of the British College of Obstetricians and 
Gynecologists Mr. BaLpwin said he wanted to 
see the day come when the best form of anesthesia 
should be within the reach of every parturient 
woman. In reply, Dr. J. S. FAIRBAIRN, speaking 
as president of both Board and College, pleaded 
that he was ground between upper and lower mill- 
stones—between those who would trust the 
midwife with any available anesthetic, and those 
who hesitated to place dangerous weapons in the 
hands of women not qualified to use them. What, 
he said, was needed was a scientific clinical test 
on a large scale, for the method adopted must be 
without increased risk for mother or child. This 
is in brief the origin of the investigation into the 
use of analgesics in midwifery, the report of which 
appeared last week and was summarised in our 
columns (pp. 282-3). The subcommittee of the 
College entrusted with the investigation consisted 
at first of Dr. FAIRBAIRN, Mr. EARDLEY HOLLAND, 


Prof. FLETCHER SHaw, Mr. Rivert, and Mr. 
CHRISTIE Brown. Later Mr. G. F. GIBBERD 
was codpted to assist in drawing up the forms of 
record, Dr. Z. MENNELL to advise about the 
analgesics employed, Prof. E. MELLANBY as 
nominee of the Medical Research Council, and 
Dr. MatrHEw Young for expert statistical help. 
The investigation was a wide one; 36 hospitals 
in various parts of the British Isles took part 
in it, and they were kept in touch by supervisors 
prepared to clear up doubts as to the purpose of 
the investigation and to give instruction in the 
use of the standard methods. Although the 
special reference was to the use of chloroform 
capsules by midwives the investigation was 
widened to cover the efficacy and safety, in the 
hands of various groups of administrators, of 
nitrous oxide, of paraldehyde, and of chloroform 
given in three different ways. 

On all these methods of producing analgesia the 
committee have come to definite conclusions, on 
which equally definite recommendations are based. 
The ground can at once be cleared of paraldehyde 
per rectum because “it does not provide adequate 
analgesia at the time of the actual birth.” Gas 
and air administered by the Minnitt apparatus 
“is a safe and satisfactory method of producing 


analgesia, although the apparatus is expensive 


and the nitrous oxide costly’; its use should 
be “ extended to the practice of midwives, provided 
they are specially trained in its administration.” | 
Chloroform, on the other hand, given by any 

method, “ should not be used by midwives acting 
alone. This conclusion,’ the report says, ‘has 


‘been reached with regret, but both immediate 


and delayed dangers, which are well recognised, 
occurred in this investigation, and it is not possible 
fully to guard against such occurrences if the 
administration of chloroform is in inexperienced 
hands. This finding should not, however, be 
taken as prejudicing the use of chloroform by 
registered medical practitioners, who, aware of the 
dangers, can take precautions to lessen the risks.” 
These recommendations it will be noted bear on the 
question of safety rather than on that of efficacy, 
for, to repeat Dr. FarrBarrn’s words, the method 
adopted must be without increased risk for mother 
or child; but it is interesting to note the high 
degree of efficacy both in gas-and-air and chloro- 
form analgesia, no matter what the method or 
agent of administration. The proportion of patients 
who obtained satisfying relief from pain varied 
from 79 up to 94 per cent.; it was 84 per cent. 
for chloroform capsules administered by the 
midwife (in 695 reported cases). This method which 
was the primary object of the investigation is 
therefore well justified by the relief afforded, and 
it is natural to inquire more closely into the reason 
for the conclusion that it should not be used by 
midwives acting alone. 

Among a total of 4975 cases in which chloroform 
was given by various methods to produce analgesia, 
with or without general anesthesia, 6 mothers 
died ; and these deaths were studied in detail. 


In 3 of the 6 the conclusion is reached that 


chloroform was in no way responsible for death ; 


320 THE LANCET] 


in 2 it was an important factor in the fatal issue ; 
and in 1 chloroform was directly responsible for 
death. This last case was the only one in which 
chloroform was given in the form of capsules. 
The patient was a primigravida, 21 years of age, 
with well compensated mitral disease, who had 
received a standard dose of paraldehyde and late 
in the second stage was given chloroform capsules 
by a medical student. When the head was about 
to be born the woman became difficult to control 
and six capsules were used within two minutes. 
This death, says the report, illustrates that chloro- 
form capsules are not foolproof and shows that the 
display of precise instructions as to dosage is not 
a sufficient safeguard against misuse, even in 
hospital. It will be noted however that the 
report contains no evidence of harm being done by 
chloroform capsules to any woman in normal health, 
nor of any harm being done by chloroform capsules 
given by a midwife, or even by a pupil midwife. 
On the other side we have a statement to the 
Birthday Fund in 1933 that among 4000 patients 
who had capsules at Queen Charlotte’s and 
Middlesex Hospitals there was no maternal death, 
while out of every 100 women 90 obtained some, 
and 50 very great, relief. Commenting on these 
figures Mr. RivettT declared that “this is a 
completely safe and foolproof method of relieving 
the intense pains of childbirth and one which is 
easily learned at a very short course of instruction ”’ ; 
_ and if the committee have obtained evidence which 
reverses this verdict, they have not produced it. 
It was already common knowledge that some 
patients given chloroform capsules are noisy and 


difficult to control during the. second stage, but: 


so far as we are aware this has never led a midwife 
to disobey instructions and crush capsules so 
freely as to produce an over-concentration of 
chloroform vapour. In the other two fatal cases 
in which chloroform was blamed it had been given 
for prolonged periods by the Mennell inhaler and 
was later pushed to full surgical anesthesia, the 
illness being typical of the diffuse acute necrosis 
of the liver which occasionally follows the 
administration of chloroform. For example, in 
his analysis of 999 fatal cases in a Glasgow maternity 
hospital (see p. 295 of this issue) Dr. DvuGaLp 
Batrp finds that delayed chloroform poisoning 
was the sole cause of death in 5 forceps deliveries 
. after long labour. The report admits that it was 
the full surgical anzsthesia rather than the pre- 
liminary analgesia which was the important factor 
in the cause of death, but regards the previous 
prolonged analgesia as weighting the balance 
against recovery. Whatever lesson is to be drawn 
from these cases against the use of deep chloroform 
anesthesia in obstetric operations when so safe 
an anesthetic as nitrous oxide is available, they 
seem again to have little if any bearing on the 
safety of a limited number of chloroform capsules, 
spaced at intervals of not less than five minutes, 
in the hands of a midwife acting alone. 

But while the report is clear that chloroform by 
any method should not be used by midwives 
acting alone, it recognises that the administration 
of gas and air is a safe and satisfactory means of 


A NEW INSULIN COMPOUND 


[FEB. 8, 1936 


producing analgesia, and recommends its extension 
to the practice of midwives under proper controls. 
Unfortunately, as we have seen, the committee 
find themselves obliged to lay stress on the expense 
of the apparatus and the costliness of the nitrous 
oxide. The expense of the apparatus is not argu- 
able, but the cost of the gas in the investigation 
was enhanced by wastage ‘“‘ owing” it is said, 
“to the fact that, as the apparatus is now con- 
structed, leakage may occur at many places unless 
constant attention is given to minor adjustments.” 
It seems that in the investigation itself the leakage 
in question assumed such proportions as to 
invalidate any estimate of the cost of gas-and-air 
administration per patient; but we should like 
to call attention to the experience of Dr. J. ELAM, 
as set out in our own columns a few weeks ago 
(Tur Lancet, 1935, ii., 1253), in which particular 
attention was paid to the competence of the 
midwife to administer gas-and-air analgesia and 
to the cost-of the case itself. At the Wellhouse 
Hospital, Barnet, midwives have been trained to 
use gas and air for their own patients, the only 
trouble met with in district work being to decide 
when to start the administration, a difficulty 
which was soon overcome in practice. Dr. ELAM 
was satisfied that the cost of nitrous oxide per 
case at Barnet was working out at about two 
shillings. 


A NEW INSULIN COMPOUND 


In treating endocrine deficiencies with glandular 
extracts it is not always easy to imitate the steady 
controlled secretion of the normal gland. Where 
the injected or ingested extract is stored in the 
body and used as required, as happens in ‘thyroid 
therapy, no difficulty is experienced. But more 
often the available extracts have only transient 
effects, and when in addition the preparation must 
be given hypodermically serious obstacles may 
arise ; for a point is reached at which the patient 
will revolt against a life punctuated by too frequent 
pin-pricks and will prefer his deficiency as the 
lesser evil. 

The treatment of diabetes mellitus with insulin 
is a case in point. The average diabetic needs 
two daily injections of insulin and a considerable 
number require three; but few patients would 
tolerate more. Since the action of insulin is 
limited to a few hours the humane physician is 
usually forced to give larger doses of insulin than 
the immediate level of the blood-sugar would 
indicate. His patient accordingly oscillates between 
glycosuria with its attendant threat of ketosis, 
and the less dangerous but decidedly unpleasant 
state of hypoglycemia. More than one attempt 
has been made in the past to avoid this difficulty 
by delaying the absorption of injected insulin. 
Some years ago Leyton’ tried powdered insulin 
suspended in castor oil and showed that the 
latter hindered the absorption of insulin and 
smoothed out the grosser oscillations of the 
blood-sugar. But the oily vehicle is only very 
slowly dispersed (by phagocytosis) and the risk 


1 Leyton, O.: THE LANCET, 1929,i., 361 and 756. 


THE LANCET] 


of local infection is increased. Recently Prof. 
HAGEDORN and his associates in Copenhagen have 
attempted to solve the problem by combining 
insulin with various organic bases to form com- 
pounds which are relatively insoluble at the pH 
of tissue fluids and are accordingly more slowly 
absorbed. HAGEDORN has just published some of 
his preliminary results? and Root and others 3 
have reported their experiences with samples of 
the same preparation, supplied by Prof. HAGEDORN. 
The preparation in question, protamine insulinate, 
is made by mixing a solution of insulin hydro- 
chloride with a protamine extracted from the 
sperm of a species of trout, Salmo irideus. The 
insulin combines with the protamine base to form 
a compound which is least soluble at pH T3, 
that is, about the reaction of normal plasma. 
When this mixture is injected into a normal 
subject evidence of considerable delay in absorption 
is observed. Compared with ordinary insulin 
the fall in blood-sugar is much more gradual, and 
although the degree of hypoglycemia obtained is 
rather less, the effect persists for about twice the 
usual time. Exactly similar differences are 
observed in diabetic subjects. Here the effect is 
greatest in those patients who are rather sensitive 
to insulin and whose blood-sugar under orthodox 
treatment displays big oscillations. Protamine 
insulinate smooths out the peaks and depressions 
to a remarkable extent, and the excretion of sugar 
and also of ammonia (an index of acidosis) is 
greatly reduced. 

The charts shown by both the Danish and the 
American workers leave no doubt in the mind of 
the reader that combination with protamine 
greatly delays the action of insulin. This is an 
important advance, but we cannot yet assess its 
practical significance. A number of incidental 
problems must first be studied. For instance, the 
blood-sugar of the diabetic usually reaches its 
highest level in the period preceding the first 
meal of the day. The morning dose of insulin 
has therefore not only to reduce this level, but also 
to balance the carbohydrate eaten at breakfast. 
It has been found that protamine insulinate is not 
absorbed quickly enough to serve this double 
purpose, and it has been found advisable to use 
ordinary insulin for the morning dose, reserving 
the protamine compound for the evening, where a 
prolonged rather than an intense effect is desirable. 
That, of course, means that the patient would have 
to carry two kinds of insulin, and his daily routine 
is already complicated enough. Moreover the 
present preparation does not remain stable 
indefinitely and the suspension must be shaken 
before the syringe is filled. Finally, the new 
compound seems to be contra-indicated in diabetic 
coma where rapidity of absorption is vital. None 
of these difficulties is necessarily insuperable 
and the further researches of Prof. HaGEDORN 
and his colleagues will be awaited with keen interest. 
Meanwhile it is necessary to point out that the 
work is still in the experimental stage. 


3 Hagedorn, H. C., Jensen, B. N., and Krarup, N. B.: Jour. 


Amer. Med. Assoc., Jan. 18th, 1936, p. 177. 
* Root, H. F., White, P., and Marble, A. : Ibid., p. 180. 


PROSTATIC INVOLUTION 


[FEB. 8, 1936 321 


PROSTATIC INVOLUTION 


HowEvER much we may pride ourselves on the 
advances made in prostatic surgery during the 
last ten years prostatectomy remains a formidable 
operation, and it is worthy of note that medical 
men who have recommended the operation to 
their patients sometimes show a disinclination to 
undergo it themselves when they begin to find 
micturition difficult. Any treatment that holds 
out a hope of saving an elderly man from the 
dangers and discomforts of a major surgical 
operation deserves consideration. Dr. PAUL 
NIEHANS, in an article which appears on p. 307 
of this issue, claims to have given relief to nearly 
400 sufferers from prostatic enlargement by the 
simple operation known as Steinach’s ligature II. 
In his opinion senile changes in the prostate are 
due to the removal of the inhibiting action of the 
hormone secreted by the seminiferous tubules 
and the unrestrained action on the prostatic 
tissues of the secretions of the interstitial cells 
of Leydig and of the basophil cells of the anterior 
pituitary, together with the female hormone which 
is known to exist in men as well as in women. 
This endocrine view of prostatic enlargement was 
anticipated many years ago by Mr. KENNETH 
WALKER in a Hunterian lecture which was published 
in our columns.! Mr. WALKER then stated that, 
although it was not known what determines the 
onset of prostatic enlargement, the enlargement 
was undoubtedly an incident in the involution 
of the genital tract. In all probability, he added, 
it was brought about by an upset in the endocrine 
balance occurring at the time of the male 
climacteric. Since that time great advances have 
been made in our knowledge of the hormones 
regulating sexual activity and of their interaction 
with the secretions of the pituitary body; and 
it is now established that the pituitary plays a 
very important part in the changes occurring 
in the endocrine system at the time of genital 
involution. Dr. NIEHANS summarises recent work 
on this subject, and whatever may be the value 
of the method of treatment he advocates we may 
well admit that senile changes in the prostate will 
ultimately be explained in terms of endocrinology. 

After reviewing former attempts to deal with 
enlargement by such means as castration and vaso- 
ligature, Dr. NreHans relates how in 1928 he made 
use of the method of ligaturing the efferent ducts 
of the testis that had previously been employed 
by STEINACH as a means of “rejuvenation.” 
He postulates that by occluding these ducts the 
hormones of the germinal epithelium are forced 
through the pores of the tunica albuginea into the 
numerous veins surrounding the testicle, and thence 
pass into the general circulation. Since these 
hormones inhibit the action of the various secretions 
reponsible for senile changes in the prostate, any 
increase of them in the blood stream would have 
a curative effect. On p. 242 of our last issue is 
recorded the demonstration for the first time in 


— 


1 THE LANCET, 1924, i., 16. 


322 


monkeys that male hormone can cause the dis- 
appearance of prostatic hypertrophy induced by 
cestrone. This would well account for the results 
following the ligature, when not only symptoms 
improved, but the size of the prostate diminished, 
and in the majority of cases residual urine dis- 
appeared. But what Dr. Nimans does not explain 
is why ligature of the efferent tubules should prove 
so much more effective than ligature of the vas. 
By either method the same result should be 
obtained—namely, cutting off the external secretion 
of the testis and increased absorption into the 
general blood stream. Yet vaso-ligature as a 
method of treating prostatic enlargement has 
proved a complete failure. Nor does he make it 
clear how ligature can revive the activity of the 
epithelium of the tubules. If the changes in the 
prostate are the result of involution in the semi- 
niferous tubules, can it be supposed that occlusion 
of the efferent ducts stimulates their activity in 
addition to promoting absorption of their secretion ? 


Medicine however is not an exact science and 
the proof of the validity of Dr. NrzHans’s observa- 
tions should be sought in results rather than in 
deductions. Does ligature of the efferent ducts in 
fact relieve the patient of his symptoms, lead to a 
shrinkage of the prostate and the disappearance 
of the residual urine ? In assessing the value of 
any method of treating prostatic obstruction it 
must be borne in mind that the symptoms of which 
the sufferer complains are liable to fluctuate. 
Periods of increased frequency and difficulty are 
followed by intervals of improvement, and care 
must be taken not to mistake one of these quiescent 
periods for an improvement that is the direct result 
of treatment. Moreover it is now certain that 
much of the difficulty in micturition experienced 
by a prostatic patient is the result of a dynamic 
rather than a static factor, that is to say, spasm 
of the sphincter rather than mechanical obstruction. 
Those who believe that Steinach’s ligature II. 
acts through the sympathetic system, rather 
than by means of an alteration in the endocrine 
balance, may be right. But however disinclined 
urologists may be to believe that so simple a 
proceeding as that advocated by Dr. NIEHANS 
can cure prostatic obstruction, the mere fact that 
it is simple and can do no harm demands that it 
should be tried. If one man has been able to 
obtain such excellent results, others should have 
no difficulty in confirming them. The value of 
Steinach’s ligature II. can readily be proved or 
disproved. | 


EPIDEMICS OF MALARIA 


In a paper read before the Royal Society of 
Tropical Medicine and Hygiene on Jan. 16th 
and expressly confined to the epidemiological 
side of malaria, Lieut.-Colonel C. A. GILL dealt 
primarily with the epidemic which began in 
Ceylon in the autumn of 1934. In any particular 
part of the area which this finally covered it 
broke out with such startling suddenness that its 
onset could be fixed to a day, the date being a 
month later in the southern than the northern 


THE LANCET] 


EPIDEMICS OF MALARIA 


[FEB. 8, 1936 


part. Thus in the town of Kurunegala, selected 
for intensive study for its convenient situation, 
the dispensary attendances were respectively 106 
and 306 on Oct. 28th and 29th. This first wave 
had four morbidity but only three mortality 
peaks, set at about monthly intervals, the 
first morbidity peak bringing no corresponding 
rise in the death-rate. Further, as to children 
under 4, whose susceptibility to malaria is well 
known, there was an actual lowering of the per- 
centage attending dispensary during the first 
wave and this was followed by no increase in 
deaths. These facts led GIL to the conclusion 
that the first morbidity peak was caused by 
relapses among older persons—a view strengthened 
by the reasoning that, had it been due to fresh 
infections, there must first have been a great 
increase in the numbers of infective Anopheles 
culicifacies, that such increase in infective numbers 
must have taken place from a human population 
still in its normal state of health, and that when 
infective the mosquitoes must have abstained 
from children’s blood. There is no mention of 
any influx of persons not immune to the local 
plasmodial strains, so that GILL was left with 
a combination of two factors as the cause of the 
epidemic, the first being some influence on the 
plasmodium or its host making for relapse, the 
second the appearance of conditions favourable 
to multiplication of the mosquito carrier. As to 
the latter, he notes that there was a sharp rise in 
atmospheric humidity in October, 23 days before 
the onset of the first four-peaked epidemic wave, 
and another in April which in turn was followed — 
by another epidemic wave. He also points out 
that during the nineteenth century malaria 
epidemics took place simultaneously in different 
parts of the world, that they were related to the 
cycle of sunspots, and that these last produce wide- 
spread abnormality of meteorological conditions. 
He showed a curve based on the seven and a half 
sunspot cycles which fell between 1860 and 1934, 
the most striking feature of which was the associa- 
tion of malaria pandemics with maximum or 
minimum sunspot numbers. These conditions 
of the sun are apt to be associated with drought 
or floods, and GILL pointed out that drought in a 
normally wet zone and flooding in a normally dry 
zone are likely to bring about conditions favourable 
to excessive breeding of mosquitoes. It was not 
however noted at the meeting that there may well 
be a nearer relationship between a changing 
quality of light and the occurrence of malaria 
relapse ; EUGENE R. WHITMORE * has, for instance, 
shown that violet light produces relapse in the 
malaria of canaries, an infection which is due to 
another plasmodium, P. relictum. Colonel Gri 
was insistent on our powerlessness with our present 
knowledge, despite its great advance during the 
last fifty years, to prevent malaria epidemics, 
or to control them when they have begun. The 
need for further investigation was emphasised by ` 
his statement that the deaths in this outbreak 
were about 100,000, that the State relief measures 


1 Amer, Jour, Trop. Med., 1922, ii., 475. 


THE LANCET] 


cost £350,000, and that probably over a third of 
the island’s inhabitants were infected, with con- 
sequent money loss, ill-health, and misery. 

In discussion Sir RICKARD CHRISTOPHERS 
mentioned the likeness of the Ceylon epidemic to 
those in the Punjab in 1892 and 1908, the former 
the greatest ever recorded with 150,000 deaths, 
the latter covering an area greater than the whole 
of Ceylon. He described the maps of malaria 
epidemics as giving the instinctive feeling of 
“malaria cyclones”; a resemblance not merely 
superficial since their fundamental cause is meteoro- 
logical, but still not the whole matter since happen- 
ings in previous years had their cumulative results. 
It was startling, he felt, to picture the sudden 
outburst of these epidemics as due to relapses, but 
Colonel GILL’s contention needed serious considera- 
tion. The next speaker, Colonel S. P. JAMES 
laid particular stress on a possible widespread 
invasion of the area by infective anopheles, and 
said he thought that a relapse wave would imply 
a primary wave about eight months earlier. He 
urged the need for further research; especially 


` since there is still no moderately complete account 


of the life-history of A. culicifacies in its adult 
stage, though it has been known for over thirty 
years as an important agent in the spread of malaria. 
Sir MALCOLM WATSON went outside the deliberately 
limited scope of the paper by dealing with endemic, 
not epidemic, malaria, and urged the primary 
importance of the house site in prevention. It 
was first necessary, he said, to select the proper 
site for a village and then to go forward with all 
that was necessary for good sanitation on that 
site. He insisted that to make the most of funds, 
first things must be put first, and held that this 
great epidemic showed that malaria was the 
major disease problem in Ceylon. Certainly this 
looks reasonable ; nevertheless those who remember 
an effect of the great influenza pandemic of 1918 
will hesitate to accept Sir Matcoum’s diagnosis 
without question ; for at that time, among 14,640 


persons who had been treated for hookworm ~ 


infection? the death-rate per mille was 7:5, whereas 
among 3253 on the same estate who had been left 
untreated it was almost double, 13°8. An under- 
lying cause of ill-health may be of greater 
importance than an evident cause of deaths. 
The further investigation which this speaker also 
urged is necessary before there are data for any 
firm conclusions ; and in the meantime we suggest 
that the result of no constant drain on bodily 
reserves can safely be disregarded. | 

Prof. D. B. Buacktock, in referring to the 
possibility of an epidemic of relapses, mentioned 
the work reported from Liverpool in the post- 
war years, which showed that treatment from 
July to December had a relapse rate of 38 per 
cent., while a similar treatment in January had 
one of 94 per cent. He dissented from the view 
that modern medical science was powerless to 
prevent and control these epidemics, and held 
that if the £350,000 spent on relief had been 
available for prevention the course of events would 


t Rockefeller Foundation, Internat. Feslth Board, Fifth 


Ann. Rep., 1919, p. 61. 


STANDARD BLOOD COUNTING APPARATUS 


[FEB. 8, 1936 323 


have been very different. He spoke, then, 
essentially of endemic malaria, but he further 
pointed out the diffculty of dealing from that 
point of view with a free rural population in the 
tropics. Sir WELDON DALRYMPLE-CHAMPNEYS felt 
that, as put forward to the Royal Society of 
Medicine by Dr. R. BRIERCLIFFE and himself,’ the 
three most important factors in the causation of 
this epidemic were the encouragement of breeding 
of A. culicifacies in river pools left by the drying 
rivers, the fact that the population in the wet 
zone of Ceylon was little “‘ salted ” to malaria, and 
the semi-starvation of the people owing to partial 
failure of the paddy crop. He, too, urged the 
need for concentration on research, and was sure 
that remarks by Colonel GIL which had been 
taken as pessimistic were merely meant as pointers 
to lack of knowledge and stimulants to fill its 
gaps. Certainly all who commented on his paper 
were at one with the opener about the need for 
more intensive study of the problem of epidemic 
malaria. Colonel GILL has introduced a new and 
promising line of thought which is certain to be 
put to the test as soon as opportunity offers. 
His valuable paper and the informative discussion 
will be available in full in the coming issue of the 
Society’s Transactions (vol. xxix., No. 5). 


STANDARD BLOOD COUNTING 
APPARATUS 


WE printed last week a request to hematologists 
from the British Standards Institution for criticism 
of a specification drawn up for counting chambers 
and dilution pipettes. This institution, which has 
done good work in standardising many technical 
processes used in commerce and engineering, has now 
turned its attention to the technique of the medical 
laboratory and has drafted a specification for a 
standard hemocytometer. This contains no novelties 
with the exception that the ruling of the counting 
chamber embodies features of both the Neubauer 
and Glaubermann rulings, with one or both of which 
most workers are familiar. It is manifestly a good 
thing for laboratory methods to be standardised, so 
far as this is possible. Few people other than those 
actually engaged in laboratory work realise the wide 
divergence in results which may be obtained from 
the same specimen by the use of different techniques 
of examination; standardisation of method is the 
first step towards a valid comparison of results 
obtained in different laboratories. In selecting the 
hemocytometer to start on the British Standards 
Institution has taken a relatively simple test object ; 
even for this however the specification occupies 
ten foolscap sheets of typewriting and five sheets 
of line drawings. The specification is still only in 
draft form and the institution is anxious that before 
it is completed it should receive the consideration 
of all interested parties. Copies of the draft may 
be obtained on application to the director, British 
Standards Institution, 28, Victoria-street, London, 
S.W. 1. 


*See THE LANCET, 1935, ii., 1176. 


324 THE LANCET] 


[FEB. 8, 1936 


ANNOTATIONS 


CESTRIN AND CANCER 


No branch of biological science shows such rapid 
progress as the study of sex hormones, and unlike 
advances in our knowledge of other series of pharma- 
cologically active substances, this progress has 
covered all the aspects of the subject—physiological, 
pathological, and chemical. There is little doubt 
that the original stimulus for the work now develop- 
ing so successfully was the observations of Allen 
and Doisy, some twelve years ago, which put research 
on the ovarian hormone on a sound experimental 
basis. A second great stimulus came through Asch- 
heim and Zondek’s recognition of cestrus-producing 
hormone and prolan in the urine. A year or so later, 
crystallisation of the former led to the foundation 
of the accurate chemical investigations in which so 
many have taken an active and important part. 

Some of the most surprising results of this work 
concern the chemical relationships of the oestrus- 
producing hormones. Their recognition as deriva- 
tives of the sterol series has linked them up with 
vitamin D on the one hand and such substances as 
the cardiac aglucones on the other, and it is only 
natural that this chemical relationship should lead 
to speculation about the possibility of sex hormones 
having other actions besides the main one. It has 
been shown, for example, that many of the male 
hormone derivatives are estrogenic, and Zondek’s 
discovery of the cstrus-promoting factor in the 
urine of stallions indicates the complexity of the 
physiological activity of these bodies. The further 
observation that certain carcinogenic substances 
are also œstrogenic raises the question whether there 
is some relation between cestrin and malignant 
disease—a question of more than academic import- 
ance now that ostrin in substantial doses is widely 
used in medical practice. It has been claimed by a 
number of workers, particularly by Lacassagne, that 
it is possible to increase the incidence of mammary 
carcinoma by administration of ostrin, and it has 
also been pointed out that administration of very 
large quantities of ostrin will bring about changes 
in the epithelium of the genital tract of a type which 
suggest malignant proliferation, although no epithe- 
liomata have been reported. Fortunately, however, 
we have the clear-cut demonstration, by E. L. Kenna- 
way and his co-workers,! that ostrin, when painted 
on the skin of mice according to the standard tech- 
nique employed by the Cancer Hospital workers in 
testing for carcinogenic properties, was entirely 
without effect. From this it appears that ostrin 
is not carcinogenic in the same way as 1:2:5:6- 
dibenzanthracene or methylcholanthrene are carcino- 
genic. It must be remembered also that the animals 
in which Lacassagne produced carcinoma of the 
breast were of inbred stock, selected for suscepti- 
bility to cancer, and that the conditions were there- 
fore very different from those of administration of 
cstrin to human beings. Moreover, as Dr. Cramer 
and Dr. Horning pointed out in our last issue, all 
these experiments, including their own, involve the 
treatment of animals with large quantities of cestrin 
over a very long period, and here again the condi- 
tions do not resemble those of clinical practice. 

In reviewing the relationship of sex hormones, 
carcinogenic hydrocarbons, and synthetic cestrogenic 
agents, Prof. E. C. Dodds? has lately remarked that 


i 1 Proc. Roy. Soc., B., 1935, exvii., 318. 
* Ergeb. d. Physiol. u. exp. Pharm., 1935, xxxvii., 264. 


the similarity, in chemical structure, between carcino- 
genic hydrocarbons and cstrin is by no means so 
close as the similarity between the male and female 
sex hormones; yet there has never been any sug- 
gestion that the treatment of women with large doses 
of cestrin is likely to lead to masculinisation effects. 


GONOCOCCAL EPIDIDYMITIS 


TuE frequency of infections of the epididymis 
secondary to gonorrhcea reflects unfavourably on 
the application of present methods of treating this 
disease. Various authorities place the incidence of 
this complication at from 2 to 25 per cent. of all 
cases of gonorrheeal urethritis, and the average is 
probably in the neighbourhood of 10 per cent. In 
fact, though nearly always preventable, it is by far 
the commonest of all intrascrotal infections. The 
way in which it is transferred nevertheless remains 
in dispute. There is little evidence to suggest a 


‘blood-stream infection; but the theories of spread 


through lymphatics or by surface continuity along 
the mucous membrane of the vas deferens have their 
advocates, while Pelouze! believes that infected 
material is forced down the lumen of the vas deferens 
into the epididymal tube—a belief widely shared in 
the United States. The xtiology of the condition, at 
any rate, is not in doubt. Trauma to the. posterior 
urethra, in the presence of infection, is the almost 
invariable cause, and may result either from the 
patient’s indiscretion or the doctor’s mismanage- 
ment. Unfortunately it seems that the latter is often 
to blame. The posterior urethra may be damaged 
by the use of excessive pressure in urethral irriga- 
tions, by too frequent irrigation, or by fluid which 
is too hot or too strongly antiseptic, and a similar 
result may be produced by prostatic massage or 
urethral instrumentation carried out too vigorously 
or too early. On the other hand, the patient may 
cause or contribute to his own misfortune by sexual 
and aleoholic indulgence or by vigorous exercise, 
especially when the bladder is full. 

Robertson and Lee? have recently described their 
methods in the treatment of 65 patients with epididy- 
mitis, in 90 per cent. of which the infection was 
known to be gonococcal. They emphasise the 
importance of avoiding this complication by care in 
treatment, and once it is established they advocate 
conservative methods, which proved successful in 63 
of their 65 patients. The difficulty of achieving com- 
plete immobilisation of the scrotum by the ordinary 
methods of support, by suspensory bandage or jock- 
strap, is overcome by the use of an ingenious but 
simple application of strapping, which is a modifica- 
tion of that used in the Bellevue Hospital, New 
York City. The scrotum is brought forward to the 
suprapubic region and there immobilised, while at 
the same time the scrotal skin is protected from the 
irritating effects of the strapping by a layer of gauze, 
and in this way local applications of heat or cold 
are rendered unnecessary for the patient’s comfort 
and there is no need of operation or admission to 
hospital. At the same time rest in bed for the first 
three days is advised. The indication for operation 
is the persistence of fever and acute pain at the 
end of this period, and the operation of choice is 
epididymotomy, which was performed in 2 cases. 

The treatment of gonococcal epididymitis by 


1 Pelouze, P. S.: Surg. Clin. North America, 1935, xv., 213. 
a eo erie J. P., and Lee, A. B.: Amer. Jour. Surg., 1935, 
XXX., 462, 


THE LANCET] 


surgical incision and drainage has never found favour 
in this country, and the present support for con- 
servative measures is therefore welcome. In the 
rare cases where surgical intervention has seemed 
advisable excellent results have been obtained by 
simple needling of the globus minor, accompanied 
where possible by aspiration of pus or inflammatory 
secretion. | 


INCENTIVES IN INDUSTRY 


EXPERIMENTS recently carried out by C. E. Mace ! 
were directed towards determining the efficacy of 
setting up standards of achievement as an encourage- 
ment in the performance of tasks or the learning of 
them. Measurement of results was necessarily adopted 
as a criterion of comparison between different 
standards, and conclusions emerged that should find 
application in industrial life. The investigation 
falls into place with other work, such as the study 
of the actual movements involved in a specific 
industrial activity, which is aimed at the attain- 
ment of optimum results consistent with the comfort 
and well-being of the worker, without which proviso 
there is more than a danger that opposition will be 
aroused against what is regarded as a process of 
“speeding up.” The experimenter in this case is 
interested in the human side rather than the 
mechanical, and expresses his appreciation of the 
larger problems when he hopes that the incentives 
of industry may ultimately be assimilated more 
closely to those of professional life. 

Industry has changed greatly since the bad old 
days when a worker was paid as little as possible and 
driven as hard as his physical powers allowed, his 
need for the necessaries of life being regarded as 
sufficient incentive to work. That need will always 
be a primary urge to human endeavour, but man, for 
good or ill, is driven by so many other motives that 
industry is compelled to take account of them. It 
is a commonplace to lament the decay of handicraft 
with its gratification of the pride of achievement, 
which Mr. Mace calls upon in his experimental subjects ; 
and to regret the repetitive processes that accompany 
mass production and appear to condemn workers to 
a day of monotony and boredom. Yet it is a 
discovery of industrial psychology that repetitive 
work need not be subjectively monotonous or inevit- 
ably accompanied by boredom ; human nature is so 
adjustable that with reasonable conditions of work, 
including rest pauses, such tasks can be happily 
performed. Rest pauses were introduced, on obvious 
physiological grounds, to avoid fatigue, and increased 
output justified them. But some paradoxical results 
obtained by Elton Mayo suggest? that unexpected 
factors such as a sense of social solidarity in regard 
to one’s fellows and the management of the firm, 
rather than diminished physiological fatigue, were 
the cause of the improved output in a batch of workers 
who were closely observed over an experimental 
period of two years. This observation indicates 
a trend of thought that is coming more and more 
to influence industrialists, who have passed beyond 
the stage when Factory Acts were necessary to ensure 
attention to material safeguards of the health of the 

worker, to sanitation, ventilation, protection against 
accidents, hours of juvenile labour and, in some 
cases, rates of pay; their chief function to-day is 
to protect standards from violation, not to establish 
them. 


1Incentives: Some Experimental Studies, Industrial Health 
Board Report No. 72. H.M. Stationery Office. 
*The Human Problems of an Industrial Civilisation. 


York: The Macmillan Company. 1933. 


New 


INCENTIVES IN INDUSTRY.—BROMIDE INTOXICATION 


[FEB. 8, 1936 325 


The human and social aspects of industrial organisa- 
tion are now receiving attention, one sign of this 
development being the employment of industrial wel- 
fare workers in factories and similar establishments. 
In the beginning welfare workers were expected to 
supervise matters affecting the comfort and material 
well-being of employees—canteens, amusements, and 
the like; this they still do, but gradually there is 
emerging the principle that they serve as interpreters 
between the ideas of the administrative and employing 
side and the aspirations or even the dissatisfactions 
of the workers. An essential in the running of an 
industrial establishment is attention not only to the 
material but the emotional welfare of the employees, 
and in this way the difficulty of adjusting the human 
element to the demands of modern industry may 
perhaps be overcome. Welfare workers are now 
sufficiently numerous to have their own organisation 
and journal, and they are accumulating knowledge 
as to the mental attitudes and emotional reactions 
of individual employees which will fit in with the 
work of the Industrial Health Board and lead us 
nearer to the ideal of making the worker happy in 
his work; for this is, after all, the first condition 
for the successful working of any system of incentives. 


BROMIDE INTOXICATION 


OF late years several American observers have 
thought it well to call attention to the prevalence 
of bromide intoxication among psychotic, neurotic, 
and epileptic patients. To such patients bromide 
is often given for its sedative or anti-convulsive 
action, and mental symptoms due to too much 
bromide may pass unrecognised through being 
attributed to the disease that already exists. This 
is emphasised in a paper by Preu, Romano, and 
Brown! who describe what they term the sympto- 
matic psychoses of bromide intoxication, and illus- 
trate their description by details of nine cases. 
General retardation of mental processes, with anorexia 
and constipation, are well recognised as symptoms 
of bromism ; but further intoxication may, according 
to these writers, give rise to insomnia, restlessness, 
disorientation, and loss of memory, followed by 
ataxia, tremor, and delirium. Refusal of fluid as 
well as food is common, and still further aggravates 
the condition, which indeed is most likely to occur 
in patients who are cachectic, short of fluid and 
chlorides, or suffering from renal impairment. Sudden 
onset of insomnia or delirium in a patient taking 
bromides should always suggest bromism, and the 
absence of skin lesions in no way negatives this 
suggestion. Diagnosis can be made with certainty 
only by an estimation of the bromide content of the 
blood. If this exceeds 250 mg. per 100 c.cm., the 
mental symptoms can with confidence be attributed 
to bromide intoxication. Once the diagnosis is 
established the rest is easy. Bromide administra- 
tion is stopped; fluids are administered in large 
quantities, together with 2 to 3 drachms of common 
salt a day; and under this treatment the symptoms 
rapidly disappear. 

What dosage of bromide is likely to cause this 
condition? Unfortunately the evidence on this 
point is inadequate. In two of the cases the quantity 
taken was unknown; in the other seven it varied 
from 60 to 115 grains a day, generally for no very 
long period, but the doses may have been larger. 
General clinical experience would, indeed, lead us 
to suppose that they must have been larger, because 


1 New Eng. Jour. Med., Jan. 9th, 1936, p. 56. 


, 


e 


326 THE LANCET] 


very large numbers of epileptics in time past have 
taken much more heroic doses for prolonged periods 
without these ill-effects. It may be, however, as 
Preu and his colleagues suggest, that debilitated 
patients who for any reason are short of fluid, or 
whose blood is deficient in chlorides, will react in 
this unfavourable way to smaller doses. In any 
case the condition is one which the practising 
physician should keep in mind. 


VASOMOTOR RESPONSES 


In the current number of Brain Dr. E. Carmichael 
and his collaborators report the results of some recent 
investigations. Their intention was to test the func- 
tional capacity of the sympathetic nervous system 
in normal individuals and in patients suffering from 
various nerve lesions, particularly cases of hemiplegia. 
They sought first to ascertain whether there was 
any difference between the vasomotor response in 
the normal and paralysed limb.! Simultaneous 
temperature readings were taken from the cheeks 
and tips of the digits of the hands and feet by means 
of thermocouples, rectal temperature being also 
registered by this method. Changes in the tempera- 
ture of the body were stimulated by the immersion 
of one or more limbs first in hot and later in cold 
water. The main outcome of these studies was the 
demonstration that if one or other foot is immersed in 
hot water the first change observed is a rise of rectal 
temperature, quickly followed by a rise in the tem- 
perature of both right and left hands, the curve 
of rise being identical for both upper extremities. 
On transferring the heated limb to a cold bath the 
temperature of the other extremities falls at once 
without any appreciable latent interval. The 
responses obtained in cases of hemiplegia are exactly 
the same as those obtained in a normal subject. 
In a further investigation ? a more delicate method 
of estimating the vasomotor reaction was employed. 
A plethysmograph was applied to a finger or toe in 
such a way that a slight alteration in the volume of 
the enclosed digit could be recorded photographically 
by means of a tambour to which was attached a 
mirror reflecting a beam of light on to a moving 
strip of bromide paper. Slight changes i in the volume 
of the digits could thus be continuously recorded. 
By this method the results previously obtained were 
amply confirmed and additional observations were 
made on the effect produced by various extrinsic 
and intrinsic stimuli. It was found, for example, 
that the sudden application of pain or cold to any 
part of the skin, or the occurrence of a sudden noise, 
produces an almost immediate fall in the volume of 
the digits in all limbs. . This effect is also produced 
by voluntary deep breathing, by mental activity, 
and by visceral pain. It was shown that this effect 
still occurs when the normal blood-supply of the 
limb is entirely cut off by a ‘tourniquet. In subjects 
from whom the sympathetic control to one limb has 
been either removed hy operation or destroyed by 
injury this vasoconstrictor action fails to occur in 
the affected limb. Further, the stimulus is only 
effective if applied to a part of the body from which 
normal sensory nerve conduction is intact. When 
a painful stimulus is repeated the initial vaso- 
constrictor effect gradually passes off, even though 
the last stimuli are as painful as the first. The 
23 patients suffering from lesions of the cerebral 


* Uprus, V., Gaylor, J. B., Williams, D. J.. and Carmichael, 
E. A.: Brain, 1935, Iviii., 448, 

* Sturup, G., TOON B., ae: and Carmichael: Ibid., 
p. 456.. 


VASOMOTOR RESPONSES 


[FEB. 8, 1936 


hemispheres examined all showed responses exactly 
similar to those obtained with the normal subject. 
As the lesions ‘in these patients involved between 
them all parts of the cerebral hemisphere the authors 
conclude that lesions of the cerebral hemisphere have 
no effect on the sympathetic vasomotor control of 
the extremities. They believe, however, that this 
control is dependent on the integrity of both pre- 
and post-ganglionic sympathetic fibres and on the 
integrity of the main sensory pathway from the 
point at which the body is stimulated. The sym- 
pathetic vasoconstrictor responses which occurred so 
constantly in these experiments were apparent in 
less than 4 seconds after the stimulus was applied. 
On the other hand, the vasodilator effects produced 
on warming the body only developed after the rectal 
temperature had begun to rise. 


Ow1ne to the death of King George the annual 
dinners of the Hunterian Society and of the Medical 
Society of London will not take place this year. 


Mr. C. H. Fagge will deliver the Hunterian oration 
of the Royal College of Surgeons of England at 
4 P.M. on Friday, Feb. 14th, his title being John 
Hunter to John Hilton. 


OwING to inadequate response from candidates, 
optional translations from Latin and Greek will no 
longer be set in the membership examination of the 
Royal College of Physicians of London. More 
importance will be attached to the translations from 
French and German, and there will be a definite small 
allotment of marks for these in the total qualifying 
marks. They will however remain optional. 


Tue death occurred at St. Andrew’s on Sunday, Feb. 
2nd, of Mr. FARQUHAR MACRAE, consulting surgeon 
to the Western Infirmary, Glasgow, and the “first 
secretary-inspector of the Indian Medical Council. 


WE regret to announce the death of Mr. W1Ltram H. 
BATTLE, consulting surgeon to St. Thomas’s Hospital, 
which occurred on Feb. 2nd, at Woking, Surrey. 
Mr. Battle earned high esteem from the medical 
profession both as general surgeon and as specialist 
in more than one important department. while 
to this journal he rendered valuable service as a 
collaborator for over twenty years. 


INDEX TO “THE LANCET,” VoL. II., 1935 


Tne Index and Title-page to Vol. IJ., 1935, 
which was completed with the issue of Dec. 28th, 
is now ready. A copy will be sent gratis to sub- 
scribers on receipt of a post card addressed to the 
Manager of THE LANCET, 7, Adam-street, Adelphi. 
W.C.2. Subscribers who have not already indicated 
their desire to receive Indexes regularly as published 
should do so now. 


PorRT REGIS PREPARATORY ScHOOL.—At this 
preparatory school two scholarships of £100 each are 
annually awarded to the sons of medical men. The 
school is at Broadstairs, Kent, and the scholarships 
were recently founded by Sir Milsom Rees. The next 
examination will be held on March 3rd, 1936. Candidates 
must be under 9 years of age at the time of competing, 
and the scholarships are normally tenable till the holder 
leaves the school. The holders will be selected at an 
interviow in London from among those boys who have 
done best in some simple examination conducted in or 
near their houses. Applications for the scholarships must. 
be addressed to the headmaster, Port Regis School. 
Broadstairs, from whom full particulars may be obtained. 
The applications must be made not later than Feb. 20th. 


THE LANCET] 


 [FEB. 8, 1936 327 


PROGNOSIS 


A Series of Signed Articles contributed by invitation 


LXXXVII.—PROGNOSIS IN HEMIPLEGIA 
IN MIDDLE LIFE 


HEMIPLEGIA occurs so often as a sudden event in 
the life of a person who has appeared to be in normal 
health and is actively engaged in his occupation that 
the question of prognosis is likely to arise immediately, 
a forecast being demanded both as to life and to 
return to activities. In general the prognosis as 
to life depends on the nature of the cerebral lesion 
and the vascular condition, while the return of 
function in recoverable cases ‘depends upon a variety 
of other factors, not the least being the method of 
treatment adopted. 


Causation 


The great majority of hemiplegias result from 
vascular lesions —- hæmorrhage, embolism, or 
thrombosis. 

In my opinion a hemorrhage sufficient to cause 
hemiplegia is nearly always fatal at the time or soon 
after. On the other hand a majority (probably from 
60 to 75 per cent.) of victims of hemiplegia occurring 
_ between the ages of 40 and 65 from thrombosis or 
embolism survive the event. Estimation of the imme- 
diate prognosis depends, therefore, to some extent on 
detection of evidence of cerebral hemorrhage, and 
a guarded one must be given unless this point has been 
settled. It cannot always be easily settled, nor is it 
of great immediate importance. If lumbar puncture 
has been performed, a hemorrhagic fluid points 
strongly to cerebral hemorrhage and to a fatal issue. 


If a patient has retained or has fully recovered 
consciousness the questions which arise are the extent 
to which he will regain his normal health, and the 
likelihood of a recurrence of a vascular cerebral lesion. 
These questions depend upon the state of the vascular 
system, and will only be briefly summarised here. 
Hemiplegia from embolism is usually an accompani- 
ment of mitral stenosis, and often occurs in patients 
whose myocardial function is adequate and who are 
capable of fairly normal activity for many years. 
In them the liability to recurrence must be considered. 
It is probable that a second stroke occurs only in 
a minority; at any rate there may be an interval 
of many years before it does so, and there are no 
means of foreseeing to which individuals it will 
happen. If a second embolus lodges in the opposite 
side of the brain to the first one the effects are more 
serious, since pseudo-bulbar symptoms will be produced 
in addition to the paralysis of the limbs. In cases 
such as these it is well worth while endeavouring to 
secure good recovery of motor functions; when the 
embolism occurs in association with auricular fibrilla- 
tion or infective endocarditis the prognosis does not 
justify any serious effort in this direction. 


The commonest cause of residual hemiplegia in 
middle life is thrombosis. Here the prognosis as 
regards recovery from the stroke varies very greatly, 
according to the cardiovascular condition. It is not 
nearly so unfavourable in middle life as in the 
elderly patients in whom it is often seen. In a 
certain number, however, even of those below the 
age of 60, an advanced state of arterio-sclerosis makes 
the prospect of recovery doubtful ; further thrombosis 
may occur, or hemorrhage may take place into the 
softened area. Hyperpiesis which persists, or returns 


after the stroke, not only increases the risk to life, 
but diminishes the amount of active treatment which 
is justifiable. These patients must be spared effort 
and inconvenience, both of which are necessary 
elements in a successful re-education. 


There are, however, a large number of patients 
who make good recovery from thrombosis and 
live for many years in a satisfactory state of general 
health. In some of them the degree of vascular — 
degeneration is remarkably slight, so slight that the 
cause of the thrombosis seems hard to explain. 
Most favourable of all are those in whom the lesion 
is a manifestation of vascular syphilis, which may 
respond well to treatment. The future of these 
patients depends on the extent to which muscular. 
power and skill can be restored to the limbs, and 
more particularly to the hand. It is to the prognosis 
of residual hemiplegias of this type that consideration 
will mainly be given here. 


Effect of Treatment 


Some recovery of function in hemiplegia usually 
takes place spontaneously, but the final result is 
one of considerable disability, and falls far short of 
what may be achieved by suitable treatment. The 
ultimate outlook can therefore only be considered 
in conjunction with the mode of treatment adopted, 
and this should be made clear to the patient as soon 
as he is capable of realising it. The result in a case 
which is left to nature may be summarised: by saying 
that the face recovers well, the leg fairly, and the arm 
badly or not all. The difference in improvement 
between the two limbs is mainly due to the fact 
that the sound arm can be used alone whereas the 
leg cannot ; if this can be circumvented the improve- 
ment in arm and leg will be similar. In a neglected 
case the disability is often aggravated by contraction 
of joint-capsules and ligaments as well as by muscular 
contracture. If these occur they affect the prognosis 
unfavourably, as they are difficult to deal with 
satisfactorily. 

The patient’s conception of prognosis in hemiplegia 
is apt to be a gloomy one. He will quote the case 
of a relative or friend who lost the use of one side, 
who never recovered it, and for whom ‘‘the doctor 
said there was nothing to be done.” If his medical 
attendant has clear ideas on the subject, is aware 
that the outlook for uncomplicated hemiplegia is 
potentially good, and can convince the patient of 
this fact, he may appreciably improve the prospect. 


EXPLANATION TO TIE PATIENT 


In general the prognosis of hemiplegias, even of 
a favourable type, is not altogether good; many 
excellent recoveries are seen, but also many patients 
whose affected arm is of little use to them. The 
reason is that a considerable number of them do not 
obtain, or carry out, a suitable form of treatment, 
and this circumstance should not be allowed to 
obscure the fact that the prognosis in an uncomplicated 
case, treated from the outset on rational lines, is 
much more favourable. The situation may be 
represented to the patient as follows: In the leg 
it will probably be possible to prevent the formation 
of any deformity ; he may eventually walk almost 
normally on the level, but will experience a slight 


328 THE LANCET] 


disability in going upstairs or a steep incline; once 
he has begun to walk the condition will continue 
to improve. Should spasm of the calf muscles 
prove more than usually intractable the result will 
not be quite so good, but can be improved by small 
orthopedic measures. Jn the arms there will always 
be inequality in power, but the affected limb should 
become capable of use for most ordinary purposes. 


The grip may be only slightly reduced; extension 
of the wrist and fingers will be more so. The move- 


ment which is most likely to remain defective is 
supination, and herein lies the chief disability which he 
will encounter. He may, in fact, be able to lead the 
life of a middle-aged man in a fairly normal way. 


It should be made clear to the patient that this 
result will not be brought about by drugs or any form 
of treatment which he undergoes passively, but may 
be achieved if he will submit himself for some weeks 
to a régime involving discomfort and tedious effort. 


IMPORTANCE OF ACTIVE MOVEMENTS 


Having indicated to the patient what he may 
reasonably hope for, it remains to assist him to bring 
about his recovery, and the next important factor 
in prognosis will be found in the extent of his willing- 
ness to cooperate. To expect him to make constant 
effort to use the paretic arm while the sound one 
is free is to make demands on memory and patience 
which will seldom be fulfilled. If the sound arm is 
immobilised by a bandage or splint, continuously 
at first and intermittently at a later stage, his attempts 
to use the paretic one will become reinforced by 
habit, many reflex movements will be performed 
unconsciously, and the arm will partake of the 
improvement which takes place as a rule in the leg. 
The only purely passive forms of treatment which 
are necessary are full movements of joints to maintain 
mobility, and to ensure positions of the limbs which 
will not permit of the formation of deformities. 


In the leg, and to a lesser extent in the arm, the 
prognosis is affected by the duration of confinement 
to bed. It is much improved if his general condition 
permits the patient to sit in a chair for part of the 
day at an early stage, and if, by means of a wheeled 
frame, he is enabled to perform the movements of 

walking at a stage when the leg will not bear his full 
weight. If this treatment is persisted in, and supple- 
mented by suitable exercises, the results are often 
remarkable, and a bad prognosis should not be given 
unless it has been tried. AN cases do not respond 
alike, and in a few, although the spasm diminishes, 
muscular power does not show corresponding improve- 
ment. 

In the cases considered so far treatment on the 
lines described has been instituted from the start, 
before the initial flaccidity has been replaced by 
spasm. There are, however, many patients in whom 
this has not been done, because their minds and those 
of their relatives are set on other measures. A large 
number obtain faradic stimulation, by which spastic 
muscles are goaded to further spasm while the 
re-establishment of nervous paths is not promoted. 
Many others put their trust in prolonged courses of 
massage, which is in fact not indicated and diverts 
attention from measures of real importance. Practi- 
tioners will at times be consulted about the outlook 
in cases of this kind. In them it is always less 
favourable, but there is hope of improvement in any 
limb in which the range of passive movement is not 
restricted. When this range is restricted the question 
has become an orthopedic one. 


PROGNOSIS IN HEMIPLEGIA IN MIDDLE LIFE 


[FEB. 8, 1936 


Complicating Factors 


Uncomplicated hemiplegia has been considered 
above; the prognosis is often affected unfavourably 
by concomitant defects in neurones outside the 
pyramidal tract. The most important of these are 
expressed by psychic changes, which may be present 
in almost any form or degree. If they persist they 
may render successful treatment impossible. But 
their duration cannot be foretold ; quite often they 
clear up with surprising rapidity after a few days, 
and they should not be regarded as contra-indications 
to the line of treatment referred to. Some of the 
best results I have seen were obtained in patients 
who were at first completely non-codperative. In 
some of them it may be advisable to put the sound 
arm in a plaster. It will often be found that 
irritability in itself provides a stimulus for move- 
ment, and it is less to be feared than apathy. 

Hemi-anesthesia, usually in the form of a diminu- 
tion rather than absence of tactile and muscle senses, 
may accompany a hemiplegia; it impedes recovery 
to some extent by increasing the awkwardness of the 
paretic limh. In many cases, however, it undergoes 
spontaneous improvement, and it does not call for 
anv modification of treatment. 

The prognosis in hemiplegia is influenced to a con- 
siderable extent, though in different directions, by the 
side of the body affected. Right hemiplegia in right- 
handed individuals is more to be feared than left, 
because it is likely to be accompanied by aphasia, 
though in thrombosis this does not always happen. 
But it has been my experience that the prospect 
of recovery of motor function is decidedly better 
when the right side is affected. The greatest danger 
is that the hemiplegic will accept his disability and 
settle down to the use only of the unaffected arm. 
It is much more diflicult to prevent him from doing 
so when the sound arm is the one which he uses 
by choice and by habit. From the purely motor 
point of view the best recoveries are seen in right 
hemiplegias, and the most favourable type of case 
is a right hemiplegia which has escaped aphasia. 


NEILL Hosnovusek, M.D., F.R.C.P., 


Physician, Royal Free Hospital; Assistant Physician 
West-End Hospital for Nervous Diseases. 


ABERYSTWYTH AND CARDIGANSHIRE GENERAL Hos- 
PITAL,—It is proposed to build an entirely new block to this 
hospital on the site now occupied by the women’s ward. 
A sum of £25,000 will have to be raised to mect the cost 
of equipment and the provision of 24 more beds. 


FELLOWSHIP OF MEDICINE AND POST-GRADUATE 
MerpicaL Association. — For F.R.C.S. primary can- 
didates a courso of lecture-demonstrations in anatomy 
and physiology will be given on Mondays, Wednes- 
days, and Fridays at 8 P.M., from Feb. 24th to 
April 24th, at the Infants Hospital, and an evening 
clinical and pathological class for M.R.C.P. can- 
didates at the National Temperance Hospital on 
Tuesdays and Thursdays at 8p.m. from Feb. 25th to 
March 12th. The following courses will also be held: 
gynecology, at the Chelsea Hospital for Women (Feb. 10th 
to 22nd); chest diseases, at the Brompton Hospital 
(Feb. 10th to 15th); thoracic surgery, at the Brompton 
Hospital (Feb. 24th to 29th); orthopedics, at the Royal 
National Orthopedic Hospital (March 9th to 21st). 
Week-end courses have been arranged as follows: 
children’s diseases, at the princess Elizabeth of York 
Hospital (Feb. 22nd and 23rd); chest diseases, at the 
Brompton Hospital (March 7th and 8th); clinical surgery, 
at the Royal Albert Dock Hospital (March 14th and 15th), 
Full details may be had from the secr etary of the fellowship, 
1, Wimpole-street, London, W.1. 


THE LANCET] 


[FEB. 8, 1936 329 


SPECIAL ARTICLES 


MEDICINE AND THE LAW 


A Conflict of Loyalties 


In October last the German legislature passed an 
Act forbidding marriage between two persons one 
of whom is (1) suffering from an infectious illness 
which may seriously injure the health of the other 
or of the offspring ; or (2) under guardianship for 
being a spendthrift or insane ; or (3) is suffering from 
a disorder of the mind which would make the marriage 
“undesirable ° in the public interests, or from a 
hereditary disease. The chief diseases which act as 
a bar to marriage are venereal disease and unhealed 
tuberculosis. In other infectious diseases it is 
for the doctor to make up his mind in each individual 
case whether there is a grave danger to health. 
In deciding whether a given marriage is undesir- 
able he must treat it on its own merits. Dr. 
Schläger, in an article on the new Act,! points out 
that the doctor will in each case have to strike a 
balance between his duty of secrecy to his patient 
and his duty to disclose information in the interest 
of the community. The law binds him, when he 
can stop an undesirable marriage only by breaking 
his duty of professional secrecy, to put the public 
interest first. Naturally it is impossible to lay down 
any hard-and-fast rules which will fit every case. 
It is for the doctor ultimately to make up his mind 
just how much he thinks it necessary to disclose. 
He may go too far and commit a breach of the law 
which binds him to professional secrecy. In certain 
circumstances he might be found guilty of negligence. 

German medical men thus have now placed upon 
them an extremely invidious duty. It seems to have 
no analogue, fortunately, in English law. Any 
English physician must notify certain infectious 
diseases and industrial diseases, but the hardship 
which this statutory breach of professional confidence 
may cause is not comparable to the injury which 
may be done to a patient who consults a doctor in 
good faith and then finds afterwards that the doctor 
has played the part of what amounts to a police spy 
in preventing a marriage which, apart from statute, 
is no concern of the doctor at all. Mr. Justice 
Avory tried in 1914 to throw upon doctors the duty 
of disclosing to the police any cases of abortion which 
they came across in their practice, and the profession 
has successfully resisted the imposition of such a 
repugnant duty. The position of the German doctor 
is the more difficult in that his duty of secrecy is not 
only a professional but a legal duty in a far stricter 
sense than in this country. Our colleagues in 
Germany are not to be envied the problems they will 
apparently have to face and the decisions they will 
have to make under this legislative venture. 


Married Women and Doctors’ Bills 


The Law Reform (Married Women and Tortfeasors) 
Act of 1935, the relevant section of which came 
into operation last August, has made a radical 
alteration in the position of married women in respect 
of contracts and their liability to pay (amongst other 
things) the doctor’s bill. Before that date a married 
woman was not ‘personally responsible for her con- 
tracts. A judgment could only be obtained against 
her separate estate (Scott v. Morley, 20 Q.B.D. 120), 
and if she had no available separate estate the creditor 


’ Deut. med. Woch., Jan. 24th, 1936, p. 152. 


was unfortunate, because unless the married woman 
carried on business either alone or jointly with her 
husband she was not liable to be made bankrupt. 
A judgment summons was useless, for although her 
separate estate was lable, she was not personally 
liable to pay, and in order to obtain an order on a 
judgment summons committing a debtor to prison 
a personal liability to pay has to be proved. As a 
result of the protection given to married women, 
doctors, like other purveyors of necessaries, were 
in the habit of regarding them as contracting as 
agents for their husbands, and so making the husband 
and not the wife liable as she pledged her husband’s 
credit and not her own. Whether a married woman 
contracted personally so as to make her separate 
estate liable or as agent for her husband was a question 
of fact. To the question “Whom did you trust, 
the husband or the wife?” the wise man always 
answered ‘‘the husband.” Now he should think 
twice before giving a reply. If the wife has private 
means, it might be advantageous to regard her as 
contracting as principal rather than as agent, since 
judgments can now be enforced against her as if she 
were a feme sole. In cases where the worldly goods 
are in the wife’s name—not an uncommon position in 
many households—the practitioner would be well 
advised to open the account in the ledger in the 
wife’s name, rather than in that of her husband. 
There still however remains one snag, for if a testator 
by his will, dated prior to 1936, gives property to a 
married woman subject to a restraint on anticipation 
and dies after 1936, but prior to 1946, such property 
is not available for creditors. The practitioner might 
therefore be well advised to ascertain the date of 
his female patients’ marriages. 


Card Party for Medical Charity 


In Williams v. Trevor, a case before Mr. Justice 
Finlay last week, the plaintiff claimed damages for 
the loss of a sum of £10,000 at a card party held 
at Sunderland House at the end of 1934 for the 
benefit of the Ivory Cross National Dental Aid Fund 
and the Royal Northern Hospital. He said that he 
had been invited to attend and that the defendant 
had assured him that the organisation of the party 
would be perfect and that everybody assisting would 
be personally known to the defendant or to members 
of the committee of the hospital. It was the plaintifi’s 
complaint that the games (which included baccarat 
and chemin-de-fer) were unfairly played and that 
card-sharpers were present. Legally, Mr. Williams 
could establish no cause of action against Mr. Trevor 
unless there was some breach of contract or breach 
of duty. When the plaintiff’s witnesses had been 
called and examined, the judge stopped the case. 
He found no breach of warranty. The letter of 
invitation to the card-party did not constitute a 
contract; it was not a warranty but a mere pufi. 
Indeed, though the learned judge seems not to have 
gone into this aspect of the case, the law declines to 
recognise a social invitation as having contractual 
consequences. For instance, if A invites B to dinner 
and makes elaborate and expensive preparations for 
his entertainment, A cannot recover damages when 
B, having accepted the invitation, fails to appear. 
Mr. Justice Finlay was not quite sure what kind of 
duty (apart from contractual liability) the organisers 
of such a party owed to their guests. They must 
he thought, take reasonable pains to exclude undesir , 
able persons; but he could not rule that there wa- 


330 THE LANCET] 
ges 
any positive undertaking that no bad characters 
would find their way in. 
of such parties was the probability that undesirable 
persons would be present; everyone attending such 
a party must be aware of that risk. If Mr. Williams 
was to succeed, he must further prove damage arising 
out of the alleged breach of duty. But the evidence, 
said the judge, seemed to establish the contrary ; 
Mr. Williams, early in the evening, suspected that 
there was cheating, yet he continued deliberately to 
play. 

Mr. Justice Finlay is not a judge to chatter in 
court about extraneous matters. The more weight, 
therefore, attaches to his condemnation of this 
association of gambling with charity. He said he 
knew from personal experience how hard it was to 
raise money for charities; but he hoped that, after 
this case, no reputable charity would ever resort to 
so questionable a method of raising money. He quite 
appreciated that the patrons of the charities for 
whom the party was given knew nothing about it, 
but “‘ such methods were to be severely discouraged.” 
The jury associated themselves with his lordship’s 
remarks, and there is every reason to beheve that 
public opinion will agree. 


Alleged Morphine Poisoning at Nursing-home 


The inquest on Miss Ada Baguley, who died on 
Sept. llth at a home in Nottingham, ended last 
week in a verdict that the deceased met her death 
by a fatal dose of morphine or heroin or both, and 
that the dose was feloniously administered to her 
by Ronald Sullivan and Nurse Waddingham who 
together conducted the home. The death certificate 
had originally stated that Miss Baguley died of 
cerebral hemorrhage; post-mortem examination 
showed that this was incorrect. Mr. Baguley, father 
of the deceased, died in 1929, leaving an estate of 
£1600 to his daughter, subject to a life interest to 
his wife. Mrs. Baguley, the 87-year-old widow, died 
in the home last May. Miss Baguley, her daughter, 
described as a helplèss cripple, had made a will 
bequeathing the whole of her estate to N urse Wad- 
dingham and Mr. Sullivan in consideration of their 
looking after her and her mother. Nurse Wadding- 
ham at first denied having given the deceased morphia 
or having had any morphia in the house. Later she 
stated that she gave Miss Baguley morphia under 
medical instructions. Her evidence was in conflict 
with that of the practitioner who attended the 
deceased. Dr. Roche Lynch, recalled by the coroner, 
had expressed the opinion that a dose from one grain 
upward of the morphine preparations mentioned 
during the inquest would be a positive fatal dose. 
The chlorodyne medicine which Miss Baguley had 
been taking would not, he said, have given her any 
marked tolerance of the drug. He considered that 
a fatal dose of morphia must have been administered 
within six to twelve hours of death. 


SCIENCE AND INDUSTRY 


Tue Department of Scientific and Industrial 
Research has many activities, most of which are 
unconnected with medicine or surgery, but all have 
a close bearing on human life and progress. Some 
account of these researches is given in the annual 
report of the Department for the year 1934-35 
(H.M. Stationery Office, Cmd. 5013, 3s.). 

The protection of X ray workers from gamma 
rays, by remoteness and shielding, has been investi- 


SCIENCE AND INDUSTRY 


One of the risks and evils © 


[FEB. 8, 1936 


gated, and the conclusion is reached that it is undesir- 
able for the personnel to remain in the immediate 
vicinity of patients undergoing treatment with large 
quantities of radium. The investigators point out 
the high degree of protection attainable with pro- 
perly designed radium safes, the necessity for expe- 
ditious bench manipulation of radium containers, 
and the superiority of bulky postal transport boxes 
with only moderate lead shielding over small con- 
tainers utilising the maximum lead shielding possible. 

The Food Investigation Board has investigated 
the destruction of bacteria in meat by a, B, and y rays 
and with 6 particles from radon. In both cases dis- 
infection goes on at the same rate within a very 
long range of temperature. The effect of varying 
oxygen pressure on the rate of oxidation of hæmo- 
globin to methemoglobin, besides being of theore- 
tical interest, is of importance in the practical problem 
of the bloom of gas-stored meat and fish. An interest- 
ing research was made into the retarding effect of 
iodised paper wrapping on the rotting of cèrtain 
fruits. 

Fundamental standards, however unattractive to 
the unlearned, form bases for all exact scientific 
knowledge, and the National Physical Laboratory 
has redetermined the freezing point of platinum, 
obtaining a value (1773°3° C.) in agreement with the 
results recorded at the national laboratories of 
Germany and the United States, within the limits of 
accuracy obtainable at present; other freezing 
points up to that of iridium (about 2450° C.) are being 
redetermined. Close agreement with the Physi- 
Kalisch-Technische Reichsanstalt in the definition 
of the metre in terms of the wave-length of the red 
radiation of cadmium has been reached, making this 
fundamental unit independent of al existing 
standards. 

The various trade research associations have been 
active in the investigation of problems arising directly 
out of industry, and perusal of the report should 
convince readers that the Department is doing fine 
work in coérdinating researches which, directly or 
indirectly, add to the comfort or safety of civilised 
life. The measurement of noise, for instance, may 
eventually lead to the suppression of unnecessary 
noises—a matter of the greatest interest to all who 
have the care of the sick. The medical practitioner 
is likely to find in the report hints towards solving the 
increasingly complex problems of diagnosis, treatment. 
and régime. The volume is inexpensive and is not 
heavy reading. 


THE TROPICAL HOUSE 


AN OBJECT-LESSON AT LIVERPOOL 


INSTIGATED by Prof. D. B. Blacklock, the Liverpool 
School of Tropical Medicine has rented a piece of land 
adjacent to the city for the purpose of building small 
replicas of houses used in different parts of the 
tropics. The aim of the model is to illustrate the 
actual disease-producing conditions which, exist in 
each type of defective dwelling along with such 
simple methods of dealing with defects as can readily 
be put into operation. This enterprise may not be 
very remarkable in itself. Models of unhygiene at 
home and abroad can be found in museums and other 
instructive places. But what is remarkable is the 
conviction of Prof. Blacklock and his group that 
something effective can be done about it, for the 
fatalistic belief still widely rules that people, and 
especially native races, get the houses they deserve., 


THE LANCET] 


THE TROPICAL HOUSE.—THE SERVICES 


[FEB. 8, 1936 331 


It is no new idea that houses in our tropical 
dependencies breed disease. Sixty-five years ago 
Surg. Major David Boyes Smith, then sanitary 
commissioner of Bengal, wrote as follows :— 

“ The people live in villages which appal the sanitarian. 
Every revolting abomination conceivable is to be met 
with in these villages—obstructed ventilation, corrupted 
ground, polluted atmosphere, putrid organic matters, 
fecal gases, the revolting water tank, with consequent 
sickliness, debility, degeneration and cachexia of the 
people,” 
and in a Chadwick lecture last year 1 Prof. Blacklock, 
who cited this appalling word-picture, went on to 
enumerate the many diseases still directly traceable 
to defects in housing, indicating categorically those 
diseases which could be avoided by proper selection 
of site and of material for construction. In our own 
rural areas bad housing chiefly connotes such defects 
as inadequate lighting, dampness, draughtiness, or, 
what may be worse, lack of ventilation and inadequate 
air space, and the diseases connected with these 
defects—rheumatism, bronchial catarrh, and tubercle 
—though important enough, are relatively few in 
number. In our urban areas structural defects 
provide lodgement for vermin, while bad ventilation 
and overcrowding facilitate the spread of epidemic 
disease, largely by droplet infection. While all 
this is serious enough, the problem of domestic 
hygiene in a temperate climate is simple in com- 
parison with the prevention of the variety of diseases 
due directly to the type of housing in places where the 
air is always warm and moist. In the tropics the 
site of a house selected in ignorance of the dangers 
from anopheline breeding -places may result in constant 
malaria with its consequent anemia, fever, and 
repeated interruptions of agricultural work. The 
foundations, floor, and walls of a house composed of 
dried mud or mud bricks are likely to be the source of 
relapsing fever and many other infections. The 


materials of which the roof is composed may conduce 


to the spread of bubonic plague in endemic areas. 
These relations of cause and effect were set out three 
years ago by Prof. Blacklock, entitled ‘‘ The House 
and Village in the Tropics ” (London. 1932. 3s. 6d.), 
which contains among much serious argument an 
entertaining chapter on the skin of the native child 
who from the hour of its birth upwards is subjected 
to a perpetual series of injuries and pin-pricks of 
every kind—an aspect of tropical medicine to which 
too little attention has so far been paid. 

The conviction is growing that in many parts of 
the hot regions of the world the reform of housing 
methods would mark a definite advance in the preven- 
tion of disease, and the Liverpool enterprise is to 
be welcomed as an agent in putting these ideas into 
practical form. Students who come to Liverpool 
to study tropical hygiene, professional and business 
men going out to live in the tropics, may see for 
themselves some of the manifold ways in which 
danger to the health of the tropical household arises. 
While no doubt research is needed into the best 
methods of house construction and into the choice 
of materials for building, the object-lesson at Liverpool 
should afford the stimulus to such research and the 
incentive to apply it. 


1 THE LANCET, 1935, i., 526. 


STAFFORDSHIRE GENERAL INFIRMARY.—The general 
committee of this hospital have decided to begin work on 
extensions which will include a new ward for private 
patients, a new general ward, and achildren’s ward. X ray, 
massage, and electrical departments are also to be built. 


THE SERVICES 


ROYAL NAVAL MEDICAL SERVICE 


Surg. Capt. A. T. Rivers placed on Retd. List. 

Surg. Lt.-Comdr. P. B. Jackson to Drake for R.N.B. 

Surg. Lts. D. Simpson to Halcyon, P. K. Fraser to 
Aphis, H. E. B. Curjel to Carlisle, and D. Chute to Curlew. 

The Gilbert Blane Gold Medals for 1935 have been 
awarded to Surg. Lt.-Comdr. A. A. Pomfret, R.N., and 


_ Surg. Lt.-Comdr. W. G. Fitzpatrick. 


ROYAL NAVAL VOLUNTEER RESERVE 


Surg. Lt. J. D. Lendrum to Pembroke for R.M. Infirmary, 
Chatham. 
ARMY MEDICAL SERVICES 


Maj.-Gen. J. P. Helliwell, C.B.E., late A.D. Corps, 
retires on ret. pay. 

Maj.-Gen. J. P. Helliwell, C.B.E., late A.D. Corps, 
relinquishes the appt. of Dir., Army Dental Serv., War 
Office. 

Col. J. V. M. Byrne, late A.D. Corps, appointed Dir., 
Army Dental Serv., War Office. (See also THE LANCET, 
Jan. 4th, 1936, p. 42.) 


ROYAL ARMY MEDICAL CORPS 


R. Hospital, Chelsea.—Maj. J. B. Fotheringham, 
M.B., R.A.M.C., relinquishes the appt. of Dep. Surg. 
Maj. E. M. Townsend, M.C., R.A.M.C., to be Dep. Surg. 

Temp. Commissions : Capt. A. F. Campbell to be Maj. ; 
R. B. Grey, J. Shields, and "p. W. Dill-Russell to be Lts. 


ARMY DENTAL CORPS 


R. J. Godfrey is granted a temp. commn. in the rank 
of Lt. (Vide also Army Medical Services.) 


REGULAR ARMY RESERVE OF OFFICERS 


Capt. W. G. Burns resigns his commn. and retains the 
rank of Capt. 
TERRITORIAL ARMY 


Capt. P. Dwyer to be Div. Adjt. 50th (Northumbrian) 
Div., vice Capt. P. F. Palmer, vacated. 

Capt. J. J. O'Dwyer to be Divl. Adjt., 55th (W. Lan. 
Div.), vice Maj. J. H. Bayley, M.C., vacated. 

Capt. J. G. Black to be Divl. Adjt., 43rd (Wessex) 
Div., vice Maj. J. E. Rea, vacated. 

Capt. R. V. Powell to be Maj. 

J. C. H. Speirs to be Lt. . 

R. M. H. Anning (late Cadet, Epsom Coll. Contgt., 
Jun. Div., O.T.C.) to be Lt. 


ROYAL AIR FORCE 


E. B. Harvey and D. S. MacL. MacArthur are granted 
short service commissions as Flying Offrs. for three years 
on the active lists. 

D. W. I. Thomas is granted a short service commission 
as a Flying Offr. for three years on the active list and 
is seconded for cluty at St. George’s Hospital, London. 


RESERVE OF AIR FORCE OFFICERS 


Flying Offr. T. P. Mulcahy relinquishes his commission 
on appointment to a commission in the Indian Medical 
Service. 

INDIAN MEDICAL SERVICE 

Majs. to be Lt.-Cols.: P. Verdon, D. V. O'Malley, 
O.B.E., and 8. A. Phatak. 

S. W. Allinson to be Lt. (on prob.). 

-= Lt.-Col. W. D. Keyworth retires. 

Indian Medical A see —Maj. 
R. S. Keelan retires. 


(Sen. Asst. Surg.) 


ROYAL MANCHESTER CHILDREN’S JIOSPITAL.—A 
year ago this institution launched an appeal for 
£100,000 for the maintenance of the convalescent home, 
to add a wing to the nurses’ home, and for other necessary 
extensions. A good start was made and in the first four 
months after the appeal was issued £10,000 was collected, 
but the £30,000 figure has not yet been reached. 


332 THE LANCET] 


[FEB. 8, 1936 


CORRESPONDENCE 


IS COUSIN MARRIAGE DANGEROUS ? 
To the Editor of THE LANCET 


Sir,—There has long been a vague belief that 
human inbreeding is undesirable, and some unions 
of blood relations are forbidden by law. Recent 
research has shown that certain diseases are vastly 
commoner among the offspring of blood relations 
than in the general population. In Western Europe, 
marriages of first cousins rarely amount to more than 
1 per cent. of all marriages. The following per- 
centages of first-cousin marriages have been found 
among the parents of patients with certain diseases :— 


Per cent. 

Xeroderma pigmentosum (Siemens’s Bites anor 

1906 only) .. 7 

Retinitis pigmentosa (Usher’ 8 cases) f s 27 

Juvenile amaurotic idiocy (Sjögren’ 8 cases) $e 15 

Ichthyosis congenita (Cockayne’s data) .. Py, l4 
These examples might be considerably multiplied. 
Unfortunately, however, research into rare diseases 
gives us little idea of the importance of the 
phenomenon for general health. 

The fact that the children of first cousins are some 
thirty times more likely to develop retinitis pigmen- 
tosa than the general population does not tell us 
whether abnormalities of this type (in genetical 
language, due to rare autosomal recessive gene 
substitutions) are sufliciently common to render 
cousin marriage undesirable. Animal experiments 
give no clear answer. In some species the inbreeding 
of members of wild populations leads to the appearance 
of numerous recessive abnormalities. In others it 
does not. For this reason the Committee on Human 
Genetics appointed by the Medical Research Council 
have obtained the coöperation of hospitals in a large- 
scale inquiry on this question. All patients in the 
participating hospitals are being asked whether 
their parents were related, and if so how. It was 
thought that any less comprehensive inquiry would 
be worthless, since the data on animals suggest that 
not only congenital abnormality but liability to 
certain infections or degenerative diseases might 
be due to recessive genes. 

The preliminary results are distinctly encouraging. 
Certain rare conditions seem to be rather commoner 
among the progeny of related than among those of 
unrelated parents. Nevertheless, the results will 
not be statistically significant until at least three 
times the present number of cards have been com- 
pleted. It is particularly desirable to obtain more 
data regarding children ; and from country districts, 
where more inbreeding occurs than in towns. While, 
therefore, the Committee acknowledge with the utmost. 
gratitude the assistance so far given by hospital 
staffs, they hope that the same efforts will be 
continued until really adequate data are available. 
The coöperation of additional hospitals would also 
be most welcome. 

I am, Sir, yours faithfully, 


London, Jan. 31st. J. B. S. HALDANE. 


MALARIA EPIDEMIC IN CEYLON 
To the Editor of THE LANCET 


Sır, —In your account of the discussion at the 
Royal Society of Medicine on Nov. 16th (THE LANCET, 
1935, ii., 1176), which has only recently been brought 
to my notice, there is room for misunderstanding in 
the remarks attributed to me. I should be grateful 
if you would allow me to explain my position. Your 
report runs: “He (myself) agreed with the use of 


atebrin only in hospitals (my italics) in Ceylon, but 
thought that this drug would prove to have many 
advantages owing to its better and more rapid 
absorption and action. He was sorry that it had 
been rather pushed into the background.” This 
statement implies that in an epidemic the use of 
atebrin should be limited to institutional cases 
solely. Nothing could, in fact, be further from the 
truth, for it is widely known to-day that peroral 
atebrin is a well-tried routine remedy in all condi- 
tions. Actually in the paragraph quoted above, I 
was referring to atebrin musonate, the new salt of 
atebrin which is given by injection, and which, 
being in a trial stage at the time of the epidemic, 
was suitable only for hospital cases. In my speech 
I followed up these remarks on atebrin musonate 
by saying : 

“ I am sorry to note that the exaggerated idea of using 
atebrin musonate as a panacea in all cases has caused 
the peroral treatment: of atebrin to be relegated into the 
background. . . . Suitable administration of atebrin has 
availed to reduce the relapse rate and sequele.... A 
treatment combining atebrin and plasmoquine, the 
drugs given according to a strict schedule on certain 
days of the week, is very promising, but where there is a 
floating population it is advisable to give atebrin alone.”’ 

I think this quotation should make my views 
reasonably clear. 

I am, Sir, yours faithfully, 
Elberfeld, Germany, Jan. 31st. W. SCIULEMANN. 


CONTROL OF MEASLES 
To the Editor of Tue LANCET 


Sir,—I have no desire to enter into competition 
with Dr. Copeman when he claims to have been the 
first person to introduce into this country the modern 
method of prophylaxis and attenuation of measles 
by means of convalescent serum. At the same time, 
it may interest him and others to know that, mainly 
due to the stimulus of the late Dr. Claude B. Ker, 
convalescent measles serum was used in the Edin- 
burgh City Hospital between the months of February 
and September, 1924. I was then senior assistant 
to Dr. Ker, and was his collaborator in this experi- 
mental work of attempting to immunise measles 
contacts in certain wards of the hospital. Unfortu- 

nately the findings were not published, partly owing 
to the fact that 1 left the hospital to take up another 
post, but mainly owing to the death of Dr. Ker a 
few months later. The figures seemed too few to 
publish as a paper, but a few: notes may be of interest— 
even if somewhat belated. 


During the month of January, 1924, I took some blood 
from several adult measles patients who happened to 
be admitted to the hospital. The blood, taken off about 
ten days after the rash, was allowed to clot and the serum 
was pipetted off and a small percentage of phenol added. 
In that month ward 7 became infected by an incubating 
casc—introducing measles to the ward, The childwas prob- 
ably infectious for three or four days before being removed 
on Jan. 21st, on which day also another child from the 
samo school occupied a bed on the other side of the ward 
for a fow hours and was diagnosed measles and removed. 
Of the other 23 children in the ward, all but 7 had a 
history of measles; of these 7, 2—one in the next bed 
to the first case, and the other roughly opposite and three 
beds away from the second case—were protected by 
3 ccm. of convalescent measles serum. Nether.: took 
measles, whereas 4 of the remaining unprotected 5 took 
measles on Feb. 2nd, 4th, 4th, and 6th E E 

From the infectious cases above mentioned, treated 
in side wards, infection was apparently carried to ward 74 


THE LANCET] 


PANEL AND CONTRACT PRACTICE 


[FEB. 8, 1936 333 


where a small boy developed measles and was isolated 
on the appearance of his rash on Feb. 14th. Of the 
14 children in the ward, 4 had not had measles; all were 
protected on Feb. 14th. None took measles definitely, 
but one child on Feb. 26th had a flick of temperature— 
no catarrh or Koplik’s spots—then remission of tempera- 
ture, and on March Ist a definitely morbilliform rash 
and a rise of temperature to over 100° F. for one reading. 
This seemed to have been a case of abortive or modified 
measles. 

In May, 1924, a boy with whooping-cough was admitted 
to ward 20 and on the next day (May 24th) was isolated 
for a measles rash which had come out in the night. 
The exposure of the contacts was in all about 16 hours. 
The ward contained 15 children, of whom 8 had not had 
measles. The 8 children received 3 c.cm. of convalescent 
measles serum on May 25th, nearly 48 hours from the 
first exposure. None of these children took measles. 


Convalescent measles serum was given in several 
other wards during the summer of 1924, and attenua- 
tion of the disease was noticed in many of those 
measles contacts injected. In one particular case 
the prodromal period lasted seven days before the rash 
appeared, and the incubation period in many instances 
was as long as the twentieth day and once (apparently) 
the twenty-fourth day, although this was a very 
doubtful case. During August, 1924, cases of measles 
occurred in Victoria Park House, a children’s home 
in Edinburgh, and I was asked by the then medical 
oliicer of health, Dr. Robertson, to give the contacts 
some convalescent measles serum. Ten of the 20 
children who were contacts had not, according to 
the history, had measles, but 10 who gave no history 
of having had the disease were protected with 5 ¢.cm. 
of the convalescent measles serum. None of these 
children took the disease. 

Another experiment which was not, however, so 
successful was carried out in a certain ward of the 
Craiglockhart Hospital, a poor-law institution near 
the City Hospital, where an epidemic of measles had 
broken out among children mainly under two years 
of age. The serum was given late in the incubation 
period. Out of 11 contacts who had not had measles, 
8 took the disease and 5 of these died later in the 
wards of the City Hospital to which they were 
moved. 

It could be deduced from these experiments that, 
if given early enough, convalescent measles serum 
was of value, not only in preventing but in attenuating 
the disease. 

I am, Sir, yours faithfully, 
JON McGaRrRITy. 

Little Bromwich Hospital, Birmingham, Feb. 3rd. 


LONDON HOSPITAL CATGUT 
To the Editor of THE LANCET 


Sir,—A report of an inquest at Cambridge appeared 
recently in the lay press in which it was stated that 
death was due to tetanus, and the house surgeon in 
giving evidence said that he agreed that the infection 
was from the catgut. There was also in the report 
the direct implication that the catgut had been 
supplied by the London Hospital. 

This is incorrect. I have been in communication 
with the secretary of the hospital at which the death 
occurred, and he writes: “I am glad to be able 
to inform you that the suspect catgut was not London 
Hospital catgut.” I might add that since the pub- 
lication by the Medical Research Council in 1929 of 
the results of the long investigations carried out at 
this hospital by Prof. Bulloch, in collaboration with 
Dr. Lampitt and Mr. Bushill, into the ‘‘ Preparation 
of Catgut for Surgical Use,” the demands for London 
Hospital catgut have increased very considerably, 
and we now supply catgut all over the world. 

I am, Sir, yours faithfully, 
ARTIUR Q. ELLIOTT, 
House Governor, London Hospital. 

Whitechapel, E., Feb. 3rd.. 

PREMATURE BURIAL 

WE have received the following communication ¢ 
“The Society for Prevention of Premature Burial. 
founded in 1896, has for its object the reform of the 
law relating to the granting of death certificates. 
Until the beginning of this year the Society existed 
as an independent body, but it is now affiliated with 
the Council for the Disposition of the Dead Inc., 
one of whose basic objects is the revision and the 
codification of the laws relating to death. The 
Council now have in hand a Bill for the registration 
of funeral directors. This affiliation has a twofold 
purpose, (1) the machinery necessary for the reform 
is strengthened, and (2) overlapping is eliminated. 
But the internal policy and expenditure of the 
Society for Prevention of Premature Burial continues. 
and while informing the public of this affiliation we 
would like to take this opportunity of seeking further 
interest and support. Funds and increased member- 
ship are earnestly desired. All inquiries should be 
addressed to the secretary of the Society, 30, Castelnau- 
gardens, Barnes, London, S.W. 13.” 

This letter is signed by Major Reginald Austin 
(R.A.M.C., retd.), Dr. Jane Hawthorne, Dr. J. 
Lachlan-Cope, Miss Maud Yandell, and Miss Lettice 
Macnaghten. 


PANEL AND CONTRACT PRACTICE 


Defaults in Clerical Work 


PERSONAL difficulties, encountered in panel prac- 
tice, are from time to time illustrated by the reports 
of inquiries (under the Medical Benefit Regulations) 
into the etficiency of the service rendered by a par- 
ticular doctor. A recent case from Lancashire shows 
that his shortcomings can be admitted with frankness 
by the practitioner and treated with sympathy by 
the authorities concerned. Between 1925 and 1934 
sums amounting to a total of £123 were withheld 
by the Minister from the moneys payable to the 
insurance committee, and a corresponding amount 
was recovered by the cominittee from the remunera- 
tion of the doctor, for the following breaches of the 
terms of service: failure to furnish divisional and 


regional medical officers with the required information 
on Forms R.M.2; failure to keep proper medical 
records ; failure to return to the committee on request 
the medical records of insured persons removed from 
his list; and issue of prescriptions on the official 
form of the committee to persons not on his panel 
list. The doctor received formal warnings from the 
Minister on four occasions during 1928 and 1929. 
A year ago the medical service subcommittee reported 
on the failure to furnish on request the records of 
removed patients, and the withholding of the sum 
of £75 was recommended. Meanwhile, no medical 
records of insured persons had reached the committee 
from him since Oct. Ist last, though he undertook a 
year ago to return all outstanding records within a 
week or so. No acceptances of insured persons had 


334 THE LANCET] PUBLIC 


reached the committee from him since last September. 


In March last year the clerk to the insurance committee - 


asked for particulars as to prescriptions issued by 
him in the previous October, November, and December 
to persons not on his register ; reminders were sent, 
but elicited no information. These complaints offered 
considerable material for the allegation that his 
conduct as a panel practitioner had been such as 
to bring panel practice into disrepute and that he 
had repeatedly infringed the terms of service. 

The doctor frankly admitted his omissions and 
stated that he had been treated at all times with 
great consideration by the committee. While allow- 
ing himself the extenuation, if such it be, that’ he 
had a natural dislike for clerical work and a “ mistaken 
but stubborn notion that the essential business of a 
medical practitioner is solely the treatment of ill- 
health,” he candidly confessed his faults but claimed 
that, at the end of 1933, he had fully appreciated the 
duty of better clerical work and had then made a 
great effort to bring his record cards up to date. 
In 1934 he had cause to be seriously anxious about 
his own health, and he diagnosed early pulmonary 
tuberculosis. He acquired an open-air shelter and 
lived the complete sanatorium life in the grounds of 


HEALTH [FEB. 8, 1936 
his house, keeping up his visits and attendances on 
patients but sacrificing everything else to the recovery 
of his health. He was now able to report a marked 
improvement in his physical condition. He could 
claim that he was not a man of vicious habits, and 
that the clerical side of his private practice had been 
as badly neglected as the records of his panel work. 
He stated that he had found paid secretarial help 
disappointing. At the inquiry he had to admit that 
33 cards had still not been returned. The inquiry 
committee briefly reported that the doctor excused 
himself in the manner already described but called 
no evidence of his state of health ; he had stated that 
his sputum was examined by the tuberculosis officer 
of the county in October, 1934, with negative results. 
The inquiry committee summed the matter up by 
saying that, even accepting the doctor’s own evidence 
of his health, it found no sufficient excuse for his 
continued neglect of his duties. The Minister of 
Health announces that, after considering the report 
and taking into account the evidence of the prac- 
titioner’s personal character and professional standing, 
he has decided not to remove his name from the 
medical list of the insurance committee. He makes 
no order as to the costs of the inquiry. 


PUBLIC HEALTH 


Mental Hospitals in London 


AMONG the many tasks of local government, the 
care of the mentally affected has become more 
prominent as it has been exercised with more 
thoroughness and unity of control. Nowhere better 
than in London can one see that this duty is a heavy 
one and that it may be carried out in a spirit of 
enlightened generosity. A recent report?! describes 
many activities in connexion with the 33,000 mental 
patients for whom the London County Council is 
responsible. The report deals separately with the 
mentally disordered, and with the defective patients 
the majority of whom were until 1930 under the 
administration of the Metropolitan Asylums Board. 


MENTAL DISORDER 


For the mentally disordered nearly 700 more beds 
are being provided, according to plans approved 
during 1934, and there was also contemplated an 
additional 360 beds at Ewell. For these and other 
works an expenditure of £31,000 was authorised ; 
further large sums are being spent on the modernisa- 
tion and better equipment of individual hospitals. 
The figures published in this report indicate that 
voluntary treatment is being more availed of; at 
the beginning of 1935 the number of voluntary 
patients in residence was 18:5 per 1000. As the 
public and those concerned with certification come 
to realise better that voluntary treatmentis permissible 
and advantageous for many of the certifiably insane, 
it is probable that the number of direct referrals of 
voluntary patients will continue to rise and the 
number of certified patients to fall. The voluntary 
patients in the mental hospitals cannot in 
London be considered without regard to the 
Maudsley Hospital, which during 1934 dealt with 
nearly 1000 in-patients, all of them by its constitution 
on a voluntary basis. In its various out-patient 
departments, including those in North London, 
4600 patients were treated. If it were not for the 


2 .C.C. Annual Report. of the Council. 


1934. 
Mental Hospitals and Mental Deticiency. 


Pp. 64d. 1s. 


Vol. VI. 


work of this hospital, including that done in a ward 
of King’s College Hospital which is temporarily 
used as an annexe to the Maudsley, the number 
under treatment in mental hospitals would be 
appreciably greater. 

So far as direct admissions to mental hospitals 
are concerned, the proportion these bear to the total 
population of their district varies between 5 and 9 
per 10,000, the average for all London being 7 per 
10,000. It would be unsafe to take such figures as 
fully representing the frequency of insanity in the 
average population, even if the necessary corrections 
were made for readmissions and age-groups ; criteria 
used in determining the need for mental hospital 
care vary in different countries and in different parts 
of the same country. In the admirably detailed 
report for 1934 of the commissioner of mental diseases 
in the State of Massachusetts, which has a population 
about equal to that of London, the rate for all 
admissions is shown as 15 per 10,000 of population, 
far higher in cities than in rural districts. It would 
not however be fair to conclude that there is a 
much higher incidence of mental disorder in 
Massachusetts than in London. The same difficulty 
is foundifan attempt is made to compare rate of dis- 
charge or duration of treatment with figures published 
elsewhere. Among the factors affecting the length of 
detention is the adequacy of social care likely to be 
available for discharged patients. Psychiatric social 
workers, trained to deal with such problems, have 
been employed experimentally at selected mental 
hospitals of the L.C.C. since 1931; the appoint- 
ment of a social worker at each of the ten mental 
hospitals has now been authorised, in addition to 
the five who work at the Maudsley Hospital. 


MENTAL DEFICIENCY 


It is in regard to mental defect that social 
treatment is most conspicuous in the report. 
Systematic supervision of defectives in their own 
homes has been carried out in more than 3000 cases ; 
a third of these are engaged in remunerative work. 
The Council also maintains fourteen occupation and 


THE LANCET] 


CLEAN WATER PROBLEMS 


[FEB. 8, 1936 335 


craft centres for the training of defective patients 
outside any institution, while for the 6000 cared for 
in hospitals and homes there is educational provision 
and employment, the extent of which may be 
recognised from the financial appendices to the 
report. 

RESEARCH 


The recognition by the Council of the necessity 
for more than the routine care of the mentally ill, 
exacting and primary though it be, is strikingly seen 
in the passages dealing with research and teaching. 
The Council is responsible for the maintenance of the 
only university psychiatric clinic in England; as a 
centre of post-graduate teaching in this branch of 
medicine, the Maudsley Hospital occupies a place 
and influence comparable to that of the Henry 
Phipps Clinic in the United States. 
carried out there, in the wards and the central patho- 
logical laboratory, could hardly have been so active 
and fruitful if the Council had not shown an 
enlightened concern for these less obvious obligations. 
Throughout the mental hospitals, as may be seen 
from one of the appendices, investigation is pursued 
into the manifold problems of mental illness along 
varied and profitable lines. Such evidence disposes 
of the notion that in mental hospitals lethargy is the 
doctors’ portion, as well as the patients’. 


CLEAN WATER PROBLEMS 


THE Water Pollution Research Board, in addition 
to its exhaustive survey of the River Tees summarised 
in a previous issue (1935, ii., 1322), has engaged in 
many other activities during the past year. These 
are briefly described in the annual report, in which 
is included the report of the director of research, 
Mr. H. T. Calvert, Ph.D.} 

The work on base-exchange methods of water 
softening has been continued and materials have 
been obtained from clays found in Britain which 
are equal in softening properties to some of the 
imported materials used for this purpose and are 
more resistant to disintegration. Experiments with 
synthetic resins prepared at the Teddington laboratory 
have shown that some of these possess marked base- 
exchange properties. Other synthetic resins prepared 
from aromatic bases such as aniline will remove not 
cations but anions, so that by the combined use of 
the two classes the solids in Teddington (equals 
London) tap water can be reduced from about 33 
to 1 part per 100,000, while the same process carried 
out two or three times will remove most of the salt 
from sea water. This fact may be of the greatest 
importance to seamen who, like Bligh of Bounty 
fame, are forced to make voyages in open boats or 
other small craft where storage for water is so limited 
that sea water must be distilled, a process which 
requires not only a still but a supply of fuel to be 
carried. If Prof. G. T. Morgan and his colleagues 
can render untrue the words of the Ancient Mariner : 
“Water, water, everywhere, nor any drop to drink,” 
they will deserve well of all seafaring men. 

Work on the activated sludge process of sewage 
purification goes on under Prof. Topley at the London 
School of Hygiene. Sludges suited for treatment 
of special impurities in liquids have been prepared. 
The effect of bubbling various gases through sewage, 
directed by Prof. F. G. Donnan at University College, 


2 Department of Scientific and Industrial Research. H.M. 


Stationery Office. 1s. 


The research . 


seems to indicate that the production by this means 
of thin layers, almost all surface, causes a separation 
of colloid matter, whilst simple stirring has some 
effect in this direction. We know of cases where 
this action is being tried for improvement of sedi- 
mentation. It is, after all, a common laboratory 
practice to stir a liquid in which a precipitate has 
been produced, in order to render the separated 
substance coarser grained and easier to filter. 

The officers of the Board do not rely only on the 
printed word to make the present state of knowledge 
of water purification known to interested persons. 
We have before us a summary of a lecture given by the 
assistant director, Mr. A. Parker, D.Sc., to the Bristol 
branch of the Society of Chemical Industry. The 
effluent from a beet-sugar factory of average size 
(3 or 4 million gallons a day) would, said Dr. Parker, 
have about the same polluting action on astream asthe 
sewage of a city of the size of Bristol, and the waste 
waters of all the factories in this country would be 
roughly equivalent to the domestic sewage of London. 
This shows the magnitude of the pollution from a 
relatively new industry, and explains the many 
rivers which have been temporarily ruined by it. 
Investigations completed by the Board have shown 
that after simple preliminary treatment the waste 
waters from such works can be used again in the 
factory processes, leaving little or no effluent for 
disposal. What effluent there is can be effectively 
purified before discharge by biological oxidation in 
percolating filters. Similarly the effluent from dairies 
and milk products factories in Britain, amounting 
in wash waters alone to the equivalent of the sewage 
from a population of 400,000, can be satisfactorily 
purified by oxidation, assuming that the whey, skim 
milk, and buttermilk are not run to waste. The story 
of river pollution is, said Dr. Parker, one of v'un- 
balanced development of industry in districts not 
already industrialised. In many cases the knowledge 
of purifying processes was available to render the 
effluents harmless and to prevent not only the dis- 
figurement of our watercourses but the rendering 
useless of the water for other industries down stream. 
The methods whereby the discharge of sewage can 
be rendered harmless cost money, but it is money 
well spent, and it may be hoped that by systematic 
research the cost may be reduced. 


INFECTIOUS DISEASE 


IN ENGLAND AND WALES DURING THE WEEK ENDED 
JAN. 25TH, 1936 


Notifications.—The following cases of infectious 
disease were notified during the week: Small-pox, 
0; scarlet fever, 2505; diphtheria, 1356; enteric 
fever, 19; acute pneumonia (primary or influenzal), 
1376 ; puerperal fever, 47; puerperal pyrexia, 92; 
cerebro-spinal fever, 21; acute poliomyelitis, 9; 
acute polio-encephalitis, 1; encephalitis lethargica, 
9; dysentery, 33; ophthalmia neonatorum, 70. No 
case of cholera, plague, or typhus fever was notified 
during the week. 

The number of cases in the Infectious Hospitals of the London 
County Council] on Jan. 31st was 4111, which included : Scarlet 
fever, 1108; diphtheria, 1081; measles, 578; whooping- 
cough, 653; puerperal fever, 22 mothers (plus 16 babies); 
encephalitis lethargica, 282; poliomyelitis, 4. At St. 
Margaret’s Hospital there were 23 babies (plus 6 mothers) 
with ophthalmia neonatorum. 


Deaths.—In 121 great towns, including London, 
there was no death from small-pox, 1 (0) from enteric 
fever, 57 (7) from measles, 7 (1) from scarlet fever, 
33 (10) from whooping-cough, 45 (5) from diphtheria, 
42 (16) from enteritis under two years, and 104 (20) 


(Continued at foot of next page) 


336 THE LANCET] 


[FEB. 8, 1936 


se a a a a a a 
OBITUARY | 
a a a 


SIR JOHN MARNOCH, K.C.V.O., M.B. Aberd. 
HONORARY SURGEON, H.M. HOUSEHOLD IN SCOTLAND 

THE death occurred on Sunday last in Aberdeen, 
in his sixty-ninth year, of the well-known surgeon 
Sir John Marnoch, emeritus regius professor of 
surgery in the University of Aberdeen. 

John Marnoch was the son of the late James 
Marnock of Aberdeen, where he was born in 1867. He 
was educated at his native grammar school and 
university (King’s 
and the Marischal 
College), and 
graduated as M.B., 
C.M.A berd. in 1891 
with the highest 
honours, having 
previously taken 
the M.A. degree. 
He acted as house 
physician and 
house surgeon at 
the Aberdeen 
Royal Infirmary, 
and held similar 
posts at the Aber- 
deen Hospital for 
Sick Children, and 
was marked out 
for promotion by 


being appointed 

assistant to the 

SIR JOHN MARNOCH professor of physio- 
logy in the uni- 

[Photograph by Elliott & Fry versi ty. He was 

elected assistant 


surgeon to the Royal Infirmary, promoted quickly 
as full surgeon, and filled the post of lecturer on 
clinical surgery at the infirmary. In 1909 he became 
regius professor of surgery in the university, a posi- 
tion which he held at the outbreak of war. During 
the war he was in charge of the section of special 
surgery, lst Scottish General Hospital, with the rank 
of brevet-colonel, A.M.S., and in 1915 received the 
C.V.O. At different times he held local public 
appointments as medical officer of the Shipmasters’ 
Society and the Gas Corporation, and as secretary 
of the Medico-Chirurgical Society of Aberdeen, and: 
was also medical assessor of the district under the 
Workmen’s Compensation Act. l 

. From a man,with such medical and‘ multifarious 
public duties no large literary output could be 
expected, but Marnoch’s earlier contributions to 
medical literature ranged over a large area, contri- 
butions from his pen appearing on various clinical 
subjects in the Journal of Anatomy and Physiology, 


a ae = 


(Continued from previous page) 


from influenza. The figures in parentheses are those 
for London itself. 

The mortality from influenza is maintained, the total deaths 
for the last eight weeks (working backwards) being mi 9, 
110, 110, 80, 67, 62, 45. The deaths this week aro scattered 
over 48 great towns, Manchester reporting 8, Birmingham 1, 
Leeds 5, Liverpool 4, Bolton 3, no other great town more than 2. 
Liverpool had to report 13 deaths from measles, Manchester 8, 
Birkenhead and Warrington each 4, Croydon and Salford each 3. 

Birmingham had 4 deaths from whooping-cough, Birkenhead 3. 
Deaths from diphtheria were reported from 35 great towns ; 
3 from Bury, no other great town more than 2. 


` The number of stillbirths notified during the week 
was 260 (corresponding to a rate of 41 per 1000 total 
births), including 31 in London, 


in the Scottish Medical and Surgical Journal, in the 
Annals of Surgery, in the British Journal of Surgery, 
the British Medical Journal, and The Lancet. A 


. paper in the British Medical Journal in 1909 on 


treatment of gastric ulcer gave a useful account of 
the complications and sequele as then understood 
attendant on the treatment of gastric ulcer, while a 
paper in THE Lancet, published shortly before, 
formed a practical contribution to the pathogenesis 
of cancer. The two essays show how thoroughly 
well and practically informed Marnoch was. He was 
appointed examiner in surgery at different times in 
the universities of Edinburgh and Durham, and was 
a fellow of the Association of Surgeons of Great 


. Britain and Ireland. He was appointed surgeon to 


His Majesty’s Household in Scotland, and a D.L. 
for his county. In 1928 he was created K.C.V.O., 
while in 1932, when his position of regius professor 
of surgery terminated, he was appointed emeritus 
professor and received the distinction of LL.D. Aberd. 


Prof. J. R. Learmonth writes: “It was my mis- 
fortune that I did not meet Sir John Marnoch until 
after his retirement from active surgical practice; 
yet so profound an impression had he made on pro- 
fessional life in the north of Scotland, and so frequent 
are references to his judgment and skill, that it is 
difficult to think of him as other than still in his 
hey-day. 

“For the first eight years of his professional 
career, Marnoch carried on a general as well as a 
surgical practice. This experience was reflected 
throughout his whole life, for it enabled him to 
understand the social and economic factors that 
may influence treatment, and his advice was always 
tempered by an appreciation of these. He could and 
did understand the difficulties under which practi- 
tioners may have to work, and throughout his long 
and busy life he was ready to help them in these 
difficulties, irrespective of any financial return for 
his services. In 1900 he was elected as full surgeon 
to the Aberdeen Royal Infirmary, and remained in 
charge of wards for the long period of 32 years. 
This period saw rapid advances in the possibilities 
and applications of surgery, and of these he took full 
advantage. Early in his career, therefore, he 
acquired an exceedingly large clinical experience. 
This he constantly tempered by the exercise of his 
own judgment ; and it is to be noted that he brought 
to this task intellectual qualities of the first order, 
which his academic record as a student had promised. 
In consequence, he soon acquired the power of making 
rapid judgments, and the almost invariable correct- 
ness of these has been traditional. To this power 
he added operative dexterity that was frequently 
uncanny. He was never obviously in haste, nor 
was his extraordinary rapidity of a spectacular type. 
It was part of the man himself: a ruthless shedding 
of all but the essential steps, and a minimum of 
movement in accomplishing these. At the end of 
each operation he had done his best. 

“ During the years of the war the combination of 
his military and civil duties, and lack of assistance, 
laid upon him a burden that must have been well- 
nigh intolerable. He never enjoyed really robust 
health ; yet the work he overtook so uncomplainingly 
would have proved too much for ‘many a stronger 
man. There is no doubt that the incessant toil of 
these years contributed to his final illness. As a 
teacher he was essentially eclectic. He taught 


THE LANCET] — 


OBITUARY 


(FEB: 8, 1936 337 


fundamentals, and that dogmatically. His aim was 
to equip his students with a sound elementary frame- 
work on which they might build; and no one was 
better able than Marnoch to select what was needed 
for the general practitioner ; he knew from experience. 
The same principle of reduction to fundamentals 
coloured his whole outlook upon the art and craft 
of surgery ; and it is well that there be those who can 
assess so broadly. Only three weeks ago, alas, 
I asked him what knowledge had been of greatest 
service to him in his crowded life. Without hesitation 
(and Sir John never hesitated, wherein lay his strength) 
he replied: ‘A knowledge of inflammation, its 
results and its treatment.’ This might well become 
a motto for surgical class-rooms, in an era when 
students are apt to be enamoured of intricate pro- 
cedures. Those who knew him will remember well 
the click of the tongue with which he commented 
upon, and so surely relegated to their proper place, 
the ‘ingenious’ operations that still find their way 
into surgical literature. To speak colloquially, what 
he taught, stuck ; and it could not escape the notice 
of a newcomer to the district, that practitioners 
trained by him constantly made the comment: 
‘Sir John used to say.’ 

‘“ It was characteristic of Marnoch that his pleasures 
and hobbies were simple, and once chosen remained 
his life-long solaces. He was a skilled violinist, and 
for many years delighted .in weekly quartettes in 
which his fellow players were invariably the same. 
As an alternative, he delighted in Highland music, 
and it is sad to know that his illness separated him 
from his violin during the years of his retirement. 
His sport was salmon-fishing, and this he was able to 
follow until the summer of 1935, when to his great 
delight he was able to land the biggest fish caught 
that year in the Spey. In his friendships his early 
loyalties were lifelong, and ended only by death. His 
allegiance, once given, was enduring, and carried 
with it the invaluable attribute of unbiased comment 
and criticism; of this I speak with gratitude, for 
frequently I turned to him as one who would give 
me wise and penetrating advice; and I never turned 
to him in vain. 

‘‘Marnoch’s whole life was determined by his 
intellectual honesty. He was honest in his surgery ; 
honest in his appraisal of it; honest in his dealings 
with his colleagues ; and honest in his dealings with 
his fellow-men. He would have despised a panegyric 
as an obituary notice; his view was that he had 
given due consideration to his duties, and had then 
carried them out to the best of his ability. How 
well he succeeded, a generation of students of Aberdeen 
can testify.” = ot & 


Sir John Marnoch married in 1900 Agnes Holt, 
daughter of the late Alexander Macdonald, of Gar- 
mouth, whose devoted care did so much to lessen 
the bitterness of physical incapacity during the later 
phases of hisillness. Of their two daughters, the elder 
is married to a biologist in Melbourne, the younger 
is the wife of a physician in Toronto. 


JOSEPH WILLIAM ROB, O.B.E., M.D. Camb. 


Joseph William Rob, who died in London on 
Feb. lst, was born at Skipton-on-Swale in 1876, the 
son of Mr. J. D. Rob, and received his education at 
St. John’s College, Cambridge, where he was ascholar 
and graduated as B.A. in 1898 with first-class honours 
in the Natural Sciences Tripos. He proceeded to St. 
Thomas’s Hospital. where he served as house surgeon 
and graduated M.B., B.Chir.Camb. in 1902, later 


‘decided soon after 


proceeding to the M.D. degree. He practised for a. 
time in Thirsk and later at Weybridge, and was. 
medical officer at the Walton-on-Thames Cottage 
Hospital and the Masonic Institution for Girls. He 
contributed interesting clinical papers to THE LANCET 
in 1906 and 1908, and earned a sound reputation as. 
a practitioner. | 


AMY SHEPPARD, O.B.E., M.B.Lond., D.P.H. 


Dr. Amy Sheppard, consulting ophthalmic surgeon. 
to the Elizabeth Garrett Anderson Hospital, died on 
Jan. 22nd in her 77th year after an illness which 
had lasted a few months. 

The daughter of Thomas Sheppard of Kingswood, 
near Birmingham, Amy Sheppard was born at 
Dudley, Worcestershire. She was educated at a 
private school in Stourbridge, and before taking up: 
medicine, which was at that time still an unusual 
career for a woman, she studied science at Mason 
College, Birmingham, now incorporated in the 
University of Birmingham, whence she matriculated 
in 1884. She then 
went to University : 
College, London, 
and passed the pre- 
liminary science 
examination in 
1885 before enter- 
ing the London 
(R.F.H.) School of 
Medicine for 
Women in October 
of the same year. 
She qualified M.B. 
Lond. in 1892 and 


to specialise in 
ophthalmology, 
becoming clinical 
assistant at the 
Royal London 
Ophthalmic Hos- 
pital and she con- 
tinued this work 
for many years. 
In January, 
1895, she was appointed assistant physician to the 
Elizabeth Garrett Anderson Hospital (then the New 
Hospital), but only held this appointment for a few 
months, resigning it in the following April to become 
assistant ophthalmic surgeon to the hospital. In 
1898, for no other reason than to prepare her- 
self to give a short course of lectures on public 
health, Dr. Sheppard took the D.P.H. Camb. ; 
though this diploma had been established more than 
20 years before she was one of the first two women 
to take it, the other being the late Dr. Helen 
Bittell. In 1906 she succeeded Miss Charlotte Ellaby 
as ophthalmic surgeon to the Elizabeth Garrett 
Anderson Hospital, a post which she held for 16 years. 
Dr. Sheppard was also ophthalmic surgeon to the 
Medical Mission Hospital at Canning Town and 
medical examiner to the Girls’ Public Day School 
Trust. By the time the late war started Dr. 
Sheppard was thus well established in her specialty 
and when the Military Hospital, Endell-street, run 
entirely by medical women. was established she 
accepted the invitation to join its staff in the capacity 
of ophthalmic surgeon. She also acted as ophthalmic 
surgeon to the Q.M.A.A.C. at Isleworth, and for 
these services she was made an O.B.E. in 1919. Dr. 
Sheppard continued her private consulting practice 


DR. AMY SHEPPARD 
[Photograph by Elliott & Fry 


338 THE LANCET] 


until the late spring of last year when the state 
of her health caused her to live more and more at 
the country cottage near Limpsfield which had 
already been a week-end resort for many years. 

Dr. Sheppard might be called one of the pioneer 
medical women, since she was only No. 140 on 
the register of the London School of Medicine for 
Women. She took the greatest interest in the 
development of opportunities for women in profes- 
sional and other work. Though she never joined the 
militant section of the suffragettes she had sympathy 
with their activities and lost no opportunity of 
explaining the need for militant tactics to those who 
were sceptical. She was prominent among those 
who made a principle of resisting taxation because 
they had no vote, and as a result more than once 
her possessions were sold up. Early in her career 
Dr. Sheppard paid a special visit to India to study 
cataract operation by the method of “ Jullundur ” 
Smith, and on her return recorded her impressions of 
this technique in a contribution to the British Medical 
Journal. She was a prominent member of the London 
Association of the Women’s Medical Federation, and 
when she lived chiefly in London regularly attended 
its meetings. She was always alert to notice new 
members or visitors and to put them at their ease 
with a friendly word. Her rather diffident manner 
concealed decided opinions and she won the respect 
of her colleagues on the council of the Association by 
her pertinacity in sticking to her views on important 
points of principle, though she was always ready to 
defer to the opinion of others when no great matter 
was at stake. 

Dr. Sheppard was an expert and very clever 
gardener with a special interest in the culture of 
lilies. She had a large circle of acquaintances but 
few close friends; there was something elusive 
about her which perhaps added to her charm. She 
will be greatly missed at the gatherings of the London 
Association and at the larger parties when members 
of the council of the Medical Women’s Federation 
are entertained. 


GILBERT EDWARD BROOKE, L.R.C.P. &S., 
D.P.H. Edin. 


News has reached this country from Singapore 
of the death of Dr. Gilbert Edward Brooke, formerly 
chief health officer of the Straits Settlements. The 
son of the late Capt. E. F. B. Brooke, he was born 
at Hyéres in 1873 and educated at Monkton Combe 
School, Bath, and at the Ouchy School, Switzerland, 
whence he proceeded to Pembroke College, Cambridge. 
He graduated at Cambridge as B.A. in 1894, did not 
pursue the medical curriculum, but continued his 
studies at the London Hospital, where he was a 
prominent footballer. He took the triple Scottish 
qualification in 1897 and later the diploma of D.P.H., 
and after brief service in the mercantile marine, 
became Government medical officer to the East 
Harbour, Turk’s Island, West Indies. He was 
appointed medical officer of health to the Caicos 
Islands, while at the time of the war he had been 
port health officer at Singapore for some years, later 
becoming chief health officer of the Straits Settle- 
ments. At Singapore he was lecturer on hygiene to 
the medical school, acted as examiner in chemistry 
and physics, and wrote several small text-books on 
hygiene, parasitology, and sanitary science from the 
tropical point of view. 

In 1920 there appeared from Brooke’s pen a 
well-written ‘‘ Manual for Ships’ Surgeons and Port 
Health Officers,” in which he informed the ship’s 


OBITUARY 


[FEB. 8, 1936 


surgeon what the sanitary authorities of the port 


will want from him in the matter of returns, how he | 


can help them most effectively, and how as a 
consequence he can secure for his ship the shortest 
delay at quarantine. The double aim of the book 
was to prevent dangerous conditions from eluding 
medical observation and to abbreviate periods of 
detention of the ship that must hamper trade, and 
the advice was succinct and practical. In the same 
year there appeared a new and enlarged edition of a 
work on ‘‘ Medico-tropical Practice,” which had been 
written some twelve years before and whose favourable 
reception justified reissue. A communication from 
him to THE LANceET of March 14th, 1931, set out 
fully the importance which he considered should be 
attached to the bills of health carried by sea-going 
ships, and regretting certain movements made for 
their abolition. The Far Eastern Health Bureau in 
connexion with the health organisation of the League 
of Nations came into existence in 1925 when Brooke 
was appointed director. His organising work in the 
collation and distribution of information as to the 
prevalence of epidemic disease was recognised as of 
the first value, for the bureau was placed by him 
in a position to collect regular information from a 
large number of ports. Similar capacity for strenuous 
work on organised lines was displayed by him in the 
construction in Sarawak of a health service; on 
this he was engaged until the time of his death. 

Gilbert Brooke by both his practical labours and 
literary output, which was large and varied, won for 
himself a high position in the Colonial Medical 
Service. . 


WILLIAM CRAN DUTHIE, M.B. Aberd. 


THE death occurred in Blackburn Royal Infirmary 
on Jan. 24th of Dr. Cran Duthie; he died in the 
institution with which he was long and valuably 
associated. The son of the Rev. George Duthie, 
he was born at Kinkell. Perthshire, in 1871, and.was 
educated at Aberdeen University where he graduated 
M.B., C.M. in 1893. In the following year he started 
practice in Blackburn and later was appointed 
assistant surgeon to the Blackburn Infirmary. He 
was for 15 years, until his retirement in 1931, a 
member of the staff where he was popular alike with 
colleagues and patients, and unanimous expressions 
of gratitude for his services were expressed by the 
board on his retirement. Dr. Duthie is survived by 
a widow and a large family, four of whom are connected 
with the medical profession, two as doctors—Dr. Lister 
Duthie being in practice with him—one daughter as 
a nurse, and another daughter as a radiographer. 


HENRY BULLEN BEATTY, L.R.C.P. & S.I. 
SURGEON-CAPTAIN R.N., RETIRED 

Surgeon-Captain Henry Bullen Beatty, who died 
on Jan. 2Ist, 1936, at his residence, in Rathmines, 
aged 75, was born in Dublin, and educated at Wesley 
College and at the Carmichael Medical School in that 
city. He obtained the conjoint qualifications of 
Ireland in 1884, and joined the medical service of 
the Royal Navy, where he saw much foreign service, 
first on the west coast of Africa, and later in the 
South Seas and on the Australian station. In 1904 
he was appointed to the Royal yacht, H.M.S. Osborne, 
and after that appointment, from 1908 to 191], he 
was surgeon to the Marines at Chatham. Subse- 
quently he served again on the Australian station, 
and was due to retire in 1914, but owing to the out- 
break of the war he was retained in the service until 
1917. Ie returned to Dublin in broken health, but 


THE LANCET] 


was able a year later to assist in establishing the 
earliest Pensions Boards in Dublin. For several 
years he was engaged in pensions work, acting as 
chairman of boards, a work for which he was specially 
fitted by his quick grasp, his knowledge of regula- 
tions of procedure, and his judicial mind. Those 
who worked with him found him a very fair, efficient, 
and pleasant chairman. During the last five years his 
health failed badly, and he was rarely able to leave 
the house, but his interest in world and domestic 
affairs was unimpaired. 


ARCHIBALD ALEXANDER GEORGE DICKEY, 
M.B.E., M.D.R.U.I. 


Dr. Archibald Dickey, who died on Jan. 19th 
at the age of 74, was a well-known physician in Colne 


MEDICAL NEWS 


[FEB. 8,1936 339 


and later in Bolton. He was for 33 years in practice 
at the former centre and for 15 years at the latter, 
only leaving on his retirement a few months ago. 
He received his medical education at Queen’s College, 
Belfast, was a scholar and prizeman, took the double 


Irish diploma, and in 1883 graduated as M.D. R.U.I. 


At Colne he was in charge of the Military Hospital 
during the war and was awarded the M.B.E. He was 
a justice of the peace for the borough, surgeon to the 
Post Office and the St. John Ambulance Brigade, 
and honorary medical officer to the Cottage Hospital. 


When in 1921 he left Colne to practise in Bolton, 


he held various public appointments and continued 
his interest in the work of the St. John Ambulance 
Brigade. He died at the residence, in Pwllheli, 
of his son, Dr. H. W. Dickey. 


MEDICAL NEWS 


University of Cambridge 


Dr. Samuel Nevin has been appointed to the Pinsent- 
Darwin studentship for the study of mental pathology. 
He has lately held a Halley Stewart research fellowship 
at the National Hospital, Queen-square. 


University of London 


Prof. H. H. Woollard has been appointed as from 
Oct. lst, 1936, to the university chair of anatomy tenable 
at University College. Since 1929 he has been professor 
of anatomy at St. Bartholomew’s Hospital medical 
college, having previously held the chair of anatomy at 
Adelaide University. 


The title of reader in pharmacological chemistry in the 
University has been conferred on Mr. H. R. Ing, D.Phil., 
in respect of the post held by him at University College. 

Dr. Ing was born in 1899, and was educated at Oxford High 
School and at New College, Oxford, where he graduated as 
M.A. in 1921 and D.Phil. in 1924. From 1923 to 1925 he was 
a university demonstrator in organic chemistry at Oxford, 
after which he went to Manchester with a Ramsay memorial 
fellowship. In the following year he became research chemist 


for the Manchester cancer committee, and in 1928 he came to - 


London to take up his present post as lecturer in pharmaco- 
logical chemistry at University College. 


The William Julius Mickle fellowship for 1936 has been 
awarded to Dr. H. P. Himsworth, deputy director of the 
medical unit at University College Hospital medical 
school. 

Owing to the illness of Dr. H. M. Traquair, the lectures 
on Perimetry, which were to have been given at University 
College Hospital medical school on Feb. 10th and llth, 
have been postponed. 


Royal College of Physicians of London 


At a meeting of the College held on Jan. 30th, with 
Lord Dawson of Penn, the president, in the chair, it was 
announced that the Gilbert Blane gold medals for 1935 
had been awarded to Surgeon Lieutenant Commander 
A. A. Pomfret and Surgeon Lieutenant Commander W. G. 
Fitzpatrick. Dr. Rupert Waterhouse was appointed a 
representative on the medical advisory committee of the 
British Health Resorts Association. The Harveian 
librarian announced the presentation by Prof. Roy 
Dobbin of a sumptuously bound copy of the manuscript 
of Ibn Al-Naphis, which dates from the thirteenth century, 
and in which is the first-known description of the Mechanism 
of the Lesser Circulation. 

Dr. E. L. Middleton will deliver the Milroy lectures on 
industrial pulmonary disease due to the inhalation of 
dust, with special reference to silicosis, on Feb. 27th and 
March 3rd; Dr. R. A. 
on medical problems in mineral metabolism on March 5th, 
10th, and 12th; Dr. John Parkinson the Lumleian lectures 
on enlargement of the heart on March 17th and 19th; and 
Mr. Joseph Needham, Sc.D., the Oliver-Sharpey lectures 
on chemical aspects of morphogenetic determination on 
March 24th and 26th. 

The following candidates, having satisfied the censors’ 
board, were admitted members of the College :— 


Felix Wilfrid Arden, M.D. Adelaide ; Sailendra Mohon Basu, 
M.B. Rangoon; James Frederick Brailsford, M.D. Birm. ; 


.Coleman, M.B. 


MecCance the Goulstonian lectures . 


Geoffrey Oswald, Atyeo Briggs,M.B.Camb.; Francis Hayling 

Camb. ; Leybourne Stanley Patrick Davidson, 
M.D. Edin.; Richard Heyworth Dobbs, M.B.Camb.; Colin 
Campbell Edwards, M.B. Sydney; David Stanley Fairweather, 
M.B. Edin.; David George Ferriman, M.B. Oxon. ; Alan 
Morton Gill, M.D. Lond.; Arthur Rupert Hallam, M.D. Edin. ; 
Ernest Arthur Hardy, M.B. Lond. ; Herbert Edward Holling, 
M.B. Sheff.; Philip William Hutton, M.B. Camb. ; Alan Leon 
Jacobs, M. B. Oxon. ; Evan Idris Jones, M.B. Lond. ; Francis 
Avery Jones, M.B. Lond.; Edwin James Reid Leiner, M.B. 
Aberd.; Jack Watson Litchfleld, M.B. Oxon. ; Leo McGoldrick, 
M.B.N.U. Irel. ; Wilfrid Marshall, M.D. Aberd.; James Lister 
Newman, M.D. Camb. ; John William Osborne, M.B. Sydney ; 
John Scholes Parkinson, M.B. Manch. Abdel Aziz Sami, M.B. 
Cairo; Alice Mary Stewart, M.B. Camb. Charles Henry 
Stewart-Hess, M.B.Liverp.; Harold Midgley Turner, M.D. 
Manch.; and Rustom Jal Vakil, M.B. Lond. 


Licences to practise were granted to 140 candidates 
(132 men and 8 women) who have passed the final examina- 
tion of the Conjoint Board. The following are the names 
and medical schools of the successful candidates :— 


A. W. Abramson, Camb. and St. Thomas’s; Ruth M. 
Addison, Roy. Free; G. W. Alderman, London and Leeds; 
Sivasithamparam Balasingam, King’s Coll.; E. J. W. Barnard, 
St. Bart.’s ; H. F. Barnard, Westminster ; ; A.B. Baxter, Guy’s ; ; 
David Bobker, Charing Cross ; ; E. S. Bompas, St. Thomas’s ; ; 
A. W. Bone, Camb. and London; J. C. B. Bone, Middlesex ; 
R. E. Bonham-Carter, Camb. and St. Thomas’s 8; J. P. Brazil, 
St. Mary’s ; B. B. Bridges, Guy’s; D. H. D. Burbridge, 
Middlesex ; J. C. Busby, Camb. and St. Mary’s ; >; L. S. Calvert, 
Leeds ; Josephine H. Campbell, King’s Coll.; W. me Cashmore, 
Guy’s and Birm.; S. R. Chandra, Calcut a; E. P. Clarke, 
St. Bart.’s; J. H. Coles, King’s Coll. ; Kathleen Craddock, 
Roy. Free ; Montugue Curwen, Middlesex ; C. S. Darke, Guy’s ; 
J. E. A. David, Camb. and St. Bart.’s; J. R. Davidson and 
H. J. Davies, Univ. Coll.; J. N. Deakin, Birm.; G. G. Doel, 
King’s Coll.; B. J. Doran, Guy’s; C. A. Dowding, Camb. and 
King’s Coll.; H. G. Earnshaw and R. B. Evans, London ; ; 
F. 1. Firth, Manch. Robert Fleming, Geneva and London ; 
C. B. Franklin, St. Bart.’ s; D. F. Freebody, Guy’s; J. E. 
Garson, Madras and West London ; Joyce M. George, King’s 
Coll. ; Jaharlal Ghosh, Calcutta and St. Bart.’ 83 D. R. Gibson, 
St. Mary’ s; Sholem Glaser, Cape and London ; Louis Green- 
baum, London ; J. C. Harland, Westminster ; H. R. S. Harley, 
Guy’s; G. D. Harthan and Jobn Heginbotham, Manchester ; 
A. G. Hemsley, Middlesex; G. H. M. Hemsted, St. Mary's; 
R. K. R. Henry, A. G. W. Hill, and B. W. Hunt, Guy’s ; C. W. 
Hutt, Camb. and St. Bart.’s ; W.G. Hutton, Camb. and "Leeds 3 
Mohammed Inayatullah, Agra and Manch. Meir Irving, 
Charing Cross; Gwyneth M. Jenkyn- eae "Roy. Free and 
West London; A. C. Jones, Middlesex; S. E. L. Kahla, Sydney 
and London ; ' Ernest Kaplan and H. M. oe Guy’s; K.C. 
Kershaw, Manch. B. Kiernander, St. Thomas’s ; W.J. 
Latham, "London; L. 'R. Leask, St. Bart.’ s; H. A. Leggett, 
Guy’s ; Maurice Lewis, Univ. Coll. : R. N. A. Leyton, Camb. 
and Westminster ; Milton Lipson, charing Cross; S. E. Little- 
page, Manch. and St. Bart.’s; J. M. Lockett, St. Bart.’s; 
R. D. McDonald. Cape and London ; ; J. T. Mair, Westminster ; 
C. W. Maisey, St. Thomas’s ; Simon Marinker, Middlesex ; 
H. A.C. Mason, St. Thomas’ s; Leslie Merrill, Guy’s; P. J. W 
Mills, St. Bart.’s; A. G. Moore, St. Thomas’s ; F. T. Moore, 
St. Bart.’ 83 EEN Moore, Roy. Free; F. L. E. Musgrove, 


Guy’s 3 m O. G. Norman, Camb, and London; J. D. Ogilvie 
and W. A. Oliver, St. Bart.’s : >; W. V. Owen, Camb. and West- 
Seton 'D. E. Parry, St. Mary’s; J. C. Patel, Bombay ; 


N. O. Paterson, Guy’s; E. N. Pearlman, Middlesex; John 
Pemberton, Univ. Coll.; R. R. Prewer, St. Bart.’s; D. E. 
Price, St. Mary’s; Joseph Rabinovitch, Leeds ; ; 0. N. Ransford 
and H. W. Rees, Middlesex ; J. L. Reid, Oxon. and Middlesex ; 
Guy Rigby- Jones, Camb. and St. Thomas’s s; Barnard Robbins, 
King’s College; A. N. Roy, St. Bart.’s; P. S. Sambandam, 
Madras and West London; L. J. Sandell, St. Bart.’s ; 3 H. V. 
Sankarayya, Mysore and London; Eric Sayle, Guy’s; Morris 
Schwartz, Univ. Coll.; Rupert Solley, Camb. and London ; 
G. C. Steel, Middlesex ; D. E. Stephens, Cape and St. Mary’s,; 
B. P. Stone, Camb. and King’s Coll.; J. 5. Stuart, Guy’s; 
F. J. E. Stuhl, Camb. and W estminster ; K. H. Sugden, 


340 THE LANCET] MEDICAL NEWS.—APPOINTMENTS [FEB. 8, 1936 
St. Bart.’s; C. H. Tanner, Cardiff; B. W. Thomas, Univ. 
Coll.; Dorothy J. Thompson, Camb. and Bristol; T. H New Hospital for Basingstoke 


Tidswell, St. Bart.’s; R. C. Tudway, Univ. Coll.; R. G. Tuke, 
St. Thomas’s; J. E. Underwood, St. Bart.’s8; G. J. can der 
Merwe, Cape and Guy’s; C. W. H. Van der Post and W. M. 
Van Essen, Guy’s: G. L. Wainganker, Manch. and West 
London; G. W. Ward, Mancb.; J. H. Ward, Camb. and 
St. Bart.’s; A. G. Waters, Cardiff and London; S. A. Way, 
Middlesex; Samuel Weinstock, London; J. L. Whatley, 
Birm.; R. R. Willcox, St. Mary’s; E. G. Williamson, Camb. 
and Birm. ; Louise F. Wilson, Yale and West London ; Anthony 
Winder, Camb. and London; H. L. Wolfe, St. Bart.’s ; L.A. C 
Wood, Camb. and St. Thomas’s; J. E. Wooding, Camb. and 
St. Bart.’s; G. N. Wright, Guy’s; P. L. Young and W. J. 
Young, St. Bart.’s. 


Diplomas were granted jointly with the Royal College 
of Surgeons to the following candidates :— . 


Diploma in Public Health.—S. D. Elliott, R. J._Farnbach, 
R. A. Jones, G. G. Kayne, W. F. Lane, Catherina E. Murray, 
C. R. Naidu, and T. S. Rodgers. 

Diploma in Psychological Medicine.—J. L. Bates, A. J. 
Galbraith, J. F. Galloway, S. L. Last, S. A. MacKeith, W. H. 
McMenemey, K. R. Masani, J. A. Smeal, Alfred Torrie, Rosalind 
Vacher, and J. H. Watkin. 

Diploma in Laryngology and Otology.—B. T. n, 
G. B. Ludlam, R. F. J. Martin, Narayana Srinivasan, T. G. 
Swinburne, and W. E. Wiliams. , M 

Diploma in Tropical Medicine and_Hygiene.—W. K. Cheng, 
Anastasio D'Souza, J. S. Gibson, Kalidas Mitra, and V. T. 
Vagh. 

* Diploma in Medical Radiology.—E. W. Casey and Frank Ellis. 

Diploma in Anresthetics.—Olive M. Anderson, H. B. Logan, 
S. D. McAusland, G. R. Phillips, K. B. Pinson, Benjamin 
Weinbren, H. L. Willey, and C. H. Wilson. 


Society of Apothecaries of London 
At recent examinations the following candidates were 
successful :— 


Surgery.—R. H. Bembridge, King’s Coll. Hosp.; H 
Koretz, Univ. of Manch. ; 


. À. 
and G. N. Rodgers, Bombay and 
West London Hosp. 


p 

Medicine.—F. E. Bedell, St. Mary’s Hosp. ; M. G. H. Jones, 
Welsh National School of Medicine; and R. L. Walmsley, 
Univs. of Camb. and Leeds. f 

Forensic Medicine.—F. E. Bedell, St. Mary’s Hosp. ; N. Bick- 
ford, Middlesex Hosp.; E. E. Evans, Guy’s Hosp. and St. 
George’s Hosp.; M. G. H. Jones, Welsh National School of 
Medicine; and R. L. Walmsley, Univs. of Camb. and Leeds. 

Midwifery. —J. D. Anderson, St. Bart.’s Hosp. - G. B. 
Barbour, Univ. of Camb. and Guy’s Hosp. ; E. E. Evans, Guy’s 
Hosp. and St. George’s Hosp.; E. M. Frankel, Westminster 
Hosp.; D. L. Jones, Univ. of Liverp.; J. P. McGuire, Calcutta 
and St. Mary’s Hosp.; I. M. Monare, Royal Colleges, Edin. ; 
and C. J. S. Sergel, Univ. of Camb. and St. Mary’s Hosp. 

The following candidates, having completed the final 
examination, are granted the diploma of the society 
entitling them to practise medicine, surgery, and midwifery : 
G. B. Barbour, R. H. Bembridge, J. P. McGuire, G. N. 


Rodgers, and R. L. Walmsley. 


Scottish Conjoint Board 


At recent examinations by the board of the Royal 
Colleges of Physicians and Surgeons of Edinburgh, and the 
Royal Faculty of Physicians and Surgeons of ‘Glasgow, 
the following candidates were successful :— 


Eric Greenhalgh, O. S. Sela, Vartheanather Nadarajah, 
O. W. Marienfeld, N. S. Mohammed, F. H. Wilson, P. C. Burgess, 
J. H. Lichtenbelt, Harold Jacobs, Edith H. Busse, D. A. 5. 
Martin, L. L. Harrop, Fritz Buchsbaum, Alfred Rosenbaum, 
Molleurus Couperus, F. J. Beaton, Irving Dolsky, Alexander 
Crawford, Viktor Klare, R. M. Boveri, H. I. Russek, A. J. 
Snyder, N. R. Janes, O. K. Khallaf, K. G. Naidoo, Mirajud Din, 
Emma Pines, Harry Friedman, S. H. Fuchs, K. T. Bluth, 
Sophia V. Elgey, L. O. Adesigbin, S. F. Auerbach, K. M. 
El-Moshneb, and W. W. Weir. 


Pharmaceutical Society of Great Britain 

A meeting of this society will be held at 17, Bloomsbury- 
square, London, W.C., on Tuesday, Feb. 11th, at 8.30 P.M., 
when Prof. E. C. Dodds will give a lecture on chemical 
and pharmacological aspects of tho hormones. 


Presentations to Medical Men 

Kelso.—Dr. A. D. Fleming, who is retiring after 45 
years’ medical practice, has received a standard lamp 
from the people of the burgh in recognition of his services 
to them. Aboyne.—A cheque has been presented to Dr. 


Bernstein 


W. Brodie Brown who, after 35 years’ practice in the | 


district, has been succeeded by his son. Hove.—Dr. H.C. 
Upton has been given an illuminated address in com- 
memoration of 44 years’ service on the governing body 
of the town, for 27 of which he has been an alderman. 
He is now 90 years of age. U*bridge.—At the Uxbridge 
and District Cottage Hospital Dr. George Black was 
recently presonted with a cheque from his colleagues 
and friends. Dr. Black, who has been in practice in the 
town for 15 years, is retiring to Hurstpierpoint. 


out lowering their temperature. 


A good site has been secured for the erection of a new 
hospital at Basingstoke for which £1800 has been paid. 


Hunterian Society 


On Monday, Feb. 24th, Sir Lenthal Cheatle will deliver 
the Hunterian oration of this society at the Mansion 
House, London, E.C., at 9 p.m. He will speak on John 
Hunter’s Time and Ours. The annual dinner of the society 
has been cancelled. 


Milk for Juvenile Workers 


Messrs. Peek Frean and Co. are offering their juvenile 
workers, some hundreds in number, a one-third-pint 
bottle of milk at jd. per bottle. On Wednesday afternoon 
the first bottles under this scheme were handed to the 
workers. by the chairman of the Milk Marketing Board. 


Developments at Bath 


A method is in future to be used at Bath by which 
the waters can be atomised for inhalation purposes with- 
After sterilisation they 
are carried through a specially designed electric heater. 
A new kind of aeration bath is also to be installed, which 
represents a development of the whirlpool bath and offers 
the advantages of gentle massage. 


National Temperance League 


On Friday, Feb. 14th, at 5 P.M., Mr. W. McAdam 
Eccles, consulting surgeon to St. Bartholomew’s Hospital, 
will deliver the second Rae memorial lecture at the London 
School of Hygiene and Tropical Medicine, Keppel-street, 
on Progress and Problems. The chair will be taken 
by Sir Henry Brackenbury, and Mr. Eccles will illustrate 
the test for the determination of the actual percentage of 
alcohol circulating in the blood, especially in relation to 
road accidents. 


New Nurses’ Home at Hammersmith Hospital 


On Tuesday the London County Council considered 
spending £104,600 in providing new accommodation for the 
nursing staff of Hammersmith Hospital. Of the 159 
nurses now at work there, 82 occupy the nurses’ home and 
a converted block of the former institution, 17 are housed 
in the administrative block, 33 in other parts of the 
hospital, and 27 have to hve out. The non-resident 
nursing staff will be increased to nearly 180 when the new 
ward block is completed and the former institution recon- 
ditioned. The new home, to be completed in the spring 
of 1938, will be a separate building in the north-west 
corner of the ample site, six storeys in height, and 
containing 304 separate bedrooms. 


Tuberculosis in Russia 


The campaign against tuberculosis in the Soviet Union 
was discussed at a recent All-Union Conference of Tuber- 
culosis Institutes, which decided on the next steps to 
be taken. Before the late war, it is stated, there were 
only about 300 sanatorium beds in Russia, together with 
some special hospital wards and dispensaries supported 
by charity. The death-rate from tuberculosis was very 
high, reaching 33-6 per 1000 in St. Petersburg. To-day 
there are said to be 500 dispensaries in the All-Russian 
Republic alone, many of them with day sanatoria; over 
26,000 beds are available for adults and children in the 
sanatoria, and special hospitals for the tuberculous, and 
more than 27,000 physicians are employed in these insti- 
tutions. Fourteen provincial institutes and a Central 
Tuberculosis Institute have been established in the same 
territory, and each year some 500 doctors take special 
courses on the treatment of the disease. 


Appointments 


ADAMS, Mary I., M.B. Belf.. D.P.H., has been appointed 
Assistant Medical Officer for Hammersmith. 

CARTWRIGHT, F. F., M.R.C.S. Eng., D.A., Assistant Anwsthetist 
at King’s College Hospital. 

CRITCHLEY, MACDONALD, M.D. Brist., F.R.C.P. Lond., Neuro- 
logical Physician to the Royal Masonic Hospital. 

DaNcy, Naomi, M.B. Lond., Assistant Medical Officer for 
Hammersmith. 

LINDSAY, E. C., M.B. Lond., F.R.C.S. Eng., Surgeon to the 
Royal Masonic Hospital. 


THE LANCET] 


PARLIAMENT.—MEDICAL DIARY 


[FEB. 8, 1936 341 


PARLIAMENT 
NOTES ON CURRENT TOPICS 


Voluntary Hospitals (Paying Patients) Bill 

IN the House of Lords on Feb. 4th the Voluntary 
Hospitals (Paying Patients) Bill was considered 
in Committee. 

On the motion of Lord LUKE, several amendments, 
mainly of a drafting character, were agreed to. 

The principal amendment made was in Clause 6, 
Subsection 3. As printed in the Bill this read: 
“ (3) Except to the extent of an application of funds 
authorised under subsection (2) of section 3 of this 
Act, an Order authorising the provision or maintenance 
of any buildings or beds shall not be construed 
as conferring on the committee of management any 
power, which apart from the Order would not be 
exercisable by them, to apply funds in the provision 
or maintenance thereof.” 

On Lord Luke’s motion, the following new sub- 
section was inserted: ‘“‘ (3) Except to the extent of 
an ot tea oa of funds authorised under subsection (2) 
of section 3 of this Act an Order shall not be construed 
as authorising any application of funds.” 


HOUSE OF COMMONS 
| TUESDAY, FEB. 4TH 
Government and the Distressed Areas 


Miss Warp asked the Prime Minister whether he was 
in a position to make a statement to the House regarding 
the progress made with plans to deal with the distressed 
areas.—Mr. E. Brown, Minister of Labour, replied : 
Considerable progress has been made by the commis- 
sioners in & number of directions in promoting the indus- 
trial development and social improvement of the special 
areas since their last reports were published. Further 
reports for the six months to Dec. 3lst, 1935, are expected 
shortly, and these, too, will be published in due course. 


Unemployed Persons and Insurance Benefits 

Mr. Doss asked the Minister of Health whether he 
was aware that many unemployed persons who became 
voluntary contributors after Dec. 3lst, 1932, and who, 
owing to their economic conditions, were unable to keep 
up their contributions, had had to allow their insurance 
to lapse and were outside the scope of Section 14 of the 
Act of 1935; and, having regard to the serious hardship 
of having lost all health insurance and pension benefits, 
what steps would be taken to give this class the benefit 
of that section.—Sir K. Woop replied: The only persons 
who can be in the position referred to by the hon. Member 
are those who became voluntary contributors after 
Dec. 31st, 1932, but paid no contributions in respect of 
any week subsequent to Dec. 3lst, 1933. I have no 
power to deal with such cases generally by Regulations 
under Section 14 of the Act of 1935, but if any individual 
case is brought to my notice I will have it investigated in 
order to see whether on the facts of that case there is any 
possibility of securing continuity of insurance. 


Unhealthy Basements and Condemned Houses in 
London 

Mr. Day asked the Minister of Health whether he could 
state, according to his latest reports, the number of 
unhealthy basements and condemned houses there were 
in the County of London; what steps were being taken 
to deal with the same; and the number of families living 
more than two and more than three in one room, with 
separate figures for the borough of Southwark.—Sir K. 
Woop replied: According to returns obtained by the 
London County Council in 1934 there were in London 
20,108 underground rooms, including 86 in the borough 
of Southwark, used for sleeping purposes which were 
deemed unfit for human habitation within the meaning 
of Section 18 of the Housing Act, 1925. Action for closing 
such rooms is proceeding: extended powers for this 
purpose have been given by the recent Housing Act. 
As regards the second part of the question, I am not clear 


what information the hon. Member desires. The total 

number of houses scheduled for demolition in the pro- 

gramme submitted by the L.C.C. in 1933 is 33,000. Action 

with a view to demolition has been initiated in respect 
of 10,500 houses, including 757 in the borough of South- 

wark. As to the last part of the question the latest parti- 

culars available are contained in Table II. in the 1931 

census for the County of London. 


Road Accidents in 1935 


Mr. McENTEE asked the Minister of Transport the 
number of persons killed and injured in road accidents 
during 1935, giving separate figures for pedestrian crossing- 
places.—Mr. Hore-BetisHa replied: Approximately 
6550 persons were killed in road accidents in Great Britain 
in 1935 as compared with 7343 in 1934. Approximately 
219,000 were injured as compared with 231,603 in the 
previous year. 1935 is thus the first year since the war 
to show an over-all reduction in casualties. Separate 
figures for fatalities on pedestrian crossing-places_ will 
not be known until the fatal accident returns for 1935 
have been received and analysed. 


Medical Diary 


Information to be included in this column should reach us 
tn proper form on Tuesday, and cannot appear if it reaches 
us later than the first post on Wednesday morning. 


-SOCIETIES 


ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W. 

TUESDAY, Feb. lith. 

Therapeutics and Pharmacology. 5 P.M. Dr. H. P. 
Himsworth: Physiological Factors Influencing the 
Action of Insulin. Mr. H. P. Marks, Dr. Levy Simpson, 
and Dr. M. W. Goldblatt will also speak. 

Psychiatry. 8.30 P.M. Dr.E. T. O.Slater : The Inheritance 
of Manic-depressive Insanity. 

FRIDAY. 

Clinical. 5.30 P.M. (Cases at 4.30 P.M.) Dr. T. C. 
unt: 1. Persistent (Edema with Cyanosis, ? (patute: 
Ophthalmology. 8.30 P.M. (Cases at 8 P.M.) John 
Foster: Vitamins in Ophthalmology. Mie Arnold 
Sorsby and Miss L. R. Benham: Allergic Tests in 
External Eye Conditions. 
MEDICAL SOCIETY OF LONDON, 11, Chandos-street, W- 
f MONDAY, Feb. 10th.—8.30 P.M., Mr. C. S. Lane-Roberts : 
Treatment of Sterility. 
NORTH-WEST LONDON MEDICAL SOCIETY. 

TUESDAY, Feb. 11th.—9 P.M. (The Regal Rooms, Regal 
Cinema, Finchley-road, N.W.), Dr. J. Russell Reynolds : 
Cineradiography. 

PADDINGTON MEDICAL SOCIETY. 

TUESDAY, Feb. 11th.—9 P.M. (St. Mary’s Hospital, W.), 
Dr. G. B. M. Heggs: Practical Demonstration on 
Selected Cases of Skin Disease commonly met with 
in Practice. 

WEST KENT MEDICO-CHIRURGICAL SOCIETY. 

FRIDAY, Feb. 14th.—8.45 P.M. (Miller General Hospital, 
Greenwich, S.E.), Dr. Geoffrey Bamber: The Treat- 
ment of Some Common Affections of the Skin. 

SOUTH-WEST LONDON MEDICAL SOCIETY. 

WEDNESDAY, Feb. 12th.—9 P.M. (poling prone Hospital, 
Wandsworth Common, S.W.), Mr. C. D. Read: The 
Problem of Abortion and Sterilisation. 

NORTH LONDON MEDICAL AND CHIRURGICAL 
SOCIETY. 

THURSDAY, Feb. 13th.—4 P.M. (St. Mary, Islington, Hos- 

pital), Dr. W. R. M. Turtle: Clinical Demonstration. 


BIOCHEMICAL SOCIETY. 


FRIDAY, Feb. 14th.—4 P.M. (London School of Hygiene 
Keppel-street, W.C.), Short Communications an 
Demonstrations. 


MEDICAL SOCIETY OF INDIVIDUAL PSYCHOLOGY. 
THURSDAY, Feb. 13th.—8.30 P.M. (11, Chandos-street, W.), 
Dr. Frank Gray: The Psychopathology of Organic 
Disease. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 


ROYAL COLLEGE OF SURGEONS OF ENGLAND, Lincoln’s 
Inn-ficlds, W.C 
MONDAY. Feb. 10th. —5 P.M., Mr. G. C. Knight: 
Strangulation. 
WEDNESDAY.—5 P.M., Mr. G. 
Tumours of the Skull. RE lectures.) 
FRIDAY.—4 P.M., Mr. C. H. Fagge: Jobn Hunter to John 
Hilton. (Hunterian Oration.) 
UNIVERSITY OF LONDON. 
MoNDaY, Feb. 10th.—3 P.M. 


Intestinal 


Rowbotham: A Series of 


(London School of Hygiene, 


Kepnel-street, W.C.), Col. L. W. Harrison: Venereal 
Disease (II.). f 

WEDNESDAY.—3 P.M. (London School of Hygiene), Col. 
Harrison: Venereal Disease (III.). 


FRID AY.—11 A.M. (London School of Hygiene), Dr. A. G. 
Maitland-Jones: Infant Feeding. 


THE LANCET] 


342 


ROYAL SOCIETY OF ARTS, John-street, Adelphi, W.C. 
Monpay, Feb. 10th.—s5 P.M., Major-General Sir Robert 
McCarrison: Nutrition and National Health (first of 
l three Lectures). 
HAMPSTEAD GENERAL HOSPITAL, N.W. 
WEDNESDAY, Feb. 12th.— +4 P.M., Dr. H. C. Semon : 
Modern Theories and Treatment. 
NATIONAL HOSPITAL FOR DISEASES OF THE HEART, 


Westmoreland-strect, 
Dr. J. M. H. Campbell: 


Eczema, 


TUESDAY, Feb. 11th.—5.30 P.M., 
Paroxysmal Tachycardia. 
LONDON SCHOOL OF DERMATOLOGY, 5, Lisle-street, W.C. 


TUESDAY, Feb. 11th.—5 P.M., Dr. H. T. Barron: Common 
Skin Diseases in Childhood. 
WEDNESDAY.—5 P.M., Dr. I. Muende: Histopathology. 


THURSDAY.—5 P.M., Dr. J. A. Drake: Some Disorders of 
Sweating. 
HO TTAR FOR SICK CHILDREN, Great Ormond-strect, 
W.C. 
WEDNESDAY, Feb. 12th.—2 P.M., Dr. W. G. Wyllie: 
Pulmonary Fibrosis and Bronchiectasis. 3 P.M. 
Dr. W. W. Payne: Blood Chemistry in Acute Pul- 
monary Disorders. 
Out-patient clinics daily at 10 A.M. 
2 P.M. 
NATIONAL HOSPITAL, Queen-square, W.C. 
MONDAY, Feb. 1U0th.—3.30 P.M., Dr. Kinnier Wilson : Some 
Heredo-familial Diseases (1.) Pyramidal. 
TUESDAY, 3.30 P.M., Dr. Critchley: Cerebral Vascular 
Disease (III.). 


and ward visits at 


WEDNESDAY.—3.30 P.M. Dr. Kinnier Wilson: Clinical 
Demonstration. 
THURSDAY.—3.30 P.M., Dr. Carmichael]: Myasthenia 


Gravis. 
FRIDAY.—3.30 P.M., Dr. Brinton: 
Out-patient clinic daily at 2 P.M. 


WEST LONDON HOSPITAL POST-GRADUATE COLLEGE, 


Facial Neuralgia. 


Hammersmith, W. 
MONDAY, Feb. ‘10th. —10 A.M., Medical wards and skin 
clinic. 11 A.M., Surgical wards. 1.30 P.M., Gynæco- 


logical wards. 2 P.M. A wards, gy nwcologicai 
and eye clinics. 4. 15 P.M., Mr. Green Armytage: 
llormones in Gynecology. 

TUESDAY.—10 A.M., Medical wards. 11 A.M., Surgical 
wards. 2 P.M., "Throat clinic. 4.15 P.M., Mr. Woodd 
Walker: Derangements of Knee-joint. 

WEDNESDAY.—10 A.M., Children’s ward and clinic. 
Medical wards. 2 P.M., Kye clinic. 4.15 P.M., 
on aniesthesia. 

TIHURSDAY.—10 AM., 
clinics. Noon, Fracture clinic. 
urinary clinics. 

FRIDAY.—10 a.M., Skin clinic. 
ment. 2 P.M., Throat clinic. 

SATURDAY.—10 A.M., Surgical 
medical wards. 

Operations, medical and surgical clinics daily at 2 P.M. 

The lectures at 4.15 P.M. are open to all medical practi- 
tioners without fee. 

FELLOWSHIP OF MEDICINE AND POST-GRADUATE 
MEDICAL ASSOCIATION, 1, Wimpole-street, 

Monnay, Feb. 10th, to SATURDAY, Feb. 15th.—ST. JOHN’sS 
HOSPITAL, 5, Lisle-street, W.C. Afternoon course in 
dermatology. — BROMPTON HOSPITAL, S.W.  All-day 
course in chest discases.—CHELSEA HOSPITAL FOR 
WOMEN, Arthur-street, S.W. All-day course in 
gynweology. —NATIONAL PAPERAN E LIOSPITAL, 
Hampsteud-road, N.W. Tues., 8.30 p.M., Mr. A. M. A. 
Moore: Injuries to Tendons, Muscles, and Joints. 
Thurs., 8.30 P.M., Mr. E. W. Riches: Kidney and 
Bladder.—Courses ure open only to members and 
associates of the fellowship. 

SOUTH-WEST LONDON POST-GRADUATE ASSOCIATION, 

WEDNESDAY, Feb. 12th.—4 P.M. (St. James’s Hospital, 
Ouseley-road, Balham, S.W.), Dr. H. Crichton-Miller: 
The General Practitioner’s Approach to Psycho- 
neurosis. 

LEEDS GENERAL INFIRMARY. 

TUESDAY, Feb. 11th.—3.30 r.M., Dr Vining : Some Problems 
in Connexion with the New: born. 

LEEDS PUBLIC DISPENSARY. 

WEDNESDAY, Feb. 12th.—4 P.M., 
fluenza. 

UNIVERSITY OF DURHAM. 

SUNDAY, Feb. 16th.—10 A.M. 
Hospital), Mr. G. A. Mason: 

GLASGOW POST-GRADUATE MEDICAL ASSOCIATION. 

WEDNESDAY, Feb. 12th.—4.15 p.m. (Royal Samaritan 
Hospital for Women), Dr. Donald McIntyre: Hwmor- 
rhage from the Genital Tract. 


11 A.M., 
Lecture 


Neurological and = gynecological 
2 P.M., Eye and genito- 


Noon, Lecture on treat- 


and children’s clinics, 


Dr. S. J. Hartfall: In- 


= (Newcastle General 
Selected Chest Cases. 


Vacancies 


For further information refer to the advertisement columns 
All Saints’ Hospital, Austral-street, West-square, S.E.— Res. H.S. 


At rate of £100. 
N.—Asst. M.O. £250. 


Archway Hospital, Archway-road, 
Barbados General "Hospital. —Sen. Res. Surg. £450, 

Bexley Urban District Council,—_M.O.H. #800. 

Birmingham, Ear and Throat Hospital. —Third H.S. At rate 


of £150. 
Birmingham, Queen’s Hospital.—Bacteriologist and Cli 
Pathologist. £600. Also Res. Surg. Reg. £100. = 


MEDICAL DIARY.—VACANCIES 


[FEB. 8, 1936 


Blackburn Royal Infirmary.—H.S. £175. 
Bradford, Municipal General Hospital, St. Luke’s.—H.P.’s and 
_ H.S.’s. Each at rate of £150. 

Brogan, Koval aaa County Hospital.—Second Asst. Patho- 
ogist. £4090. 

Cancer Hospital, Fulham-road, S. W.—H. S. At rate of £100. 

Card H ee infirmary.—H. P. 8, H.S.’s, and Cas. O. Each at 
rate of £50. 

Chelsea Hospital for Women, Arthur-street, S.W.—Registrar 
(Gynæcological) and Radium Otħcer. £75. 

Cily of London Hospital for Diseases of the Heart and Lungs, 
Victoria Park, i.—Asst. Laryngologist. 

Colchester, Royal Eastern Counties Institution for the Mentally 
Defective. —Asst. M.O. £350. 

Constance-road Institution, East Dulwich, S.E.—Asst.M.O. £250. 

Coventry and Warwickshire Hospital.—Res. Cas. O. £125. 

Dewsbury and District General Infirmary.—Sen. H.S. £200. 

Doncaster ltoyal Infjfirmary.—H.S. to Eye and Ear, Nose, and 
Throat Depts. £175. 

Egyptian Government.—Director of Lunacy Division in P.H. 
Dept. L.E. 1020 to L.E. 1200 

Evelina P ospital Jor Sick Children, Sohar S.E.—H.P. At 
rate of £120. 

Forest Gate Hospital, Forest-lane, E.—First Asst. Res. M.O. 
£525. Also Second Asst. Res. M.O. £350. 

Gloucestershire Royal Infirmary, d&:c.—H.S. to Ear, Nose, and 
Tbroat Dept. At rate of £150. 

Halifax Royal Infirmary.—Third H.S. At rate of £150. 

A T General and N.W. London Hospital, Haverstock Hill, 
V.WV.—Cas. Surg. O. for Out- -patient Dept. At rate of £100. 

Hertjord, Weare Park Sanatorium.—Asst. M.O. £300. 

Holborn Metropolitan Borough, W.C.—Public Vaccinator. 

Hull ar! eens for Infectious Diseases, Cottingham.—Res. 

- £350. 

Hull Royal Injfirmary.—First H.S. and Second Cas. O. Each 
at rate of £150. 

Ilford, I ‘est Ham Mental Hospital, Goodmayes.—Jun. Asst. M.O. 


£350 

Infants Hospital, Vincent-square, Westminster. —Res. M.O. 
£300. Also two Physicians to Out-patient Dept. 

Ipswich Sanatorium, Forhall-road.—Asst. M.O. cite 

Kettering itural District Council, @ce.—M.O.H. £300 

Kingston-upon-Hull City and County. —Asst. M.O.H. £600. 

Leeds University.—Chair of Physiology. £1000. 

Leicester Royal Infirmary.—sSen. Cas. O. At rate of £125. 

Lewisham Hospital, High-street, S.E -—Asst. M.O. £350. Also 
Asst. M.O. £250. 

Liverpool, Alden Hey Hospital.—Res. Asst. M.O.’s. Each £200. 

Liverpool, Fazakerley Sanatorium.—Res. Asst. M.O. £200. 

Manchester, Baguley Sanatorium.—Deputy Med. Supt. £500. 

M ane r: Duchess of York Llospital.Sen. Res. M.O. At rate 
of £125. 

Manchester Victoria Memorial Jewish Hospital.—H.P. At rate 
of £120, 

Metropolitan Hospital, E.—Hon. Surgeon. Also Surg. Reg. 

Middlesex County Couneil.—Tuber. M.O. £750. 

Miller General Hospital, Greenwich-road, S.E.—Cas. O., Out- 
patient Oflicer. Each at rate of £150. Also H.P. & HLS. 
Each at rate of £100. 

National Hospital, Queen-square, 1F.C.—Res. M.O. £200. 

New End Hospital, Hampstead, N.IW.—Asst. M.O. £250. 

Northampton oe Mental Hospital, Berrywood.—Second Asst. 
M.O. £450 

Nottingham Children’s Hospital.—Res. H.S. At rate of £150. 

Nottingham General Hospitul.—Cas. O. At rate of £150. 

Portsmouth Royal Hospital.—H.P. At rate of £130. 

Preston, Sharve Green Hospitul—Sen. Asst. Res. M.O. Also 
Jun. Asst. Res. M.O. At rate of £200 and £100 respectively. 

Princess Beatrice Hospital, Rtichmond-road, Earl's Court, S.W.— 
H.S. and H.P. Each at rate of £110. 

Queen Charlotte's Maternity Hospital, Marylebone-road, N.W — 
Res. Anwsthetist. At rate of £100. Res. Anesthetist and 
Dist. Res. M.O. At rate of £90. , Also Asst. Res. M.O. 
At rate of £80. 

Royal Chest Hospital, City-road, E.C.—Clin. Assts. 

Royal National Orthopedic Hospital, 234, Great Portiand-street, 
V.—Asst. Res. Surg. for Country Branch. £250. 

Royal Naval Medical Service.— Eight vacancies, 

St. Andrew's Hospital, Devons-road, E.— Asst. M.O. £250. 

St. Bartholomew's Hospital, 1.C.— Dental H.S. £80. 

St. John and St. Elizabeth Hospital.—Surg. Registrar. £100. 
Also Clin. Asst., Ear, Nose, and Throat Dept. 

St. John’s Hospital, Lewisham, S.E.—Med. Reg. to Out-patients. 
50 guineas. 

St. Leonard's Hospital, Hoxton-strect, N.—Asst. M.O. £250. 

St. Lukes Hospital, Sydney-street, S. W. —Asst. M.O. £250. 

Salisbury General Infirmary.—H. S. At rate of £125. 

Sheffield Children’s Hospital.—H.S. At rate of £100, f 

SUKI Royal Hospital.—Clin. Asst. to Ophthalmic Dept. 
Al aa Clin. Asst. to Ear, Nose, and Throat Dept. Each 
£30 

South Eastern Hospital for Children, Sydenham, S.E.—Jun. Res. 
M.O. At rate of £100 


Swindon and. North Wilts Victoria Hospital. Res. M.O. £150. 
bs ee et aac harfedale Sanatorium.—Res. Asst. 
OO. £350, 


Warwickshire County Council.—Asst. County M.O.H. £500. 

Western Ophthalmic Hospital, Marylebone-road, N.W.—Hon. 
Surgeon to Inoculation Dept. 

West London Hospital, Hammersmith-road, W.—Half-time 
Pathologist. At rate of £306, 

Westminster Llospital Annere, 66, Fitzjohn’s-avenue, Hampstcaad.— 
Three Radiologists for Clin. Res. Work. Each £300. 

Woolwich and District War Memorial Hospital, Shooters Hill, 

S.i.—H.P. At rate of £100. 


The Chief Inspector of Factories announces a vacancy for a 
Certifying Factory Surgeon at Manchester, South East, 
Lancs. 


THE LANCET] 


[FEB. 8, 1936 343 


NOTES, COMMENTS, AND ABSTRACTS 


THE PHYSICAL BASIS OF 
PSYCHONEUROSIS 


PSYCHO-SOMATIC INTER-RELATIONS IN 
THE LIGHT OF CLINICAL MEDICINE! 


By SVEN [INGVAR 
PROFESSOR OF MEDICINE, UNIVERSITY OF LUND, SWEDEN 


For centuries the relations between British and 
Swedish sciences have been close and intimate. 
I have only to recall my famous countryman, Emanuel 
Swedenborg, who spent many years here in England 
until he died in London (1772). Another brilliant 
representative of Swedish science, Carolus Linnzus, 
spent a happy and fertile time in this country. 
Sweden will always remain indebted to English 
science for its wonderful way of cultivating the 
spiritual heritage of these two radiant geniuses of 
the Swedish tongue, through the Swedenborg and 
Linnean Societies. 

British medical science has had a great influence 
on medical progress in the world through its 
famous representatives of physiology. I think 
it is the generally accepted opinion throughout 
the world that English physiology has for a long 
time been the leading physiology—I only need to 
mention such names as Starling, Bayliss, Haldane, 
Barcroft, Dale, Hill, Adrian. The great progress of 
clinical medicine during the last decades is in the first 
place due to the progress in physiology. We have 
got into the dynamics of the different clinical symp- 
toms, meaning for the patient better diagnosis and 
better treatment. No man has a greater influence 
in the evolution of clinical neurology than your 
Sherrington. Due to the consistent work of him and 
his school, the clinical neurology of to-day is no 
longer a mere description of different syndromes, it 
has become the science of the dynamics of the 
different nervous symptoms. 

On this occasion I speak about the psycho-somatic 


inter-relations in disease, a subject that has been” 


treated very exhaustively already in the literature 
from the philosophical, psychological, neurological, 
psychiatrical, as from the viewpoint of general 
medicine. Recently Flanders Dunbar published a 
monograph of almost 600 pages with the title: 
“Emotions and Bodily Changes,” quoting no less 
than 2251 books and papers on the subject. It is 
significant that Dunbar states in his conclusions at 
the end of his extensive book that “the time is not 
yet ripe for writing a text-book on psycho-somatic 
inter-relations. It is possible,” he continues, ‘‘ that a 
text-book will never be written,” and there is really 
no endeavour towards synthesis in his book. 


Such are the difficulties met in this field. I am 
treating the subject from my personal experiences 
as a representative of general medicine. The 
majority of the workers in this field have been 
neurologists or psychiatrists, but when neurotic 
disturbances of internal organs are in question, 
nobody is more certain to collect experience than the 
general clinician. The questions form an integral 
part of general medicine, and in the general clinic 
the material of so-called organic neurosis is con- 
centrated. Many others who have theorised or 


seo delivered before the Hunterian Society on Jan. 20th, 


philosophised on the questions have not had the 
best material, neither has this material been examined 
according to the demands of the modern clinic. 


The Influence of the Emotions 


Our psychical life has in various ways a momentous 
influence on all corporeal functions. Experimental 
psychologists have convincingly established that even 
the simplest form of intellectual activity without 
being emotionally coloured, influences the blood 
pressure, the distribution of blood in the vascular 
system, and the tone of the muscles. That the emotions 
have a very powerful effect is now quite generally 
accepted and is proved both by clinical observations 
and experiments. In this connexion it is necessary 
to mention Cannon’s investigations of the influence 
of emotional conditions on animals. These physio- 
logical experiments are naturally of the greatest 
interest, but the influence of the emotions certainly 
extends much farther than we can show by physio- 
logical analysis. When we see how anguish forces its 
victim to roam about, how it banishes sleep and the 
appetite, when we see the flow of tears, the cold 
sweat and the pallor, we know, without further 
evidence, that emotion is a very serious business, 
and penetrates through every fibre of the being. 
Emotion thus always signifies a strong general 
alteration in the somatic functions of the body. If, 
in this manner the effect of psychical influence on 
the somatic functions is so visible, we are in the 
first place interested in trying to discover to what 
extent diseases in the internal organs of the body can 
arise by emotions, that is, in a psychogenic way— 
by diseases is meant a change of the anatomical 
substratum implying an irreversible process, disturbing 
life manifestations. 

As we know the vegetative nervous system inner- 
vates the smooth muscles in the internal organs 
particularly in the walls of the vessels and of the 
digestive tube, as well as the great glands, and thus 
it is to be expected that nervous disturbances will 
appear especially in the smooth musculature in the 
tubular organs, or in the endocrine glands. A very 
often quoted German writer, Alkan, has lately pro- 
posed a principle of classification along these lines, 
and indicates various ways by which emotion could 
cause anatomical changes. Through an abnormal 
innervation of the muscles in the tubular organs— 
for example the gut, a cramp or spasm arises in 
some place, producing a local ischemia which, if 
sufficiently intense, leads to ulceration ; he instances 
the gastric ulcer. From such a cramp, in certain 
circumstances a stagnation easily arises in the 
proximal part of the tube, which in its turn leads to 
dilatation, and so the characteristic distensions can 
come about. Again, sphincteric cramp of the gall- 
bladder leads to stagnation of the bile, and the 
resulting change of concentration might cause gall- 
stones, and, inasmuch as spasm leads to stagnation 
of infectious material, even severe inflammatory con- 
ditions can naturally evolve. So cholecystitis, cholan- 
gitis, and colitis by constipation have been explained. 

This seems in fact a very simple and in many ways 
acceptable scheme, but the question immediately 
presents itself as to how this theoretical plan fits in 
with our clinical experience. We are furthermore 
confronted with the question as to why this abnormal 
innervation occurs in a definite organ, differing for 
different individuals, why one person gets a spasm in 
the gullet, another in the pylorus causing stagnation 


344 THE LANCET] 


NOTES, COMMENTS, AND ABSTRACTS 


[FEB. 8, 1936 


of food with vomiting, eructations, &c., another a 
spasm in the urinary bladder, another in the gall- 
bladder, and so forth. The psychogenic organ— 
selection in the somatic expression of the neurosis— 
5 a fundamental problem which may be considered 
ere. 
The Psycho-analyst’s Attitude 


This question has especially been a subject of 
interest for psycho-analysts. They generally hold 
the view that as neurosis is to be considered as a 
general state of conflict so the manifestation of 
neurosis is a protest, and the choice of organ should 
have some sort of symbolical meaning. Differently 
talented people choose different musical instruments, 
similarly different temperaments choose different 
organs for their neurotic manifestations. That a 
disturbance in an organ really can sometimes denote 
a symbolic phenomenon created by pure psycho- 
genic mechanisms, cannot surely be rejected. Reliable 
gynecologists report, for example, how obstinate 
genital bleeding, or genital eczema, has been cured 
only after the removal of repulsive sexual psychical 
circumstances. A clinician must however be excused 
for not accepting a priori the symbolical interpreta- 
tions of organic neurosis in their entirety, and for 
trying to fit them in with our further general know- 
ledge of the pathophysiology of the organism. 


Defining Neurosis: the Association of Organic 
Disturbance 


If one wishes to define the term neurosis, I 
understand it as a disharmony of the nervous 
functions, and from this it is clear that the causes 
of neurosis must be various. All purely somatic 
injuries can cause neurosis, over-strain, chronic 
bodily disorders, intoxications (alcohol), infectious 
diseases, often cryptogenic. But especially every- 
thing which interferes with our will to live and to 
assert ourselves causes this functional disharmony. 
In this manner neurosis is the expression’of a vital 
conflict. The more highly developed an individual 
is the more complicated is this conflict inclined to 
be. In the modern man one must seek the funda- 
mental cause of neurosis in the social, moral, political, 
and religious field. It is clear that sexuality, which 
implies the tendency to lust of life in its highest 
potentiality must play a most important etiological 
rôle. Here moral attitude, philosophy of life, tem- 
perament, the finest and most subtle differentiation 
of the personality are strongly decisive. But we can 
all be subject to conflicts, and it can undoubtedly be 
said that we all react neurotically to our conflicts. 
But from pronounced nervous disturbances, the 
great neuroses, the majority of us are however 
fortunately saved. The war has in a most con- 
vincing way brought to light, what was not so clearly 
known before, how our hereditary mass, our internal 
fundamental structure or constitution, plays a deci- 
sive rôle in morbid nervous reaction. All the horrors 
and psychical torments of the war did not succeed 
in producing any new nervous disease. Naturally 
nervous exhaustion was extremely common—not 
alone among the soldiers at the front—but this 
appeared generally benign, and when occasion for 
rest and recreation was found there was a spon- 
taneous and rapid recovery. 

We know how with organic brain diseases, typical 
paralysis or convulsions arise in the muscles of 
different parts of the body. In this connexion it is 
pertinent to ask if organic brain lesions also cause 
disturbances in the internal organs. Examining 
organic brain diseases from this point of view, one 


is, in clinical medicine, instantly confronted with 
the fact that these occur astonishingly seldom. 
Organic brain diseases hardly ever cause nervous 
diseases of internal organs. The epidemic encepha- 
litis, as we have learnt it in the last years, has its 
anatomical point of attack chiefly in the vegetative 
centres in the middle brain. One might, for instance, 
find in epidemic encephalitis characteristic changes 
in the organism in its entirety, which calls dystrophia 
adiposogenitalis to mind. In encephalitis there is 
furthermore often found an increase of salivary 
secretion and a change of the functions of the seba- 
ceous glands, which gives the face an appearance of 
having been rubbed with fat, the so-called ‘“‘ oily- 
face,” or the interesting disturbance of the water 
metabolism, diabetes insipidus, but localised dis- 
turbances of internal organs are not a characteristic 
feature of encephalitis. Neither Wimmer nor Economo 
tell about these. 

It is likewise a clinical fact that organic disturb- 
ances play a very small part in epileptic attacks. 
These may consist of a vasomotor spasm in the 
brain cortex leading to violent functional discharge 
which shows itself in unconsciousness, violent mus- 
cular cramps, &c. During the fit the muscles of the 
urinary bladder in particular may contract. This 
might be in agreement with our knowledge of the 
bladder’s representation in the brain cortex. But 
localised cramps in smooth musculature of other 
internal organs are not known to appear in the 
epileptic attack. It is true also of other serious 
organic diseases in the brain, for example, brain 
tumours, that they manifest themselves to a remark- 
ably small extent in the internal organs. 

Another circumstance which certainly does not 
lack significance in the consideration of the difficult 
psychogenesis problem is organic manifestations in 
hysteria. This disease also produces characteristic 
syndromes—paralysis, contractures, disturbance of 
sensibility, and so forth—which since the time of 
Charcot have been minutely studied. Modern 
research has shown that primitive nervous mechanisms 
released by emotion appear in the manifestations of 
hysteria. It is thus remarkable that in hystena 
symptoms from the internal organs play such a small 
role in the clinical picture as they do. The tendencies 
of the hysterical personality make it understandable 
that phenomena like aerophagia followed by loud 
eructations are for certain individuals an instrument 
of self-assertion. The same likewise applies to 
hysterical vomiting. Such phenomena cannot be 
considered as organic neurosis in a proper sense. It 
is evident from all extensive compilations in medical 
literature concerning hysteria (Vorkastner and Kehrer) 
that hysterical heart, stomach, or intestinal diseases 
are not known with certainty, and that the hysterical 
mechanisms, with their tendency to protestation and 
self-assertion, have no tendency to influence internal 
organs, 


The Great Endocrine Glands 


In considering to what degree nervous disturbances 
of the greater endocrine glands really appear, it may 
first be stated that we have from the experience 
of clinical medicine no fixed evidence that diabetes 
can arise in a purely psychogenic way. For a long 
time it has been considered certain by some authors 
that psychic momentum can lead to diabetes: it 
was very often stressed that certain individuals 
living under strong psychic tension, business men 
and others with an anxious life, were disposed to 
diabetes. It has even been emphasised in medical 
literature that during great economic crises the 


Petia, 22 = Ba Pat KN a a as nu i or a 


THE LANOET] 


prevalency of diabetes increases—the blood-sugar 
in diabetes should increase in inverse proportion 
to the sinking of share prices. Similarly it is alleged 
that under certain emotional conditions sugar can 
appear in the urine. It would therefore not be 
far-fetched to suppose that if a primary psychogenic 
increase of the blood-sugar is fed emotionally for 
a long time, we can have degeneration into real 
diabetes. The experiences of the world war, however, 
again contradict this, as no definite psychogenic 
diabetic cases occurred. Umber as well as Gottstein, 
who have great experience concerning this disease, 
accentuate this very strongly, and another prominent 
investigator in the field of metabolic diseases—namely, 
von Noorden—says that only he who is born to get 
diabetes gets it. We have nowadays, it appears, the 
right to deny the existence of emotionally caused 
psychogenic diabetes. This does not of course 
interfere with the fact that nervous influences can 
have an aggravating effect on the disease in question. 
_ Everyday clinical experience tells us that. Amongst 
those who treat diabetic patients it is well known 
that the blood-sugar increases if the patient gets 
excited. Cannon found that sugar did not develop 
in excited animals after removal of the adrenals. 
Neither the Swedish investigators, Marcus and 
Sahlgren, nor the Danes, Nielsen and Jérgensen, have, 
in their extraordinarily exact observations, been able 
to cause a glycosuria in healthy persons. Widmark 
has not been able to demonstrate glycosuria in his 
students before examination. (He interprets this fact 
as a proof that he is too easy an examiner.) Malmros, 
in the medical clinic of Lund, has not been. able, in 
such serious situations as the severe final examinations 
of students or before surgical operations, to find 
either sugar in the urine or an increase of blood-sugar, 
What is said in this connexion about the pancreas 
also holds good for the thyroid gland. For a long 
time we have had a definite idea that Graves’s or 
Basedow’s disease was often caused by . psychic 
shocks, fright, anxiety, or sorrow. Amongst others, 
Chvostek champions this idea in his big monograph 
on this disease. | | 
We have ourselves, in Sweden, for a long time 
accepted the view, that Graves’s disease attacks in 
the first place women with a nervously exacting 
profession, such as teachers. Experiences from 
the war, however, have not with any convincing 
clearness given support to the idea of a purely psycho- 
genic Graves’s disease. The frequency of war- 


time Graves’s diseaSe did not rise in a way correspond- 


ing to the emotional stress of the population. In 
the occurrence of Graves’s disease, again the constitu- 
tion definitely plays an important rôle. That 
emotional conditions on the other hand play an 
enormous part in the progress and course of this 
disease we already understand, as we know that 
thyroid hypersecretion is one of its main character- 
istics, and this has in itself a great stimulating effect 
on the brain, especially on the functions of the 
vegetative nervous system; and treatment of 
Graves’s disease must be focused perhaps even more 
on the psychic state of the patient than on the purely 
somatic symptoms. Stoddard has emphasised that 
the symptoms of exophthalmic goitre and the 
anxiety neurosis are exactly the same. 


Psychical Factors in Heart and Vascular Disease 


An important group of neuroses which in later 
years in the modern clinic is decreasing in number 
are the so-called heart neuroses. Lately the prominent 
German clinician Matthes has treated this problem 


NOTES, COMMENTS, AND ABSTRACTS 


[reB. 8, 1936 345 
and has accentuated the difficulty of relying on the 
diagnosis of heart neurosis in individual cases. In 
later years the electrocardiograph -in particular 
has registered a number of disturbances in the heart’s 
rhythm, which for a long time before were interpreted 
as nervous effects, depending on anatomical lesions 
in the myocardium. Heart neurosis was according 
to Kehrer a very little used diagnosis in the German 
army during the war. In most cases of functional 
heart disturbances, organic causes could be demon- 
strated, often among these, constitutional inferiority. 
The most prevalent of all nervous heart disturbances 
during the war were palpitations. The front soldiers 
living in anxious expectation concerning their fate, 
reacted simply with an increased frequency of the 
pulse. Sometimes even a low pulse frequency. 
occurred. The effort syndrome of soldier’s heart, 
or as it has been called in U.S.A. neurocirculatory 
asthenia, that was so to speak rediscovered during 
the world war, with dyspnea, palpitation, and 
heartache is in some people the normal response to 
excessive fatigue, worry, or emotional stress, and 
to infection. The heart symptoms are only partial 
phenomena in a neurasthenic syndrome, and it is 
misleading and inadequate to consider it as heart 
neurosis. Dudley White states that there is no 
tendency for cases with this syndrome either to die 
prematurely or to develop heart diseases. | 

The diagnosis of heart neurosis has to take into 
account all the unmanifested lesions of the heart 
muscles, chronic septic diseases, degenerative sclerotic 
processes of the coronary vessels, and also disturbances 
in the internal secretions. When all these complicated 
and often subtle processes are properly considered 
there is not much room left for the conception of 
heart neurosis. l 

The influence of psychical factors on the vascular 
system is confirmed by the well-known fact that 
vasomotor phenomena play an important part in 
emotional reactions in general. One of the most 
common effects of emotions is, as we know, arterial 
hypertonia, and prolonged psychic tension undoubtedly 
also gives hypertonia of corresponding duration. 
The question arises if hypertonia so caused can 
after a time develop a real hypertension with its 
typical sclerotic alteration of the arterial system. 
The answer is by no means clear. Leading authors 
believe that hypertension begins as.a nervous spasm 
of the arterial system leading to hypertrophy of the 
arterial walls and of the myocardium, with degenera- 
tion and pronounced ‘arterio-sclerotic processes in 
the body not least in the kidneys. In this way some 
cases of nephro-sclerosis might develop. Many 
authors assert that arterial hypertension, so common 
in our modern times, is caused by psychic mechanisms. 
It is, however, necessary to state that no definite 
evidence has yet been produced for the pure psychical 
genesis, even if it must be regarded to a certain extent 
as probable. It must be emphasised that even if it 
has been clearly demonstrated that psychic stress 
has the effect of raising the blood pressure in a good 
many individuals there has not been found on the 
other hand a greater frequency in psychotic patients 
with depressive emotional states than in normal 
individuals. Researches of uniovular twins have lately 
demonstrated to what a large extent the constitutional 
factor acts in the individual cases in producing 
arterial hypertension. | 


Asthma as a Nervous Disease 


It is a prevalent idea that bronchial asthma ought 
to be regarded as a nervous illness, indeed one 


346 


often finds it stated in medical literature that it should 
be treated purely psychotherapeutically. From 
researches in later years we have now a rather clear 
conception of the asthma attack as an allergic disease. 
In accordance with this, we regard it as a general 
biological reaction of the body to foreign matter, so- 
called allergens. The reaction localises itself in 
some individuals, by what is for us an unknown 
cause, in the respiratory channels. By experi- 
mentally induced anaphylactic shocks in guinea- 
pigs, lung changes directly analogous to those resulting 
from asthma in the human body can be obtained, 
also in animals after cutting all nerves to the 
lungs. From our clinical experience we know that 
psychical causes play a somewhat important part in 
initiating an asthmatic attack, and asthma patients 
are often markedly nervous persons. They belong 
to the vegetatively stigmatised, if I may use what 
seems to me an appropriate expression, coined by 
von Bergman to replace the less adequate conceptions 
sympathicotonia and vagotonia. Many facts indicate 
that nervous people with their generally increased 
reflex irritability, to the influence of surroundings 
also have a lower threshold for the evolution of 
allergic reactions. The first asthma attack leaves 
behind it, probably for ever, a biological change 
localised in the cells of the respiratory channels. 
This means a disposition that makes way for a nervous 
reflex action which afterwards probably can be 
set in motion in a purely psychogenic way. We 
know that asthma often causes a strong feeling of 
anguish or oppression in the patient. It is not 
illogical to suppose that in certain sensitive pre- 
disposed patients any disagreeable situation can 
by degrees induce an asthma attack even without 
primary allergens. It is highly uncertain whether 
the asthma attack may even in these circum- 
stances be considered as a direct primary psychogenic 
reaction. What has been stated, however, does not 
interfere with the fact that psychotherapy must be 
given an important place in the treatment of asthma. 


THE LANCET] 


The Digestive Apparatus and Psychic Influence 


It is a well-known fact that the activity of the 
digestive tube is to a great extent dependent on 
psychical influence. This has been: proved experi- 
mentally in many interesting ways. Katsch observed 
in rabbits in which an inlaid celluloid window was 
substituted for part of the abdominal wall that the 
gut instantly pales and its normal peristalsis stops if 
the animal is disturbed while eating, frightened, or 
subjected to pain. When one feeds an animal a 
lively movement instantly occurs in the whole gut. 
In Cannon’s cats the movement of the stomach 
stops when they are confronted by an angry dog, 
and sometimes it takes an hour before any signs of 
life reappeared in it. Similar phenomena are well 
known from our clinical experience in human beings ; 
Heyer especially has been able to show by X ray 
that the functions of the human gut are obstructed 
under the influence of a depressive state of mind. 
It is commonly known that fear or great sorrow can 
cause vomiting reflexes. It is told of the Swedish 
King, Gustaf the Fourth Adolphus, that he reacted 
with intense vomitings on learning that he had been 
dethroned. Bennet and Venables found that in 
hypnotic subjects to whom suggestions of nausea 
were made there was an inhibition of the normal 
ee of the curve of stomach secretion of hydrochloric 
acid. 

If the influence of psychogenic factors on the 
motility as well as on the secretion of the stomach 


NOTES, COMMENTS, AND ABSTRACTS 


[FEB. 8, 1936 


is verified in this way, the question then arises as to 
the extent these factors play in promoting diseases 
in the stomach. Here a retrospective clinical survey 
shows that the conception of a nervous stomach 
disease appears less and less during the last decades. 
As different subjective stomach symptoms, such as 
epigastric pains and pressure after meals, gastric 
hypersecretion, eructations, vomitings, &c., have 
been discovered to be due to anatomical causes, the 
gastric ulcer or gastritis, the diagnosis nervous 
dyspepsia, if not quite rejected, is nevertheless 
highly discredited. | 

Recently gastritis, in the examination of which the 
Danish clinician Knud Faber has done such estimable 
work, has again come into repute in the clinic. X ray 
investigations of the mucous membrane in the 
stomach, which has been worked out to a high degree 
of perfection by H. H. Berg, together with systematic 
researches on the gastric juice, and last but not least 
the introduction of the gastroscope, make it probable 
that inflammatory processes in the mucous membrane 
are much more common than we have been inclined 
to believe. 
up to the modern clinician to explain the diffuse 
and abstruse phenomena from the stomach as caused 
by organic lesions. 

One observes from modern theories concerning 
nervous diseases in the stomach that readily as 
one formerly gave the diagnosis stomach neurosis, 
so reluctant is one nowadays to decide what shall 
rightly be called by this term. We must acknowledge 
that we have no definite knowledge as to the 
possibilities of psychical factors in causing primary 
irreversible processes in the stomach. 

Constipation is the commonest of all functional 
disturbances in the colon. Regarding its causes it is 
clear that as psychical influences play such a dominat- 
ing rôle, it must be straightaway regarded as a nervous 
disease. That joy improves the metabolism and 
peristalsis of the intestines, while sorrow has a 
depressing influence was already known to antiquity. 
It is well known that change of environment, for 
instance a voyage, is for many people an infallible 
cause of constipation. Regular living with regular 
habits play a vital part in the correct functioning 
of the intestines. We also understand how nervous 
influences affect the functions of the colon, from the 
fact that nicotine which has a stimulating influence 
on the sympathetic nervous system has a laxative 
effect. Many people improve the functions of the 
intestines by a morning cigar. Just as thyroid 
extract has a stimulating effect on the vegetative 
nervous system, so it also helps to stimulate the 
movement of the colon and is just the right medicine 
for certain cases of constipation. For us it is an 
interesting question as to whether anatomical lesions 
of the mucous membrane in the colon, such as colitis, 
can be caused in a purely psychical way. I think 
we may answer in the aflirmative. If stagnation of the 
contents of the intestine continues sufficiently long, 
it will cause real inflammation of the colon with 
diarrhoea. It is an old theory that constipation is 
one of the chief causes of chronic ulcerative colitis and 
in the treatment of this disease great attention 
must above all be paid to the relief of existing 
tendencies to constipation. It is ikewise known that 
a strong neurotic element can present itself in these 
patients. 

Emotional influences on the functions of the 
intestines clearly occur in so-called nervous diarrhea. 
Particularly women, but men also suffer from the 
fact that in situations which excite them or cause 


Many new possibilities are thus opened. 


THE LANOET| 


fear the intestines react with increased peristalsis 
and secretion. A suitable name for this phenomenon 
is “situation diarrhea.” The situation naturally 
varies for different individuals. Certain people can 
only sit in an outside seat nearest to the w.c. in the 
theatre, the consciousness that the nearest way 
to the latter is clear is sufficient to set the intestines 
at rest. In other circumstances violent anguish and 
diarrhœa may occur. 

Inasmuch as nervous conditions are reflected in 
the intestines so nervous disturbances often occur 
also in the bladder. Itis well known that such dis- 
turbances make themselves felt in states of excitement. 


The Influence of Psychogenic Factors : 
Summary 


From what has been said it follows that from a 
critical study of the question whether psychogenic 
factors can directly cause irreversible processes in the 
organism, there is, according to modern clinical 
experience, no convincing evidence that it can be so. 
It has been stressed how organic lesions of the nervous 
system, even in the vegetative centres in the brain, 
to a surprising degree, leave the internal organs of 
the body intact, how also the purely psychogenic 
mechanisms in hysteria seldom disturb the internal 
organs, how serious organic diseases which are an 
everyday experience of the internist play a very 
small part in the asylums, among psychotic patients, 
but how the constitutional inferiority plays a vital 
part in causing neurotic reactionary conditions. 
It has also been emphasised that as the physiological 
analysis of disease phenomena is improved by the 
development of diagnostic methods, so the conception 
of organic neurosis is more discredited, and where we 
formerly supposed primary psychogenic mechanisms, 
we now know that the symptoms depend on primary 
anatomical processes in the organ which disturb 
its functions secondarily. 

However, we will not claim that our knowledge of 
pathophysiology has advanced so far as to enable 
us to reject the possibility that psychogenic factors 
can sometimes under certain conditions really cause 
organic changes. Nevertheless it may be wiser 
to wait and see. Block proves in a reliable way that 
warts on the hands can be caused to disappear to 
purely suggestive remedies, by the same simple 
methods which for a long time have been used 
by old country women. It is stated by a series of 
authors that in suitable subjects cutaneous blisters 
could be produced by hypnotical suggestion. I 
must. be forgiven for my scepticism. I have a strong 
feeling that the production of these suggested blisters 
should be the subject of further control experiments. 

Anyhow the attempt to fit in disease phenomena in 
our knowledge of pathophysiology must be given 
due regard. Without further clear and solid evidence 
I feel we ought not a priori to interpret organic 
symptoms as psychical symbols—for instance, 
constipation must not be taken as a sign of covetous- 
ness, nor the convulsion of the epileptic attack be 
interpreted as a sexual act. Faithful to scientific 
methods, we must try to explain these and other 
similar phenomena as somatic expressions of certain 
released nervous processes in the body, where the 
organism in its manner of reaction is bound very 
closely to the nervous structures of its own within 
reach. 

This does not in any way reduce the significance 
of psychical influence in disease, that is the emotions’ 
importance in the course of any sickness. We must 
not forget that body and mind are a single unit. 


NOTES, COMMENTS, AND ABSTRACTS 


‘is a vital conflict. 


[FEB. 8, 1936 347 


The anatomical organic change produces morbid 
feeling experienced by the sick person, and this latter 
is of course a purely psychical process. Here the 
intimate reciprocity of mind and body is a simple 
reality. In this manner every disease which disturbs 
the vital processes is always a psychical process, 
for all experience contains some psychical element. 
It is also clear from this starting point that whatever 
idea is held concerning the genesis of organic 
symptoms the psychical influence can never be 
discounted. This conclusion allows free scope for 
neurotic modification of organic diseases. 

We have now a fixed attitude to the interesting 
question of psychogenic organ selection. We are 
convinced that emotion is a wave which spreads over 
the entire organism; we can only see it represented 
in certain external phenomena such as a distracted 
expression, pallor, tears, trembling, and so on, but 
at the same time we feel certain that it is a deeply 
seated business of the entire organism. We under- 
stand that there may be a predisposed state of irrita- 
tion and that the emotion fixes itself fast there. The 
fact that some organic lesion often was latent 
explains that it has for a long time been wrongly 
concluded that the emotion caused something, 
whereas it has only unveiled the cause. 

This general conception induces in us an attitude 
that will prove highly useful to our patients—we 
must be very energetic in trying to find out the 
real cause of any complaint of the patient. If 
the patient has got some consistent and persistent 
trouble in any part of his body, it implies some organic 
lesion, and the symptom should not be discounted 
as psychogenic or functional and treated purely 
psychotherapeutically. 

Neurosis has been described as a disharmony of the 
nervous functions, and maintained that neurosis 
It is true of life instinct that it 
never gives up; a man fights to the last for life. We 
understand one of the most characteristic marks of 
neurotic phenomena, intensity and frenzy. Neurosis 
is not a weakening of the nervous functions but an 
intensification in the play of reflexes. 

That neurosis is the unmasking of an organic 
lesion means the setting in motion of pathological 
reflex activity which nearly always takes the form 
of a vicious circle, and that for the neurotic person 18 
his greatest trouble, Nervous symptoms generate 
one another and like rolling snowballs they increase 
with every turn. How far-reaching the effect of 
this psycho-somatic interaction in neurosis is, in the 
individual case, depends on many things: the 
talents, temperament, religious disposition, personality 
of the person in question. Thus the treatment of 
neurosis must be very difficult ; the situation cannot 
be really understood if the disturbed organic reflexes 
are treated as pieces in a puzzle play. Neurosis 
is a human thing and the organs cannot be treated 
without considering the entire man. It has recently 
been stressed from so many different sources that the 
doctor’s profession is before all an art, and some- 
times this has been stated in a way which betrays 
contempt for medical science. As a reaction against 
the so-called morphological attitude, which medicine 
has inherited from the great days of the cellular 
pathologists, this view may be said to have a certain 
authorisation. But medicine must always remain 
a true science, the science of human nature. Anyone 
who undertakes the treatment of nervous organic 
diseases must take into consideration the experience 
of clinical medicine and of all medical science ; 
these have been collected with great labour. 


348 THE LANCET] 


THE DIONNE QUINTUPLETS 


ALTHOUGH the appearance and daily life of these 
five attractive sisters has been made familiar to the 
world at large by the screen and daily press, consider- 
able interest attaches to Dr. Allan R. Dafoe’s more 
technical account of their early life and feeding. 
He has already (Jour. Amer. Med. Assoc., 1934, 
ciii., 673) given an account of their birth and immediate 
treatment, and in the January issue of the Canadian 
Medical Association Journal he carries their medical 
history to the end of their first year. 

Shortly after birth, the five infants were placed 
in a laundry basket and kept warm by means of 
blankets heated in the oven; later in the day it 
was possible to obtain a hot-water bottle, and on the 
third day an incubator was presented. Finally, 
there was a separate incubator for each infant ; 
the gemperature was at first kept between 87 and 
90° F., and then at 84°, and by means of sponges 
soaked in hot water the humidity was maintained 
at between 50 and 55. Being born two months before 
term, the infants had the typical appearance of pre- 
maturity, breathed feebly and irregularly, and had 
frequent attacks of cyanosis and apnoea. Within 
the first week a cylinder of 95 per cent. oxygen and 
5 per cent. CO, was obtained, and the gas administered 
as an “aperitif ’’ before feeds and whenever there 
was cyanosis. This treatment was continued until 
they were three months old, by which time 
14 cylinders, containing 80 gallons of the gas, had 
been used! Dafoe gives details of the feeding, and 
includes a set of weight charts that reflect every 
credit on all concerned. The Hospital for Sick 
Children, Toronto, supplied breast milk from the 
fourth day until the fourth to fifth month, in amounts 
finally reaching nearly a gallonaday. Itisinteresting 
that at one point one of the infants was getting 
110 calories per pound body-weight, the daily caloric 
intake subsequently being gradually reduced to 
40 per pound. So far they have been free from infection 
except for one attack of upper respiratory infection 


and otitis media, and an attack of gastro-enteritis | 


which affected all five patients. After removal of 
the infants to the Dafoe Hospital, built across the 
road from their home in September, 1934, gown-and- 
mask technique was used continuously by all 
attendants. 

Dr. Dafoe gives a humorous account of the recom- 
mendations for feeding and treatment that have 
reached him from all parts of -the world—varying 
from burnt rye whiskey to sheep’s dung in water. 
He does not emphasise the inevitable difficulties with 
which he must have been faced in a back-woods 
home of the type in which the infants were born, 
nor the continual intrusion of* pressmen and sight- 
seers. One cannot fail to be impressed, however, 
with the patient, ingenious, and successful way in 
which the medical care of the infants has been applied. 


BILATERAL ECTOPIC PREGNANCY 


A case of simultaneous bilateral tubal pregnancy 
is reported by S. J. de Vletter (Nederland. tijdschr. 
v. geneesk., 1935, Ixxix., 65564). The patient, 
35 years of. age, had had two other children and 
four abortions. She was admitted to hospital com- 
plaining of acute abdominal pain and slight vaginal 
bleeding, the menstrual period being a fortnight 
overdue. The uterus was found to be slightly 
enlarged and the right tube could be felt as a distinct 
swelling. The left tube could not be felt. The 
diagnosis was made of a right tubal pregnancy, and 
as there were no urgent symptoms immediate opera- 
tion was not undertaken. Next day there was another 
attack of pain, with signs of anemia, and operation 
was therefore performed. Laparotomy disclosed a 
ruptured right Fallopian stube, with the extended 
ovum (measuring about 1'5 cm.) lying outside the 
tube in a mass of blood clot. The rupture was in the 
isthmus of the tube, which was removed. The 
left tube was seen to be ruptured at the same spot 
and was also removed. The patient made an 


BIRTHS, MARRIAGES, AND DEATHS 


Ros.—On Feb. 


[FEB. 8, 1936 


uneventful recovery. Histological examination con- 
firmed the presence of a bilateral ectopic pregnancy, 
both ova being apparently of the same age. 


CERTIFICATION OF BLINDNESS 


A. CIRCULAR (No. 1520, 1d.) issued by the Ministry 
of Health to those responsible for the administration 
of the Blind Persons Act contains a warning that the 
method of testing visual acuity by cards is liable to 
give varying results according to the degree of illu- 
mination. Acting on the advice of the Council of 
British Ophthalmologists, they suggest that artificial 
illumination should be used in preference to day- 
light, and that the degree of illumination should be 
not less than 10 foot candles, setting out a method 
of obtaining this degree. This is however not one 
of the main difficulties with which the certifying 
surgeon is confronted. More important in doubtful 
or borderline cases of blindness than small differences 
in the acuity of central vision are defects in the 
visual field, already restricted when one eye is blind, 
the presence of nystagmus, and the question whether 
the blindness is progressive, stable, or capable of 
being improved by operation, treatment, or time. 
When all these have been considered, there may 
still be room for difference of opinion in the inter- 
pretation of the phrase “‘ unable to perform any 
work for which eyesight is essential.” i 


Births, Marriages, and Deaths 


BIRTHS 


BAMFORD.—On Jan. 28th, at Ely, Cambs, the wife of Dr. Brian 
Bamford, of a daughter. 

BuckTON.—On Jan. 29th, the wife of Dr. P. R. Buckton, of 
Wymondham, Norfolk, of a daughter. 

CATTERALL.—On Jan. 27th, at Devonshire-place, the wife of 
Dr. R. C. F. Catterall, of a son. 

GARLAND.—On Jan. 23rd, at Leeds, the wife of Dr. Hugh 
Garland, of a daughter. 

HENSMAN.—On Jan. 29th, at Devonshire-place, W., the wife 
of Dr. Stuart Hensman, Buckingham-street, S.W. -, ofa 


daughter. 
MARRIAGES 


KENNEDY—SHEPHERD.—On Jan. 25th, quietly, at Woodford, 
Essex, Michael Leo Kennedy, M.B. N.U.L., 


F.R.C.S. Eng. 
of Huddersfield, to Winifred Pear] Shepherd, of Highfields, 


Chigwell. 
DEATHS 


BATTLE.—On Feb. 2nd, at Horsell Common, Woking, William 
‘Henry Battle, F.R.C.S. Eng., Consulting Surgeon, St. 
Tooms Hospital, late of Harley-street, London, in his 

Ist year. ; 

CHRISTMAS.—On Jan. 30th, at Bozeat, Northamptonshire, 

Mao R. W. 5. Christmas, M.R.C.S. Eng., late R.A.M.C., 


FARQUHARSON.—On Jan. 30th, at Chelsea, Stewart Farquharson, 
M.B. Lond., aged 4l. 
FORSBROOK. —On Feb. 3rd, 1936, at Victoria-street, London, 
S.W., William Henry Russell Forsbrook, M. 
LuNN.—On Jan. 27th, at Olton, Birmingham, Cyril R. Lunn, 
M.B. Birm. 
2nd, at Newmill, St. Andrews, Farquhar 
M.B. Glasg., consulting surgeon, Western Infir- 
mary, Glasgow. 


MARNOCH. "—On Feb. 2nd, 1936, at 28, Albyn-place, Aberdeen, 
Sir John Marnoch, K.C.V.O., D.L., LL.D., Emeritus 
Professor of Surgery in the University of Aberdeen. 

PEARSE.—On Jan. 25th, the result of an accident, Frederick 
Edward Pearse, M. R.C.S. Eng., L.R.C.P. Edin., of Ripley, 


Surrey, aged 76, 
PRipHAM.—On Jan. 27th, at Burgh, Lincolnshire, Charles 
Fortescue Pridham, B.Chir. Camb., M.R.C.S. Eng. 
Ist, 1936, in London, Joseph Wiliam Rob, 
O.B.E. M.D., of Oatlands Park, Ww eybridge, aged 59. 
Waucn.—On Jan. 29th, at Prenton, Birkenhead, Alexander 
Waugh, M.B. Glasg., aged 71. 
N.B.—A fee of Ts. 6d. ts charged for the insertion of Notices of 
Births, Marriages, and Deaths. 


Macrae, 


GREENOCK JIOSPITAL.—Provost Bell, on Jan. 27th, 
cut the first sod on the site of the Rankin Memorial 
Maternity and Children’s Hospital at Greenock. The 
hospital is being given to the town by Miss M. D. 
Rankin at a cost of £40,000 and it is expected to be 
finished within eighteen months. It will have room 
for 56 beds. 


THE LANCET] 


ADDRESSES AND ORIGINAL ARTICLES ; 


THE TREATMENT OF 
PERNICIOUS ANÆMIA WITH DAKIN 
AND WEST’S LIVER FRACTION 
(ANAHÆMIN) 


By C. C. Unetty, M.D. Durh., M.R.C.P. Lond. 


_ ASSISTANT PHYSICIAN TO THE ROYAL VICTORIA INFIRMARY, 
NEWCASTLE-UPON-TYNE ; LEVERHULME RESEARCH SCHOLAR, 
ROYAL COLLEGE OF PHYSICIANS OF LONDON 


L. 8. P. Davipson, B.A. Camb., M.D., F.R.C.P. Edin. 


PROFESSOR OF MEDICINE IN THE UNIVERSITY OF 
ABERDEEN ; AND 


E. J. WAYNE, M.Sc., Ph.D., M.B. Leeds, 
M.R.C.P. Lond. 


PROFESSOR OF PHARMACOLOGY IN THE UNIVERSITY 
OF SHEFFIELD 


In 1926 Minot and Murphy 1 reported their epoch- 
making discovery of the value of liver in the treat- 
ment of pernicious anemia. The difficulty which 
patients who were seriously ill found in eating 
250 grammes of liver daily made it desirable to 
prepare concentrated extracts from the whole organ. 
The first successful concentration of the active 
fraction was achieved by Cohn, Minot, and their 
co-workers 2 who demonstrated that the daily oral 
administration of a powder weighing 12g. (fraction 
G derived from 400 g. of liver) was as effective for 
blood formation as 250 g. of whole liver. 

By elaborate chemical procedures this fraction was 
further purified, until material injected intravenously 


in doses as small as 0°025¢. daily would produce a . 


maximal regenerative effect on the blood. General 
use of this product was not practicable because of 
its high cost, resulting from the loss of large amounts 
of active principle during fractionation. Accordingly 
Castle,’ 4 using a simple solution of the fraction G 
of Cohn and also Gdansslen,’ prepared inexpensive 
products effective when injected intramuscularly 
in daily amounts derived from 5 to 20g. of liver. 
Given by injection the extracts were 30-100 times 
more potent than when given by mouth. Attempts 
to isolate the liver principle in a state of complete 
purity have been hampered by the fact that the 
product is easily inactivated by chemical processes 
and by the lack of a reliable laboratory test for 
activi 

Recently a further stage in the concentration of the 
active principle has been announced by Dakin and 
West. For details of the complicated chemical 
processes involved the reader is referred to the 
original paper by these workers. The method 
employed in making the product used in the present 
investigation was essentially similar, fraction G 
(Cohn) 2 being treated with alcoholic calcium acetate 
to remove inactive material and subsequently 
concentrated by successive precipitation with 
ammonium sulphate, Reinecke salt, and finally 
ammonium sulphate again. 

To this product the name Anahwemin has been 
given. It is a clinically potent light buff-coloured 
granular powder. When prepared from Cohn’s 
fraction G a yield of 1 per cent. is obtained. The 
material is soluble in water and dilute alcohol, but 
insoluble in absolute alcohol and in ether. Dakin 
and West found that on hydrolysis it yielded an 
aminohexose and a number of amino-acids—namely, 

5868 


[FEP, 15, 1936 ane 


lysine, arginine, glycine, leucine, hydroxyproli 


FEB 


and aspartic acid. Pyrimidine or purine bases ‘yr 


were absent. The substance was slowly decomposed 
by pepsin and more rapidly by erepsin. Pancreatic 
juice had no effect upon it. Intramuscular or 
intravenous injections of 75 to 150 mg. have produced 
maximal reticulocyte responses. 

A supply of anahemin has been prepared by 
The British Drug Houses Ltd., under the direction 
of Mr. F. H. Carr, D.Sc., who originally suggested to 
Dakin and West the possible -value of ammonium 
sulphate in the process of fractionation. The material 
was supplied in solution in ampoules containing 
100 mg. per c.cm. 

We were asked by the Medical Research Council 
to carry out the present investigation in order to 
determine the potency of the Dakin and West liver 
fraction, anahemin, and to compare its hemato- 
logical and clinical effects with those produced by 
other (less purified) concentrates. The advantages 
gained by simultaneous investigations at three 
centres were the increased number of cases obtained 
in a limited period and the correlation of independent 
observations. 

It might be asked why, when potent preparations 
are already available, intensive research is still 
required into the purification of the active principle. 
There are at least three reasons why investigations 
in this direction are necessary. 

(1) Increased concentration should permit the use of 
smaller quantities and longer periods between injections. 

(2) Until the material is obtained in its pure state there 
is no possibility of its synthesis, a process which might 
lead to a marked reduction in the cost of treatment. 

(3) There is the obvious desirability from the scientific 
point of view of investigating the influence of the pure 
substance not only upon blood formation, but also upon 
certain neurological and other phenomena associated 
with the syndrome of pernicious anemia. 


Progress is hampered by the scarcity of suitable 
cases of pernicious anzmia in relapse, and we take 
this opportunity of asking practitioners to refer such 
patients to hospital whenever possible. At the same 
time we acknowledge with gratitude the coöperation 
of those who have already permitted the investigation 
of patients under our care. 


MATERIAL 


A total of 36 cases has been treated, details of the 
first 23 being included in Table I. For brevity, 
clinical and biochemical findings other than those 
necessary for the present analysis are omitted, but 
every case was fully investigated and conformed to 
the criteria demanded for the diagnosis of Addisonian 
pernicious anemia. In no instance was free hydro- 
chloric acid present in the gastric juice even after 
histamine stimulation. Before commencing treat- 
ment a control period without therapy was observed. 
A diet low in meat and other sources of extrinsic 
factor was given during the period of investigation. 


Results 
CLINICAL FINDINGS 


By the third to sixth day there was in most 
instances a feeling of well-being and a return of 
appetite, this subjective improvement frequently 
being less marked or delayed in patients with red 
blood-cell counts above 2 millions per ¢.mm. 

Although in two instances soreness of the tongue 
persisted for more than 20 days, in most cases it had 

G 


<o 


350 THE’LANCET] DR. UNGLEY & OTHERS: LIVER FRACTION IN PERNICIOUS ANEMIA [FEB. 15, 1936 


TABLE I.—CASES AND RESULTS 


Reticulocyte i S in AO 
; response, per cent.) (millions per c.mm.). 
Guel npe |, AON Oh ada 
No.| age, | millions A E eee Remarks. 


Ex- Days. infection, &c. 


given. 
sex. per a 3 
EE (d. =days.) | Actual Day pected 


peak. maxi- 
munı.| 10 | 20 

1 |F.T.,| 0-91 10 mg. from | 33-2 9 | 50°6 |0°7411-76 |2-21] 3-21| 3-34 — Given amm. sulphate pre- 
53, 0 to 9 d. ; | 32:2 | 10 | 38-0 cipitable (less purified) 
male. 20 from 11 material from 11 to 20 

to 20 d.; days. 
300 at 
31d. 

2 |B. R.,| 1°68 100 mg. at | 43-0 6 | 29-4 | 0-39) 0-49) 1:19) 1-39 1-58) Syphilis, aortic | S.T. ceased. P. in fingers 
oe 0,18, 36d. 18-7 aneurysm. ceased. ~ 
male 

3 H.M., 1:20 100 mg. at |27-3+] 4 | 41-5 | 1-86) 2-50] 2-50) 2-66) 3°25 — P. ceased. 

5 0 d.; 300 29-0 
fem. at 38 d. 

4 |A.M.,| 0:97 150 mg. at | 29-0 6 | 47-4 | 0-86) 1-54) 1-64; 2-27| 2-32; Chr. arthritis (afe- | Vib. absent legs. 
47, 0 d.; 400 | 30-0 7 | 34-6 brile). B.P. 152/90. 
fem at 20 d. 30-4 8 , 

5 |B. W.| 1-90 200 mg. at — — — |0-38' 1-29) 1-76|1 -73| 2-43 — S.T. persisted 20 days. 
66, 0 and 39d. P. in hands much less. 
male. S.C.D. no change. 

6 |C.A.,/ 1:13 200 mg. at | 25-8 6 | 44-3 | 0-54) 0-61) 0-96; 1-42; 1-70; Subacute cholecyst- | P. below knees ceased 
75, 0 d.; 600 81-7 itis. R.A. thick- 2nd week. Died after 
fem. at 18, 28, ened, tortuous. cholecystectomy. 

38d., then B.P. 175/95 (ith 
wkly. week). 
7 |F.C.,| 1-91 200 mg. at — — — |0-61| 1-22 1-66' 2-01 2:26 — S.T. ceased. P. ceased. 
‘| 62, 0 and 28 d. 
fem 

8 P.M., 1:38 200 mg. at | 28-4 6 | 36-2 | 0-80) 1-70| 2-14; 2-74/ 2-88! Pyorrhoa marked. P. to wrists and ankles 
55, OQand 21d. | 28-8 7 | 243 ceased. S.C.D. much 
fem. 600 wkly. improved, 

from 28 d. 

9 M.I., 1:61 200 mg. at 17-04] 5 | 31-5 | 0-87) 1-15) 1-82] 2-32) 2-67 — P. below knees less. 
44, Od.3; 300 20-4 S.C.D. improved. 
fem. at 21 and 

28d. ; 200 
on alt. d. 
from 31. l 
10 |S. W., 1:36 200mg.at 0,| 35-4 7 | 36-2 | 0-88] 1-10) 1-43) 1-95) 2-38) Dental sepsis slight. | P. to ankles ceased 10th 
72, 20,29,39d.; 24-3 R.A. thickened. week. Absent K.J. and 
male. 1000at 49d. B.P. 130/75. A.J. Vib. doubtful. 
Iron from 
69 d. 

11 E.C., 1-82 200 mg. at | 11-0 51273 | 1-41) 1-81,2-39) — | — — P. in fingers much less, 
G4, 0 d. 17-1 Slight ataxia less. 
male. l 

12 |G.G.,| 147 200 mg. at | 24-6 4 | 33-8 | 1-30) 1-72) 2-10) 2-56/2-80) R.A. thickened. — 

63, 0,21,43d. | 24-0 5 | 22-3 B.P. 160/70. 
male. 

16 B| P. H., 1:60 300 mg. (16:3)| (10) —_ | 1-69) 1-88| 2-20) 2-56) — | See Case 16. — 
56, 
fem. 

13 |W.W.,| 1:21 400 mg. at | 35-0 G | 41-5 | 0-91) 1-64) 2:18 2-60) — | Dental sepsis slight. | P. to elbows and knees 
68, 0d. 29-0 R.A. thick and tor- Psychosis developed 5th 
male. tuous. B.P. 135/65. | week. S.C.D. slight, 

improved. 

14 IC. S., 1:31 400 mg. at | 25-2 5 | 38-8 |1-10 1°72 2-14) 2-52) 2-67 — S.T. ceased. P. to wrists 
35, Oand2I1d., 26-5 and below umbilicus 
fem. and wkly. decreased to finger tips 

from 30 d. and soles. 8S.C.D. slight 
improvement, 

GBIC.A.,| 1:54 600 mg. (l1-4)) — — |0-45) — | — | — | — | See Case 6. — 

’ J 
fen. y 

15 |C. E.,| 2-55 100 ng. at 4°3 6 | 14-1 | 0-02) 0-67/ 1-19) 1-38) 1-52) Pyorrh@a slight. | S.T. ceased 3rd day, No 
13, Od.; 600 | (4:2) ) (13) 7-5 R.A. thickened. true P.—** dead fingers ” 
male. at 11 d.; BP. 122772. only. 


500 at 21, 
29, 36 d. 


16 |P.¥.,| 2:13 100 mg. at 7-8 7 | 21-8 | 0-18 Zoss| 1:16) 1:42!1:71| Marked arterio- | P. in fingers ceased. Old 
56, 0 d.; 300 | (16-3) | (29) 12-9 -| sclerosis. Cerebral bemiplegia. 
fem. at 19 d. vascular lesion. 


B.P. 220/110. 


17 IJ. R.,]| 2°56 100 meg. at 8:0 7 | 14-1 | 0-35) 0-84) 1-17] 1-45) 1-57| Pyorrhæa. R.A. sl. | S.T. ceased. P. to wrists 
62, Od.; 400 7-5 thickened. B.P. and umbilicus less. S.C.D. 
male. at 11, 21, 164/94. sl. improvement. 
and 36 d, 
2p B. R.| 2-15 100 mg. — — — |0-60/ 0-88; — | — | — | See Case 2. — 


56, 
male. 


THE LANCET] 


ceased altogether by the end of the first week. This 
prompt relief of sore tongue by Dakin and West’s 
liver fraction, which from its chemical nature and 
mode of preparation is unlikely to contain any of the 
known vitamins, is interesting in view of the theories 
of Hutter, Middleton, and Steenbock ? and of Groen,?}® 


DR. UNGLEY & OTHERS: LIVER FRACTION IN PERNICIOUS ANÆMIA [FEB. 15, 1936 351 


who suggest that the tongue changes in pernicious 
anemia are due to deficiency of some portion of the 
vitamin-B complex. 

Gastro-intestinal symptoms such as epigastric 
discomfort, vomiting, and diarrhoea usually cleared 
up in the first ten days. The rapid gain in weight 1 


TABLE I.—(continued) 


Days. 


20-1 | 0-45) 0-93] 1-40; 2-18) 2-08 
11:6 


0-62; 1-14) 1-47) 1-941 2-08 — 
0-44| 0-37| 0-57; — | — 
0-47| 1-21) 1-33) 1-81) 1-91 — 
0:95| 1-76, 1-83; 1-58| 1:36 


0-10) 0-73 0-78 — | — 


Increase in R.B.C. 
(millions per c.mm.). 


Arterio-sclerosis, 


infection, &c. Remarks. 


See Case 10. — 


Chr. bronchitis. R.A. ge 
thickened. B.P. 
150/85. 


0-62) 1:07; 1-07) 1-17) 2-15 — Ta 


Occasional P. legs ceased. 
Vib. absent legs. 


Osteo-arthritis. No P. K.J. absent. Vib. 


absent or diminished. 


S.T. severe till 22nd day. 
Recurred on 47th. Ting- 
ling to elbows worse at 
first: less after 40th. 
No definite S.C.D. 


Simple goitre. S.T. persisted. 


See Case 4. — 


See Case 15. ' — 


Reticulocyte ; 
response, per cent. 
Initial Amount of |. i 
Case, | R.B.C. material 

No.| age, | millions given Ex- 

Sex. per (d. =days.) | Actual | pected 
c.mm. peak, Day Mari- 
muwuni. 

10 B S | 2-11 200 mg. — — — | 0-30 — 

male 

18 | R.G., 2-21 200 mg. at 9-6 5 
65, 0, 19, 28, 9-0 6 

male 39 d. . 

19 |H.M.,| 2:35 200 mg. at — — — 
62, 0 and 37 d. 

fem 

20 | R. E., 2-34 200 mg. at | 18-0 6 | 185 
5l, 0, 20 d. 10-5 
fem À Iron at 

36 d. 

21 | U. L.,| 2-63 300 mg. at 3-2 6 | 14-1 
42, 0 and 2i d. 7-5 

fem. 

22 |R. J.,| 2-12 300 mg. at | 27-8 9 | 21-8 
34, (aver.) d.; 500 12-9 
em. at 20 and 

48 d. 

23 | B. E., 2-24 100 mg. at 3-0 9 | 20-1 
55, 0 d.; 200 3-0 10 11-6 
fem. at 6d.:100 

at 28 d. 
4 B| A. M.,| 2:51 400 mg. — — | — 
47, 
fem. 

15 B] C. E., 2-57 600 mg. (4:2) | (2) — |0-64| — 

male. 


AAbbreviations.—R.B.C. =red blood-cells. 
tongue. P.=paresthesiv. S.C.D.=subacute combined 
sense. Sl.=slight. D. & W.=Dakin & West. 


B.P.=b ood pressure (systolic and diastolic). 
degeneration. 


S.T. =sore 
Vib. =vibration 


R.A. =radial arteries. 


K.J. =knec-jerks. A.J.=ankle-jerks. 


EXPLANATORY NOTES FOR TABLE I 


“ Days” in every instance refers to days after the 
commencement of treatmont, the day of the initial 
injection being “‘ 0.” 

Reticulocytes.—Where the summit of the response was 
a “plateau” rather than a “ peak,’ counts closely 
approximating to the maximum are given. The + sign 
in Cases 3 and 9 indicates that the actual maximum was 
probably higher than the recorded figures, the reticulocyte 
count not having been made daily in these two instances. 
The expected maxima are those calculated by Bethell 
and Goldhamer ? for intravenous injection of liver extract. 
Actual calculations for intramuscular injection are not 
yet available. The expected maxima for oral liver 
therapy (Riddle 8) are given in italics. 

Red blood-cell increases attributable to the injection of 
a single dose are printed in heavy type. At the time of 
the second injection in Cases 2, 4, 6, 10, 15, and 16 the 
red blood-cell increase following the first dose had ceased 
and the erythrocyte level remained below 3 milhons 
per c.mm. These cases are included in the table for a 
second time (e.g., as Case 2B) in order to show the rate 
of red blood-cell increase produced by the second dose. 
Secondary reticulocyte responses produced by second 
doses of material are given in parentheses (e.g., in Cases 16 
and 16 B). 

A column is included for “ arterio-sclerosis and infec- 
tion,” since these factors have been shown to influence 
the response to treatment. 


€ 


Under the heading “ Remarks ”? the presence and the 
effect of treatment upon sore tongue, paræsthesiæ, and 
neurological phenomena are recorded. When not speci- 
fically mentioned such manifestations were absent. 
Further details of the neurological findings are given later 
in this paper under “ Discussion.” 

Order of cases.—The cases have been divided into two 
groups: those with initial red blood-cells below 2 millions 
and those with initial counts at this level or above it. 
In each group the cases are arranged according to the 
amount of Dakin and West’s fraction given in the first 
10 days. Cases receiving similar amounts of material are 
put in order of 10 day increase of red blood-cells. 

Shetlield cases : 5, 11, 19, and 2 others. 

Aberdeen cases: 2, 3, 7, 9, 16, 20, 21, 23, and 6 others. 

Newcastle cases: 1, 4, 6, 8, 10, 12, 13, 14, 15, 17, 18, 22, and 
5 others. 

The initial dose in Cases 8 and 10 and the first two doses 
in Cases 12 and 18 were given intravenously, but all 
other injections were made intramuscularly. 


REACTIONS 


When a second intravenous injection was given Case 18 
suffered from pains in the limbs and back, flushing, and 
intense dyspnea as if from bronchospasm. The symptoms 
ceased within half an hour of the injection. Under similar 
circumstances Case 12 had merely a flushing of the skin. 
Except for an occasional rise of temperature to 99° F. no 
other reactions were observed. 


G2 


352 THE LANCET] DR. UNGLEY & OTHERS: LIVER FRACTION IN PERNICIOUS ANÆMIA 


which frequently accompanies a remission, however 
induced, was observed in this series also. 

Transient paræsthesiæ often brought on by exposure 
to cold and sometimes associated with obvious 
circulatory disturbances in the extremities—e.g., 
‘“ dead fingers ’’—passed off within the first two weeks. 
More constant numbness and tingling, probably 
nervous in origin, decreased in extent and intensity 
after a variable period in every instance (see Table I.). 

Objective neurological findings were observed in 
12 instances. Cases 4, 10, 20, 21, and 22 showed 
merely diminished or absent vibration sense with 
or without depression or absence of deep reflexes ; 
except for minor alterations in reflexes no significant 
changes were observed. 

The effect of treatment in Cases 11, 13, and 17 
showing evidence of subacute combined degeneration, 
but of relatively slight degree, is sufficiently indicated 
in Table I. 

There were four patients with moderately severe 
subacute combined degeneration of the cord. Case 5 
had less numbness and tingling, but showed no change 
in objective findings after 50 days, having received 
only 400 mg. in that time. In Case 14 paresthesize 
diminished and gait improved, but at the sixty-sixth 
day the physical signs were little changed. Although 
still ataxic a patient (Case 9) who was unable even 
to stand can now walk for short distances without 
help. Spasticity has decreased but the plantar 
reflexes remain extensor. Incodrdination and loss 
of cutaneous sensibility are less. Case 8 was remark- 
able in that after ten weeks the patient was free 
from paræsthesiæ, cramps, incontinence of urine, 
and dysfunction of the hands. The memory had 
become normal. The gait became quite steady and 
she was even able to run. Romberg’s sign was 
negative. 
eighth week had been clearly extensor ‘thereafter 
became flexor in type. Depressed deep reflexes 
were more readily obtainable. Vibration sense 
returned in the spine, pelvis, and lower extremities 
with the exception of the toes, and cutaneous sensi- 
bility in the feet improved. 

The fact that symptoms and signs of subacute 
combined degeneration improved during treatment 
with such a highly purified liver fraction is of consider- 
able theoretical interest. Should the results be 
confirmed in a larger series of cases it will show that 
the hypothetical cord factor, if not actually identical 
with the hemopoietic liver principle, must at least 
be allied to it chemically. 


RETICULOCYTES 


Up to a point, the height of the reticulocyte peak 
after the administration of any active substance 
increases with the quantity of material administered, 
but for a given initial red blood-cell count there is 
a maximum reticulocyte response which is rarely 
exceeded however great the amount given. The 
smallest quantity of material required to produce 
such maximal responses has been used as a measure 
of potency,!* a matter to which further reference will 
be made. Table II. indicates the degree of reticulo- 
cyte response which followed the administration of 
varying amounts of Dakin and West’s liver fraction 
anahemin, figures for commercial liver extracts and 
for Dakin and West’s own series being included for 
comparison. The reticulocyte response is described 
as good, moderate, or poor. Standard reticulocyte 
responses for the intramuscular route which was 
used in most instances are not available, but judging 
from published data1? it seems that the maxima 
usually fall somewhere between those for intravenous 


The plantar responses which until the- 


[FEB. 15, 1936 


and those for oral therapy. An arbitrary line mid- 
way between the maxima for intravenous’ and for 
oral liver therapy è? has therefore been chosen, ‘‘ good ” 
responses being those which reached or exceeded 
this level. ‘‘ Poor” responses are those which fall 
below an arbitrary level three-fourths of the maximum 
for oral therapy. ‘‘Moderate’’ refers to peaks 
falling between the two levels mentioned. 


TABLE II 
Reticulocyte responses according to dose 


No. of 
— cases: Good. |Moderate. 

150 mg. or less 8 | 1(12°5) | 4 (50) 3 (37°5) 
200 mg. da i 8 2 (25) 5 (62°5) 1 (12°5) 
300 or 400 mg. 4 2 1 1 
Total for present series 20 5 (25) 10 (50) 5 (25) 
Campolon 10 c.em. or 

Pernemon Forte 10 

c.cm. (Ungley) ee 9 4 (44°4) | 4 (44°4) | 1 (11°1) 
Campolon, Hepatex, or 

Lilly Ext. 2 to 5c.cm. 

daily (Davidson) .. 6 3 1 2 
Total 15 (46°7) 


ef ere | geen | peste eens | SS 


Dakin and West’s series 


(75 to 150 mg.) .. 16 | 10 (62°5) | 5 yen 1 (6°25) 


Percentages are given in parentheses. 


A comparison with the figures for massive doses 
of commercial liver extracts shows that the per- 
centage of “‘ good ” reticulocyte responses to 2 ¢.cm. 
of anahemin (100 mg. per c.cm.) is lower than that 
produced by single injections of 10 c.cm. of Campolon 
or Pernemon Forte, or daily injections of Campolon, 
Hepatex, or Lilly’s extract (see Table II.). There 
are not sufficient data available for doses in excess 
of 200mg. The reticulocyte responses obtained 
by Dakin and West ® are referred to later. 


INCREASE OF RED BLOOD-CELLS 


It is well recognised that cases with a high initial 
red blood-cell count show a smaller rate of increase 
in erythrocytes than cases with a low initial level. 
An analysis of our data shows that this reduced rate 
of blood production is as apparent in cases starting 
with a high initial count as in cases which have reached 
a high level consequent upon previous treatment. 
When assessing the rate of red blood-cell increase 
in a given period produced by differing kinds or 
amounts of material, it is therefore desirable to 
confine comparison to cases with approximately 
similar initial levels. An idea of the rate of increase 
to be expected from adequate therapy may be gained 
by reference to Table III. which shows the response 
to oral and parenteral liver therapy in other series 
of cases. The-initial level of red blood-cells in cases 
receiving anahemin (1:55 to 1:57) was somewhat 
higher than in those receiving other liver extracts 
(1- 2 to l 37). Such a small difference in initial level 
can only have a slight effect on the rate of increase 
in 10 to 20 days (see Bethell’s 14 paper, Fig. 5). Details 
of the effects produced by varying doses of the 
Dakin and West fraction are given in Table I. Doses 
amounting to 150mg. or less in the first 10 days 
were given in four cases having initial red blood-cell 
counts below 2 millions. There was an extremely 
rapid increase of red blood-cells in Case 3, a moderate 
increase in Cases 1 and 4, and a poor response in Case 2. 
Cases 15, 16, and 17 with initial counts over 2 millions 
showed very little response and Case 2B showed a 


TEHE LANCET] 


moderate response. The results are too variable and 
too few for purposes of comparison or statistical 
treatment. 

Eight cases (Nos. 5 to 12) with initial red blood- 
cell counts below 2 millions received 2c.cm. of 
anahæmin (100mg. per c.cm.) as a single dose. 
The rise of red blood-cells was variable, lasting as a 
rule for from two to three weeks. On the average 
the increases in 10 and 20 days were similar to those 
produced by the administration of large amounts of 


TABLE III 


Comparison of rates of increase of red blood-cells in cases 
of pernicious anemia having initial counts of 2 millions 
per c.mm., or less 


$ Average increase Sie pans 
ga in R.B.C. ao 
. 3 days. 
Preparation Dosage S- (b) Time 
q3 10 20 30 40 to reach 
i- daysidaysidays|days|4 millions 


(a) Single Injection 


(1.) D. & W. frac- | 200 mg. | 1'571 0'81) 1°36; — | — — 


ion (B.D.H.): | (2 c.cm.) 
8 cases. 
(1.) Campolon or 10 1°37) 1°1 | 2°05) — | — — 
Pernæmon | c.cm.t 
Forte: 8 cases 
(Ungley). 


(b) Divided Doses 


(m1.) D. & W. tfrac- | 359 mg. |1°55)| 0°96) 1°54) 1°84) 2°31, (a) 3°86. 
tion (B.D.H.): | (aver.) (b) 6 wks. 
11 cases receiv- |in 5 wks. 
ing not more 
than 600 mg. 
in 5 weeks. 


(rv.) Campolon : 30 to | 1°35) 0°78) 1°47) 2°11] 2°46] (a) 3°81 
12 cases (David- | 82 c.cm. 
son). in 5 wks. 

(v.) Liver extract 10 to |1°3 | 0°86} 1°68; 2°42| 2°89) (a) 4°19 
intravenously : | 20 c.cm. japp. +35 +35 
79 cases | per wk. days| days. 
(Bethell **).* (b) 5 wks. 


(c) Daily Oral Administration. 


(v1.) Ext. 343: Ext. | 1°20) 0°85) 1°90) 2°61; — — 
24 cases (Minot, 
Cohn, Murphy, | 500-600 
and Lawson ?°). ig. daily. 


(vir.) Ext. 343: Ext. 1°35) 0°46) 1°25; 1°98) — — 
9 cases (Minot, from 
Cohn, Murphy, | 250 g. 
and Lawson ??). | +daily 


* The figures for R.B.C. increase are approximate, having been 
calculated from charts in Bethell’s paper. 

t Containing from 2500 to 3500 mg. of solid matter. 

app. = approximate, 


campolon in divided doses (Table III., Series 1. and Iv.) 
but were less than those which followed the single 
injection of 10 c.cm. of campolon or pernemon forte 
containing from 2500 to 3500 mg. of solid matter * 
(Table III., Series 1. and 11.). The difficulty of assessing 
the potency of preparations is well exemplified in 
Table III., Series 11. and Iv. The 12 cases in Series Iv. 
received from 20 to 30c.cm. of campolon during the 
first week. The average gain in red cells in 20 days 
is less than that which followed the single injection 
of 10c.cm. This cannot be explained as being 
caused by the effect of a single injection, nor on the 
grounds of differences in the initial red cell level, 
but only on fortuitous circumstances by which in 
series II. a number of cases happened to be included 
which show a high grade of response. The average 
gain in 10 and 20 days in series Iv. is of the same 
magnitude as occurs in series I., III., and v. The 
contention that series II. was fortunate in containing 
cases showing a high grade of response is supported 


* Recent batches of Pernemon Forte differ from those used 
in Series 11. in containing a smaller proportion of solid matter. 


DR. UNGLEY & OTHERS: LIVER FRACTION IN PERNICIOUS ANZMIA [FEB. 15, 1936 353 


by the fact that the rates of increase are higher than 
those shown by the large number of cases in 
series V., receiving optimal amounts of liver extract 
intravenously. 

The increase of red blood-cells in 20 days is distinctly 
less, than that which follows the daily administration 
of extract 343 (fraction G of Cohn) derived from 
500 or 600 g. of liver, and slightly exceeds that which 
is to be expected after the daily oral administration 
of extract 343 from 250 g. of liver ® (see Table III.). 
It may be concluded that the optimal single dose for 
rapid production of red blood-cells in 10 and 20 day 
periods is in excess of 200 mg. 

Two out of three cases receiving 300 mg. at an 
initial red blood-cell count of over 2 millions (Nos. 21, 
22, 23) had a greater increase at 20 days than the 
three cases with a similar initial level receiving 200 mg., 
but Case 4 B receiving 400 mg. from a red blood-cell 
level of 2°51 millions showed a poor response. Only 
three cases (Nos. 16 B, 13, and 14) had 300 or 400 mg. 
at an initial red blood-cell level sufficiently low for 
adequate test, and all three gave a good response. 
The data for doses of 300 and 400 mg. are not sufficient 
however to indicate whether in the average case such 
initial amounts are likely to be optimal for the produc- 
tion of red blood-cells at a maximal rate. 

On the other hand, there were 11 patients with 
initial red blood-cell counts below 2 millions per 
c.mm. who received 100 to 600 mg. (average 359 mg.) 
in a period of 36 to 40 days. Cases with various initial 
red blood-cell counts below 2 millions receiving similar 
amounts of material tend to have much the same 
level after five weeks.14 It is significant therefore 
that not only are the rates of increase in this series 
of the same magnitude as those produced by large 
doses of campolon, but the final counts after 40 days 
are almost identical (Table III., Series III. and Iv.). 
(It would of course be incorrect to conclude that 
l to 6c.cm. of anahzemin were quantitatively 
equivalent to 30 to 82c.cm. of campolon, because 
these quantities of campolon may have been more 
than were required to produce the effect attained.) 
Bethell’s 14 79 cases receiving a regular weekly intra- 
venous injection of 10 to 20 c.cm. of liver extract 
showed a considerably greater gain in 35 days than 
either of these series (Table III., Series v.). 


Figures for red blood-cell increase are available 
in only 3 of the 20 cases reported by Dakin and 
West,® but it is noteworthy that in their series 75 
to 150mg. were usually followed by a maximal 
reticulocyte response. It would appear possible that 
the material used in the present investigation may 
be somewhat less active than that prepared by 
Dakin himself. Dr. Dakin suggests 15 as a possibility 
that when fresh liver is used instead of extract’ as 
starting material there may be less ‘‘denaturing ” 
and increased activity. 

The difficulty in drawing conclusions as to the 
potency of a product from hematological observations 
in small groups of patients must be fully realised. 
When reticulocyte counts are made only once daily 


. it is unlikely that the maximum percentage attained 


will be observed in every instance.? When, as in 
the present investigation highly purified materials 
are given and the intramuscular route is used, the 
irritant effects which may arise from non-specific 
substances present in material administered intra- 
venously are likely to be less marked. But while 
we admit that in the majority of cases a maximal 
reticulocyte rise is followed by an excellent increase 
in red cells and a poor reticulocyte rise by little or 
no gain in red blood-cells, a study of Table I. clearly 


354 THE LANCET] 


indicates that exceptions to this rule may occur. 
Thus while Case 2 showed a good reticulocyte response 
and little increase in red blood-cells, Case 11 had a 
poor reticulocyte response followed by a good gain 
in red blood-cells. In Cases 13 and 14 the patient 
with the smaller reticulocyte response had a more 
rapid increase in erythrocytes. A study of Table I. 
shows marked variations in reticulocyte response and 
red blood-cell gains in patients at similar initial 
levels receiving similar amounts of material. These 
variations may be quite independent of factors such 
as arterio-sclerosis and infection. This is well 
exemplified by the differences in reticulocyte response 
observed in Cases 13 and 14, 15 and 17, 21 and 22, 
differences for which no adequate explanation is 
forthcoming. Incidentally although we agree that 
in general cases with marked arterio-sclerosis or 
sepsis do badly (see Case 6) this does not hold good 
in every instance (see Cases 16 8 and 13). A striking 
example of an optimal response in the presence 
of very severe sepsis has been published by one of 
us. 

It might be expected that age would influence the 
degree of response. Nevertheless analysis of the 
reticulocyte response and rate of red blood-cell 
increase in cases receiving Dakin and West’s liver 
fraction showed no difference between those under 
and over 60 years of age. For this reason, although 
the age-incidence was higher in eight cases receiving 
200 mg. of Dakin and West’s liver fraction than in 
those receiving 10¢.cm. of campolon or pernwemon 
forte, the fact does not appear to aceount for the 
difference in response in the two series. 

Since this investigation was commenced Strandell !* 
has reported the isolation of an almost colourless 
liver fraction ; 2 mg. dissolved in water and injected 
intragluteally in patients with pernicious anemia 
produced a marked hemopoietic effect. The method 
of preparation has not yet been published. 


Summary and Conclusions 


A total of 36 cases of pernicious anwmia have been 
treated with Dakin and West’sliver fraction, anahiemin, 
The material has been compared with other liver 
preparations in respect to the production of reticulo- 
cyte responses, increase of red blood-cells, and clinieal 
improvement. 


The data submitted emphasise the difficulty of 
assessing potency upon reticulocyte responses and 
red blood-eell increase in tests limited to a small 
number of cases. The results indicate, nevertheless, 
that anahæmin, as prepared by the British Drug 
Houses Ltd., is highly active for blood regeneration 
in pernicious anemia. Total quantities of 1 to 6 ¢.cm. 
(100 to 600 mg., average amount 359 mg.) administered 
usually in divided doses, to 11 cases with initial red 
blood-cell counts below 2 millions per c.mm., were 
sufficient to cause an average increase of erythrocyte 
concentration amounting to 2°31 millions in 40 days. 
Good responses followed the administration of amounts 


sometimes as small as 10 mg. daily or 100-200 mg., 


as a single dose. For maximal reticulocyte responses, 
and for the production of red blood-cells at a maximal 
rate, larger doses were usually required. There is 
not suflicient data to assess quantitatively the potency 
of anahwmin as compared with other liver extracts, 
but in our experience no other liver extract given in 
the small amounts used in this investigation has 
produced such striking results. Preliminary observa- 
tions suggest that this highly purified fraction may 
prove to be at least as potent as other liver extracts 7° 


DR. J. F. WILKINSON: ANTI-AN.EMIC PRINCIPLE OF LIVER 


[FEB. 15, 1936 


in the treatment of the neurological manifestations of 
pernicious anemia. 


It is a pleasure to thank members of the staff of the 
voluntary hospitals in Aberdeen, Sheffield, and Newcastle- 
upon-Tyne for their kind coöperation, and for allowing 
us access to their patients. In the case of one of us 
(C. C. U.) the work has been carried out with the assistance 
of grants from the Medical Research Council and under 
the tenure of a Leverhulme research scholarship of the 
Royal College of Physicians of London. 


REFERENCES 


1. Minot. G. R.,and Murphy, W. P.: Jour. Amer. Med. Assoc. 
1926, Ixxxvii., 470. : 

. Cohn, E. J., Minot. Fulton, J. F., Ulrichs, H. F., 
Sargant, F. C.. Weare, J. H., and Murphy, W. P.: Jour. 
Biol. Chem., 1927, Ixxiv., 69. 

3. Castle, W. B., and Taylor, F. H. L.: 

4 


tw 


Jour. Amer. Med. 
Amer. Med. 


Assoc., 1931, xevi., 1198. 
. Strauss, M. B., Taylor. and Castle: 
Assoc., 1931, xevii., 313. 

. Gansslen. M.: Klin. Woch., 1930, ix.. 2099. 

. Dakin, He D., and West, R.: Jour. Biol. Chem., 1935, 

cix., 489. ` 
. Bethell, F. H., and Goldbamer, S. M.: Amer. Jour. Med. 
Sci., 1933, clxxxvi., 480. 

. Riddle, M. C.: Arch. Internal Med., 1930, xlvi., 417. 

. Hutter, A. M., Middleton, W. S., and Steenbock, H.: Jour. 
Amer. Med. Assoc., 1933, ci., 1308. 

. Groen, J.: Klinische en Experimenteel onderzoek over 
anemia perniciosa in voorwaardelijke deficientie, 
Scheltema et Holkema's Boekhandel, Amsterdam, 1935. 

Vaughan, J.: Arch. Internal Med., 1931, lxvii., 688. 

. Minot and Castle: THE LANCET, 1935, ii., 319. 

. Minot, Cohn, Murphy. and Lawson, H. A.: Amer. Jour. 

Med. sci., 1928, clxxv., 599. 

. Bethell: New York state Jour. Med., 1935, xxxv.. 1. 

Dakin: Personal communication to one of us (C. C. U.), 
Sept. 15th, 1935. 

Davidson, L. S. P.: Med. Press and Circ., 1933, clxxxvii., 517. 

Strandell, B.: Acta Med. Scand.. 1935, Suppl. Ixxi., 1. 

. Ungley, C. C., and Nattrass, F. J.: To be published. 


Jour. 


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ee pd pd oe 
Sento Gre SS 
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NOTE ON THE ANTI-ANÆMIC 
PRINCIFLE OF LIVER 


By Joux F. WILKINSON, M.D., M.Sc., Ph.D. Manch., 
M.R.C.P. Lond., F.I.C. 


HONORARY PHYSICIAN IN CHARGE AND DIRECTOR OF THE DEPART- 
MENT OF CLINICAL INVESTIGATIONS AND RESEARCH, ROYAL 
INFIRMARY AND UNIVERSITY OF MANCHESTER ; HONORARY 
ILEMATOLOGIST TO HOLT RADIUM INSTITUTE AND CHRISTIE 
CANCER HOSPITAL, MANCHESTER 


Mvuci work has been carried out during the last 
few years in attempts to isolate and elucidate the 
nature of the principle present in liver that 1s respon- 
sible for initiating remissions in patients with 
pernicious anemia. So far the identity of this 
liver principle remains obscure, although many 
concentrated highly purified extracts have been 
prepared. The slow progress has been due partly to 
the fact that every fraction can only be tested clini- 
cally on approved adequately controlled cases of 
pernicious anemia,! and partly to the nature of the 
liver principle itself, which is extremely readily 
destroyed by many solvents and mild reagents—the 
more highly purified fractions being particularly 
sensitive. 

In consequence of this sensitivity it has been 
difliceult to standardise preparative methods of 
fractionation that would guarantee hemopoietically 
active products every time. However, with the 
assistance and coöperation of Dr. F. L. Pyman, 
F.R.S., of the Boots Pure Drug Company Limited, 
Nottingham, I have been able to make considerable 
advances in this connexion. 

A few months ago Dakin and West? described a 
method using Reinecke acid whereby they obtained 
a product of which 80 mg. was capable of producing 
maximal reticulocyte responses in patients with 


THE LANCET] 


pernicious anemia. This was an important addition 
to our knowledge of the properties of the liver 
principle and I therefore attempted to repeat it. 

Several difficulties were encountered resulting in 
the first few experiments yielding inactive products. 
These having been circumvented, however, successful 
products can now be prepared satisfactorily and I 
have been able to confirm Dakin’s claim. 

All the fractions have been examined clinically by 
the method already described \—that is to say, each 
test case of pernicious anzemia was a typical uncom- 
plicated one in relapse without haviny had treat- 
ment: previously to complicate the picture. In 
every case a control period of 7-21 days was noted 
and the reticulocytes remained within normal limits. 
(These data are omitted from the Tables.) In each 


TABLE I 


Reticulocyte Response to Extracts prepared by Dakin and 
West’s Method 


| 


Fraction Total Equiv.|/Day of, Retics. Hb. 
and dose fresh |treat-| (ver R.B.C (per 
Case No. liver. | ment. | cent.). cent.) 
mg. | g. nae 
W.D.8 90 150 1 | 05 990,000 26 
(PA/A/43). 3 0°5 — — 
6 23°8 — — 
7 39°8 960,000 26 
12 6°0 1,630,000 39 
19 2°5 2,110,000 42 
W.D. 8 120 200 1 1'9 1,190,000 40 
(PA/512). 4 7°0 — — 
l 6 39°7 1,610,000 42 
W.D.8 120 200 1 1'8 1,310,000 34 
(PA/628). 5 6'4 — — 
7 12:0 1,410,000 40 
8 30:0 — — 
13 4°0 2,210,000 58 
23 0°7 3,500,000 70 
W.D.9 58 100 1 1°5 1,150,000 28 
(PA/622). 4 5'8 — — 
5 17:2 — — 
7 40°2 1,480,000 42 
9 25:0 — — 
14 6'8 2,160,000 54 
21 2°5 2,510,000 G4 
35 0:5 3,040,000 74 
W.D.9 116 200 1 0:6 1,216,000 35 
(PA/623). 4 3°4 — — 
6 36°2 1,304,000 39 
8 20°2 — — 
11 3°6 1,950,000 52 
W.D.9 87 150 1 1:4 1,380,000 40 
(PA/631). 4 54 — — 
6 24°7 1,020,000 28 
7 31:6 — = 
16 1°9 2,200,000 58. 


R.B.C. =red blood-cells. Hb.=hæmoglobin. 

case reported in this paper no further subsequent 
reticulocyte response was obtained after those tabu- 
lated, which indicates that they were maximal 
responses. Table I. shows results from our experi- 
mental series W.D. 8 and W.D. 9, selected to illustrate 
the repetition of Dakin’s method. It will be seen 
that maximal reticulocyte responses have been 
obtained with doses of 58-120 mg. of these fractions 
when given intramuscularly. Thus my results 
confirm the claims of Dakin and West that Reinecke 
acid can be used further to purify the anti-anemic 
liver principle, but a good deal of active material 
is lost during the various stages of these chemical 
manipulations. 

W hile these experiments were in progress Strandell 8 
reported good haemopoictic responses using specially 
fractionated liver products (details of which have 
not yet been published), and claimed maximal 
responses with doses of only 0:002 g. He kindly 
sent me some of his unpublished results in connexion 
with this, and at the same time an experimental 
quantity of a highly purified liver fraction (N.S.G.L.1) 
similar to those he had been using was obtained by 


DR. J. F. WILKINSON : ANTI-ANZMIC PRINCIPLE OF LIVER 


[FEB. 15, 1936 355 


and made available to me through Mr. Bacharach 
of Glaxo Limited; this also has been examined 
clinically. It will be seen that responses were obtained 
using doses of 4-8 c.cm. when administered intra- 
muscularly ; each cubic centimetre of this solution 
contained 10 mg. of total solid so that the dosages 
used were 40-80 mg. (Table IT.). 


TABLE II 
Response to Strandell’s Extract 


Fraction Total Day of | Retics. Hb. 
an aon treat- (per R.B.C (per 
Case No. *! ment cent.) cent.) 
mg. 

N.S.G.L. 1 80 1 1:0 910,000 27 
(PA/607). 4 5'4 952,000 28 
9 33°0 — — 

11 19:8 1,824,000 46 

. 18 2:2 2,280,000 56 

N.S.G.L. 1 60 1 2:6 1,680,000 44 
(PA/598). 5 3'9 — — 
7 9:3 1,950,000 50 

8 18°8 — — 

14 2°3 2,560,000 62 

N.S.G.L. 1 40 1 3°5 1,750,000 54 
(PA/609). 5 10°1 — — 
7 14:9 — — 

8 7°3 1,910,000 60 

15 1:0 2,670,000 68 

22 1°6 3,360,000 76 

27 0°7 3,800,000 78 


Having successfully repeated the Reinecke acid 
method of fractionation several times, I have now 
introduced it as a step- -in our methods of fractiona- 
tion. This has been done by (1) carrying out the 
Reinecke acid separation first and then subjecting 
the product to further fractionation, and (2) by 
applying the Reinecke acid separation to the pro- 
ducts obtained by our own methods. Again these 
have been carried out on a sufficiently large scale 
by Dr. Pyman so that adequate supplies have been 
available for trial. 

In series W.D.7, shown in Table III., it will be 
seen clearly that the potency of the final product 


TABLE III 


Response to Author's Extract 


Fraction Total Equiv. Day ofi Retics. Hb. 
and dose fresh |treat-| (per R.B.C. (per 
Case No. ” | liver. | ment. | cent.). cent.). 
mg. g. 

W.D.7 36 1332 1 2°8 1,340,000 36 
(PA/512). 4 5°3 — — 
5 28°8 — — 

7 40°0 — — 

11 5'8 2,350,000 52 

18 2'5 2,730,000 57 

W.D.7 27 999 1 0:5 1,320,000 36 
(PA/629). 5 4°0 = — 
7 29°0 1,850,000 48 

9 20°0 — — 

. 14 2°0 2,190,000 58 
W.D.7 18 666 1 1'4 960,000 28 
(PA/JA/51). 3 2:5 — — 
5 120 . — — 

7 32°0 1,500,000 34 

14 5'8 2,150,000 40 


has been greatly increased, since maximal responses 
have been obtained consistently with total doses of 
only 18-36 mg. representing an original amount of 
666-1332 g. of fresh liver. The product thus obtained 
was colourless and was administered in aqueous 
solution. Further fractionation is in progress and 
1 hope at a later date to report fuller details. 


SUMMARY 


The fractionation of liver extracts containing the 
anti-pernicious anzemia principle by means of Reinecke 


356 THE LANCET] 


acid to yield a more highly potent fraction has been 
confirmed. Using this method products have been 
obtained of which 58 mg. produced a maximal reticu- 
locyte response and a rapid remission in a patient 
with pernicious anemia. Applying this method to 
other methods of separation a further increase in 


hemopoietic potency has been secured so that as. 


little as 18 mg. of the product have been sufficient 
to initiate a maximal reticulocyte response and rapid 
remissions in pernicious anæmia. 


This work has in part been supported by a grant from 
the Medical Research Council. 


REFERENCES 


1, Wilkinson, J. F.: Brit. Med. Jour., 1932, i., 325. 
2. Dakin, H. D., and West, R.: Jour. Biol. Cbhem., 1935, 


cix., 489. 
3. Strandell, B.: Norsk. med. tijdskr., 1935, x., 1217. 


THE PROGNOSIS AFTER INFARCT OF 
THE HEART 


A CLINICAL STUDY 


By Joun Cowan, M.D., D.Sc., F.R.F.P.S. 


CONSULTING PHYSICIAN TO THE ROYAL INFIRMARY, GLASGOW 


THE dramatic symptoms which sometimes occur 
when a coronary artery becomes blocked, and the 
not infrequent sudden termination of life, have led 
to a pessimistic outlook in these cases. But patho- 
logical experience has shown that cardiac infarcts 
are not necessarily immediately fatal, and that 
recovery may ensue. In Moritz and Beck’s! series 
of 94 cases in which a main coronary artery had been 
occluded only 14 died after the first block. Accumu- 
lating clinical experience points in the same direction. 
Parkinson and Bedford ? state that if the patient is 
alive when seen after the occurrence of an infarct 
recovery is more likely than death. Reasonable 
health may be maintained subsequently even for 
many years. Cases have been reported where the 
patient lived for seven,® eleven,? thirteen,* fourteen,® 
seventeen,® and twenty ’ years. 


Abrupt closure of a healthy main coronary artery 
causes sudden death, but if the closure is gradual 
anastomotic developments may take place in the 
neighbouring arteries and prevent serious results. 
Clifford Allbutt 8 examined a heart where the orifices 
of the coronary arteries were so utterly obliterated 
that their very site was indefinable, and yet the 
myocardium was normal. Leary and Wearn ® report 
a case in which the orifices were almost completely 
closed and the muscle normal; and another case 
where the right coronary artery was blocked and the 
orifice of the left artery greatly narrowed, yet again 
with normal cardiac muscle. We have examined the 
heart of a man, aged 73, whose right coronary artery 
was occluded for about an inch, immediately after its 
origin, the only result being a small area of ischaemic 
fibrosis, not due to infarct, near the base of the nght 
ventricle. 

As a rule block takes place in a coronary branch 
and not in a main trunk, and the possibilities of 
satisfactory anastomotic developments are greater 
than if a main artery is affected. It seems that 
infarct is rarely due to closure of a single vessel. 
Saphir and his colleagues,!° examining with meticulous 
-care 30 cases of infarct, failed to find a single case 
in which but one artery was affected. Two might 
be completely closed, or one blocked and the neigh- 


i 


DR. J. COWAN : PROGNOSIS AFTER INFARCT OF THE HEART 


i 


[FEB. 15, 1936 


bouring arteries grossly narrowed. 
are necessary to produce an infarct. 

The size of infarcts varies. They may be large or 
small. The gross lesions, affecting large areas of the 
myocardium, were those which first attracted clinical 
attention, but we are now recognising the lesser 
lesions. In the gross lesions the early symptoms are 
severe and persist for some time. In the lesser 
lesions the early symptoms may be severe but of 
short duration, or of comparatively mild type. 
Thoracic pain is not invariably present. Pain may be 
referred to the abdomen or wholly absent. Sudden 
cardiac collapse or an attack of dyspnoea may be 
the only sign of infarct. 


Multiple lesions 


The prognosis in cases of cardiac infarct is difficult 
to assess. Sudden death, without warning, may be 
the sole clinical sign of a coronary block. In the 
major attacks half the patients die at the outset, 
or within the next month. Of those who survive 
some never regain health, and die of progressive 
cardiac failure after a variable period. Others regain 
their health and live, even for many years, in fair 
comfort. There is little available information regard- 
ing the ultimate issue in the last groups, so we have 
examined the clinical records of 66 patients, 58 men 
and 8 women, who had had an infarct of the heart 
and survived for more than six months afterwards. 
This period was chosen as we are concerned with the 
Jate results of infarct, and recovery is rarely definite 
before six months have elapsed. The records are 
necessarily incomplete for 33 of the patients are still 
alive. Forty-four patients have lived for more than 
two years, one of them for ten and another for 
fourteen years. Thirty-eight resumed their work, 
which, however, as one would anticipate from their 
age, was never manual and could usually be regulated 
according to their physical needs, 


Thirty-three patients are still alive, more than six 
months after an infarct. One patient whose infarct 
occurred nine months ago has never regained health. 
He has had several strokes and has uremic symptoms. 


TABLE I 
Showing the present health of those patients who are still 
alive 
Health 
ae o ae after 
an infarc 
° Total 
Good. | Fair. Poor. a. 
Less than one year — — 1 1 
More than one year 3 4 1 8 
b5 two years 3 1 — 4 
99 bree ry 4 3 == se 
3 four ,, 2 1 — 3 
993 five 9° 3 3 2 8 
six be 1 — — 1 


è 1 unknown. 


Eight patients have survived for more than one 
year. One of them has recently had a recurrence of 
cardiac symptoms. Four are in fair health for their 
years, and lead a quiet life without discomfort. 
Three are in good health, two in active work. One 
rides quietly and shoots driven birds. Another is 
paying visits in the U.S.A. Four have lived for 
more than two years. Three are in good health and 
lead their usual life, which in one case is very active. 
The fourth is in fair health, but resents his necessary 
abstention from golf. Eight have survived for more 


a 


THE LANCET] 


than three years. Four, in reasonable health, are 
still at work. ` One has benefited by removal of gall- 
stones. ‘Three are in reasonable health but: have 
retired from business. The other is still alive, but 
as he has left the district his activity is unknown. 
Three patients have survived for four years. Two 
are leading active lives. The third, who is in fair 
health, has retired from business. Eight patients are 
alive five years after an infarct. One has had a 
recurrence of cardiac symptoms recently, and is 
forced to lead a quiet life. Another has never 
recovered his health. He has had a stroke, and a 
foot removed for gangrene; the other foot is now 
affected. Three are in fair health, leading a quiet 
life. Three are active in business, two of them 
playing golf as well as ever, though their standard 
may not be high. One patient is still alive after 
six years and works hard at his business. 

Sixteen of these patients resumed their ordinary 
occupations after an infarct. Twelve are in fair 
health. The health of the remaining four is poor. 


Thirty-three patients have now died. Seven died 
within a year of the first attack. . Five of them never 
regained tolerable health, but two returned to work, 
one dying when shaving, the other in his garage. 
Six patients died in the second year. Three never 
regained tolerable health, but three resumed their 
ordinary avocations. Five patients died in the third 
year. One was never well and died from uremia. 
The other four resumed their usual] habits, two of 
them undertaking arduous work. Three died in the 
fourth year. Two were never really well. The third 
continued at work until the onset of a pulmonary 
tumour. Three died in the fifth year. All resumed 
their work. One died without warning in his sleep, 
one from a stroke, the third from pneumonia. Four 
died in the sixth year. All resumed their work. 
One patient died in the seventh year, having continued 
at work fairly steadily in the interval. He died in 
the bathroom within a few minutes. One died in the 
eighth year, after nearly five years of strenuous work. 
One died in the ninth year. He worked hard for 
many years and played golf. He died in his sleep 
some months after a successful operation for gall- 
stones. One patient lived for ten years after his first 
attack, and for five after the second. A third attack 
proved fatal. One patient recovered from his first 
attack and worked hard for the next five years, 
subsequently taking life easily. He had a slight 
recurrence of cardiac symptoms nine years after the 
first. He died slowly from cerebral softening fourteen 
years after the initial symptoms. 


Twenty-two of these patients resumed their ordinary 
avocations for a time after an infarct. In at least 
ten cases the work was arduous. Several played golf, 
shot, climbed hills, &c., without difficulty. 


Patients who have had a cardiac infarct do not 
always die from cardiac failure. In Parkinson and 
Bedford’s? series 21 of 83 cases, examined post 
mortem, died from other than cardiac causes. In 
this series 24 patients died from cardiac failure, 
14 slowly and 10 suddenly. But 2 patients died 
from strokes; 2 from embolism, of a cerebral and of 
a femoral artery; 2 from tumour; 1 from pneu- 
monia ; 1 from senile decay. The cause of death 
of the other patient could not be ascertained. 


The occurrence of a cardiac infarct may be merely 
a phase of a general disease. One patient had a 
stroke in 1921, a cardiac infarct in 1922, and a 
second, fatal, stroke in 1925. He had no cardiac 


DR. J. COWAN: PROGNOSIS AFTER INFARCT OF THE HEART 


[reB. 15,1936 357 


symptoms save at the time of the infarct. A lady 
complained of intermittent claudication in 1930, had 
a cardiac infarct in 1931, a right hemianopia in 1932, 
and a second, fatal, cardiac infarct in 1933. Another 
patient, who is still alive, has never been well since 
his infarct in 1932. He has had a stroke, and one 
foot had to be amputated on account of senile 
gangrene in 1934. The other foot is now affected. 


In some patients disease in organs other than the 
heart complicates the picture and the outlook. One 
patient suffered from cholecystitis in the spring of 
1930 and from a cardiac infarct in the autumn; in 
1931 from jaundice; in 1932 from cardiac, hepatic, 
and cerebral symptoms, the latter probably due to 
embolism; in 1933 and 1934 from recurrences of his 
hepatic symptoms, which necessitated the removal 
of gall-stones in July, 1934; in January, 1935, from 
convulsions. He is now in better health than for 
many years, and active at business. Gall-stones are 
not uncommon in this group of cardiac disease. 
Operative interference is, as a rule, badly borne, 
but we have seen several patients who were benefited. 
Renal and diabetic symptoms may coincide, and 
occasionally dominate the outlook. One patient, 
who is not included in this series, was adinitted into 
hospital on account of uremic symptoms of some 
months’ duration. He died in coma. Post-mortem 
examination revealed cirrhotic kidneys and a greatly 
enlarged heart, with aneurysm of the anterior wall of 
the left ventricle. Three weeks before his death his 
systolic blood pressure was 160 mm. Hg. There was a 
minimal cedema of his feet on admission, but it soon 
disappeared and did not recur, so the sole evidence 
of cardiac insufficiency lay in the presence of 
symptoms of renal inadequacy. 


In the presence of symptoms of cardiac insufficiency 
the prognosis must be based upon the symptoms as 
they emerge, day by day, as in cases of cardiac 
weakness due to other causes. In cases where 
recovery has ensued after a cardiac infarct the 
prognosis must be based upon all the data that are 
procurable, always remembering that sudden death 
is not uncommon in these patients and may occur 
without warning. An old gentleman, who had had 
a cardiac infarct five years previously from which he 
had made a good recovery, completed his usual day’s 
work, took his dogs for an airing, and went to bed, 
where he was found lying dead in the moring. 
Another patient, whose infarct had occurred eight 
years previously, who had had gall-stones removed 
some months before, was met casually one afternoon. 
He told us that he was very well and resuming his 
work gradually. After dinner he played a game of 
cards and went to bed. He died in his sleep. 


In this series nine patients are alive more than six 
and less than twenty-four months after an infarct. 
Two are active at work and straining at the leash ; 
five are in fair, and two in poor, health. As the issue 
in this group is still uncertain we have omitted them 
from our figures. Prolongation of life for two years 
or more seems to indicate that the original lesion 
has healed, and that danger lies in the underlying 
pathological state rather than in the past infarct ; in 
the possibility of the occurrence of a fresh lesion 
rather than from progressive changes in the ancient 
one. Thirteen patients died within the first two years ; 
44 have lived for more than two years. A com- 
parison of the data in these two groups is shown 
below in the attempt to estimate the favourable and 
the unfavourable factors as regards continuance of life. 


358 THE LANCET] 


Age of the patient.—The younger patients have the 
better outlook. Levine’s experience! agrees. But 
the prognosis is not good in the syphilitic group, with 
aortic incompetence and narrowing of the coronary 
orifices, whose symptoms tend to arise in the fourth 
and fifth decades. The more ample anastomoses of 
the coronary arteries, which normally develop as age 
increases, are evidently unable to cope with the extra 
work which a coronary block imposes upon the 
neighbouring arteries. 

TABLE II 

Data derived from the examination of 57 patients, at a 

variable period, after the occurrence of a cardiac infarct. 


Forty-four patients lived for more than two years after- 
wards ; 13 died within two years. 


Duration Duration 
of life. of life. 
More} Less More; Less 

than |! than 


2 Yrs. 2 yrs. 


mr a mm | | 


Age— Blood pressure— 
40—49 ee ee 3 — Above 150 
50-59 .. ane 16 3 mm. Hg | 24 11 
60—69 ee oe 19 8 below 99 99 20 2 
70-79 .. pare 6 2 eeu roe atrain- 
grams : 50 cases— 
Previous health of No appreciable 
patient was— b li 6 1 
Good .. «| 23 | 6 PODOLA UY 
Poor 21 7 Some ditto . 32 11 
ay ai T, inverted T 12 3 
Anginal attacks Te _ Ss 12 5 
before infarct-—— Ts acs Xs a — 1 
Had occurred.. 14 4 Bundle-branch 
Had not block : Type I.. 5 1 
occurred | 30 9 Heart-block 
Onse (temporary) .. 1 — 
Sudden ive 35 10 Auricular {ibril- 
Gradual sa 9 3 on ee ea 1 E 
: issociation .. — 
Initial attack— Retinal arterics— 
oieta a Sa i Degenerate .. 10 2 
: se Normal .. | 34 | 11 
Heart— Aortic diastolic 
Enlarged Be 24 10 murmur Es — 2 
Not enlarged .. 20 3 Syphilis (?) T 5 2 


Previous health of the patient.—There is little 
difference in the data of the two groups. The result 
evidently depends more upon the extent of the local 
lesion than upon the general health of the patient, 
though any deterioration of the general health must 
react unfavourably upon the process of healing. 

The occurrence of attacks of angina pectoris prior to 
the infarct does not seem to affect the ultimate 


result. Carey Coombs? and White and Bland 8 
agree. One could conceive that the occurrence of 


coronary narrowing in the past would facilitate the 
anastomotic developments required when an artery 
becomes blocked. The continuance of anginous 
attacks, however, predicates that anastomotic develop- 
ments have not been effective. Saphir’s observa- 
tions,?® too, show that infarct is a matter of multiple 
arterial lesions; and any damage to one part of the 
myocardium must necessarily augment the strain 
upon the rest of the cardiac muscle. 


Mode of onset of the illness.—In some cases an infarct 
occurs in a man whose health was apparently perfect. 
In others minor symptoms have preceded the occur- 
rence of the infarct. The results in the two groups 
seem similar. 

Severity of the initial symptoms.—lIf the doctor in 
attendance at the time of the initial attack thought 
that the patient was dying the case has been indexed 
as severe. The results in those patients whose initial 
Symptoms were severe are less favourable than those 
in the second group. The difference probably depends 
upon differences in the extent of the area which is 
affected, or upon the rapidity of the development of 
the cardiac ischaemia. 


DR. J. COWAN: PROGNOSIS AFTER INFARCT OF THE HEART 


(FEB. 15, 1936 


Physical data.—Enlargement of the heart is of evil 
significance, whether due to hypertrophy or to 
dilatation. The former indicates pre-existing strain 
upon the heart; the latter a failure of the surviving 
muscle to compensate the loss of some muscle cells. 
A high blood pressure is unfavourable. It must be 
borne in mind that we are now considering the state 
of affairs some time subsequent to an infarction. In 
the early days a low blood pressure is an unfavourable 
sign as Harrington and Wright?* and Hay ‘ state, 
for it is an indication of myocardial failure. A lessen- 
ing pulse pressure is particularly ominous. But when 
convalescence has been attained the case is different. 
A normal blood pressure suggests that the cardio- 
vascular system is fairly sound, while a high blood 
pressure suggests the opposite conclusion, and in any 
case throws a heavy strain upon a damaged myo- 
cardium. The large number of patients with normal 
retinal arteries corroborates the idea that coronary 
block is most frequently a matter of local arterial 
disease—i.e., atheroma—rather than due to the 
diffuse affection, arterio-sclerosis. It is impossible to 
assess the influence of chronic valvular disease in a 
clinical series as the significance of a systolic murmur 
is often obscure. No case of mitral stenosis is included. 
There were two cases of aortic incompetence. One 
patient was aged 76, and generally degenerate, with 
Cheyne-Stokes breathing, pulmonary infarctions, and 
copious albuminuria. The lesion in the other patient 
was possibly syphilitic. He was aged 63; dissocia- 
tion was present at one time. The first patient died 
seven months after the infarct; the second lived for 
nearly a year and a half. Slectrocardiograms were 
taken in 50 cases in this series and showed various 
abnormalities. The records are too scanty to afford 
useful information as to the relative importance of 
the different defects, but a normal record is evidently 
a favourable sign. Inversion of T in all leads and 
flatness of all T’s are unfavourable. 

The occurrence of an attack of syphilis in the past 
does not necessarily prove that the cause of the 
cardiac infarct is syphilitic. Seven patients in this 
series had probably suffered from syphilis. The 
duration of life in these patients seems to be little 
influenced by this factor. 


The prognosis after the occurrence of a cardiac 
infarct is better: among the younger patients; if 
the initial attack has been moderate in its severity ; 
if the blood pressure is not unduly high ; if the heart 
is not appreciably enlarged; and if the electro- 
cardiogram is normal in character. 


Two other factors are important elements in the 
prognosis: the care that is taken at the time of the 


infarct. and the reaction of the sufferer to his 
disability. 
‘*Cure”’ of an infarct depends upon the develop- 


ment of satisfactory arterial anastomoses around the 
lesion. The possibilities are considerable but their 
development is slow. Strain upon muscle cells so 
long as they are inadequately nourished must be 
avoided. Our best results have been attained by 
keeping our patients at absolute rest for a couple 
of months, permitting a very gradual resumption of 
physical activities during the next two months, and 
then a very gradual return to the ordinary habits of 
life. Success, too, depends largely upon the codpera- 
tion of the patient. The well-balanced individual, of 
good physique and firm muscle, accepts the situation 
and does his best to aid. The irritable podgy fellow, 
flabby of brain and muscle, resents the necessary 
restrictions and cramps the cure. Social and business 


THE LANCET] 


commitments may occasion difficulties, but they can 
be surmounted when the patient realises the nature 
of his illness, and the nature of the cure. All can 
recall unfortunate results of a too early return to 
ordinary activities. 


The occurrence of a cardiac infarct occasions grave 
danger to life, but if the patient survives the onset 
satisfactorily he has a fair chance of reasonable 
health even for many years. 


We must acknowledge, with grateful thanks, the kindly 
help of our colleagues who have supplied us with many of 
the data on which this paper is based. 


REFERENCES 


1. Moritz, A. R., Beck, C. S.: Amer. Heart Jour., 1935, x., ete 

2. Parkinson, J., Bedford, D. E.: THE LANCET, 1928, i 

3. Gibson, A. G.: Ibid., 1925, ii., 1270. 

4. Hay, J.: Proc. Roy. Soc. Med., 1934, xxviii., 1. 

5. Burton, J. A. G., Cowan, J., Kay, J. Hunter, OT 
A. J., Rennie, J. K., and Teacher, J. 
Quart. Jour. Med., 1930, xxiii., 

6. a L. A., Holt, E.: Amer. Heart Jour., 1930, v., 705. 

7. White, P. t Jour. Amer. Med. Assoc., 1933, C., 33. 

8. Allbutt, C.: Diseases of the Arteries, London, 1915, vol.{i., 

9 

0 


Ramage, J. H., 
293. 


D. 21. 
. Leary, T., Wearn, J. T.: Amer. Heart Jour., 1930, , 412. 
. Saphir, Ò., Priest, W. S., Hamburger, W. W., e Katz, 
L. N.: Ibid., 1935, X., 567, 762. 
K dec Coronary Thrombosis, London, 1929, p. 84. 
12. Coombs, C. F.: Bristol Med.-Chir. Jour., 1932, clin. 276. 
13. White, P. D., Bland, E. F.: Amer. Heart Jour.. i931, vii., 1. 
W., and Wright, J. H.: Glasgow Med. 


Jour., 1933, cxix., 1 


SOME OBSERVATIONS ON 
EXPERIMENTAL RENAL SECTION 


By J. Gray, M.Chir. Camb., F.R.C.S. Eng. 


FELLOW IN SURGERY AT THE HENRY LESTER INSTITUTE AND 
HON. SURGEON TO THE LESTER HOSPITAL, SHANGHAI 


THE effect of hemisection of the kidney is still a 
matter of dispute. With increasing accuracy of 
diagnosis the indications for this operation in man 
have become very few, but there may still be occa- 
sional cases in which, despite all investigation, 
uncertainty exists, and such an exploration might 
be desirable. The question arises whether it is 
justifiable, and I felt that it would be of interest 
to study experimentally the effects of the operation 
upon (a) the incised kidney and (b) the remaining 
normal kidney. 

INVESTIGATION 


Twelve bitches were subjected to a preliminary 
cystoscopy in the course of which 5 c.cm. of 0°4 per 
cent. indigo-carmine was injected intravenously and 
the ureteric efflux from each side noted. (This method 
of investigating the renal function was chosen because 
it was found to be the most practicable. It had 
originally been hoped to catheterise the ureters and 
collect specimens from each side, but this proved too 
ditticult to perform with certainty.) After a few days’ 
interval the kidney on one side was divided com- 
pletely from pole to pole until the pelvis was laid 
open. In order to control the hemorrhage, a Crile’s 
clamp was placed on the renal pedicle before the 
incision was made. The two halves were then brought 
together by two or three mattress sutures (catgut 
No. 2) passing through the parenchyma, three being 
usually required. The operation was completed 
with all speed, seldom occupying more than five 
minutes and never more than ten, in order to avoid 
the effects of prolonged anoxemia. (A clamp on 
the pedicle would be used in clinical practice, and it 
was felt that the experimental operation should 
approximate as closely as possible in all details, 


MR. J. GRAY: EXPHRIMENTAL RENAL SECTION 


[FEB. 15, 1936 359 


although otherwise it might have been better to 
avoid it.) After removing the clamp any further 
oozing was controlled by pressure with a hot gauze. 
The renal capsule was sewn up separately, the kidney 
replaced, and the wound closed. This was the opera- 
tion performed on the first 6 dogs. The second 
6 dogs had an identical operation except that the 
halves of the kidney were brought together by the 
use of Lowsley’s ribbon catgut inserted, in the way 
he describes, through the capsule and carried round 
the kidney. By this method the objection that 
strangulation of tissue, including blood-vessels, 
would occur is eliminated, and so this operation 
should be the better one to perform. This investiga- 
tion was undertaken partly, therefore, to compare 
the results of the two methods. 

After the operation the animals were cystoscoped 
as far as possible at monthly intervals, using exactly 
the same technique with regard to anæsthesia and 
dose of dye as on the first occasion. Particular 
attention was paid to the time of appearance and 
concentration of the drug at each ureteric orifice. 

At the end of three months the animals were 
anesthetised with Luminal, laparotomy was per- 
formed, and catheters were passed into the ureters. 
Phenolsulphone-phtbalein (1 ¢.cm.) was given intra- 
venously and specimens collected from both kidneys. 
In practice it was found necessary to give 250 c.cm. 
of saline intravenously to promote diuresis or no 
specimens could be obtained. This, while inter- 
fering with any determination of total renal function, 
would not invalidate a comparison of that of the 
two sides, which was here required. 


RESULTS 


Table I. gives details of the operation and results; 
Table II., and the ensuing text, summarises them. 
It will be seen that 4 dogs died. One of these 
(No. 39) was suffering from other conditions which 
may have been partly responsible for death, but in 
any case the kidney was completely destroyed so 
that from the point of view of this operation it 
represents a failure. One other had complete atrophy, 
so that 7 survived with functioning kidneys. Of 
these 7, 5 had changes of greater or lesser degree 
but did not show progressive impairment or degenera- 
tion during the period of observation. 

Renal Function.—The results obtained may be 
summarised as follows :— 

(a) Injured hidney.—Eight showed marked impairment 
in one or other test. (See Table I., Nos. 15, 17, 20, 30, 
35, 36, 37, and 39.) Three showed slight impairment in 
one or other test (Nos. 16, 19, and 29). 


(b) Sound kidney Eight showed increased function 
(Nos. 15, 16, 19, 20, 29, 30, 37, and 39). 


The most interesting feature was the apparent 
increase of concentration in the indigo-carmine 
excreted by the sound kidney ; although given under 
identical conditions the dye was excreted in a shorter 
time and stronger concentration than before the 
operation. Along with this there was usually evidence 
of impairment in the operated kidney, so the con- 
clusion can hardly be avoided that the sound one 
was doing more work because of the injury to the 
other. 

Pyelography.—It will be seen from Table I. that— 


Six showed marked deformity of the pelvis on the 
operated side (Nos. 15, 16, 17, 20, 29, and 30). 
Two showed slight deformity of the pelvis on the 
operated side (Nos. 19 and 35). 
Four were not investigated. The two cases of hydro- 
nephrosis fall into this latter group. 
G 


360 THE LANCET] 


MR. J. GRAY : EXPERIMENTAL RENAL SECTION [FEB. 15, 1936 


TABLE ].—OPERATIONS AND RESULTS 


Crstoscopy. 
ae of appearance Pyelography. 
tD ; of dye (minutes). ` i Post-mortem and histological 
z Operation. P.S.P. | Result. examination: 
Before After 3 Retro- 
Op Op. Intravenous. grade 
15 | Mar. 9, 1934.) Rt. 6 (1) Rt. Rt. visualised. | No abnor- = Died | Lt. kidney shows area of destruction of 
Lt. side, Lt. (cone. 24. Lt. not mality June 20. tubules particularly in cortex. Prussian 
3 mattress Lt. visualised. detected. blue injected into aorta demonstrates 
sutures. (2) Rt. rt. vessels well filled. Lt. side not well 
(conc.) 2}. filled and avascular areas related to the 
Lt. 5. scarred tissue. 
16 |Mar.15, 1934.} Rt. 3}. Rt. 4}. — Rt. pelvis |Rt. 20 %.| Killed | Rt. kidney deformed (Fig. 1). Section 
Rt. side, Lt. 4}. | Lt. (conc.) abuorma] |Lt. 25 °%.| June 27. shows areas of scarring in cortex and 
3 mattress 4. in medulla with destruction of blood- 
sutures. contour. supply as demonstrated by injection 
of carmine-gelatin. 
17 | Apr. 3, 1934.| Failure. | Failure. Rt. small pelvis Alt.in Rt.20 %.| Killed | Rt. kidney atrophied less than half the 
Rt.,3 not visualised size and |Lt. 30 %.| Sept. 4. size of left. Section shows areas of 
sutures. well suggests shape of destruction of tubules with deficient 
poor function. rt. pelvis blood-supply in these areas as demon- 
Lt. pelvis (Fig. 2). strated by injection of carmine-gelatin 
visualised well. into aorta (Fig. 3). Vessels in It. also 
better filled than in rt. 
18 |Mar. 19,1934.) Rt. 6. — — i — — Died Rt. kidney complete hydronephrotic 
Rt., 3 Lt. not l Mar. 25. shelland full of blood (Fig. 4). Section: 
sutures. seen. hydronephrosis and hemorrhage. 
19 Mar. 27,1934.) Rt. 8. | (1) Rt. 5. | Lt. pelvis ureter | Lt. pelvis — Killed | Lt. kidney much smaller than rt. and 
Lt., 3 Lt. 6. Lt. 7. visualised clearly |shows some Sept. 14. softer in consistency but otherwise 
sutures. (2) (conc.) even better abnor- looks normal. On section tbere is 
Rt. 4. Lt. 7. than right. mality of marked destruction of tubules in the 
(3) (conce.) contour. cortex, scarcely any normal tissue 
Rt. 4. Lt. 7. being left. 
20 | Apr. 9, 1934.| Both 4. (1) Rt. Rt. pelvis well Some Rt. 60 %.| Killed Lt. kidney shows destruction of tubules 
Lt., 3 (conc.) 34. visualised. abnor- ‘Lt. 35°.) Sept. 18. at upper pole. Blood-supply (carmine- 
sutures. Lt. 4. Lt. not seen. mality gelatin) deficient here. Blood-vessels 
(2) Rt. at upper on rt. side well filled ; better than on 
(cone.) 1. calyces. lt. (Fig. 5). 
t. 5. 
29 |Dec. 20,1934.) Both ao pe 12. — Rt. pelvis | Both Killed | Rt. kidney small, scarred, and adherent 
Rt.. 1i. deformed. | 15%. |Mar. 21, to liver section. Destruction of cortex 
Lowsley’s (2) it. ‘pil 1935. and pyelitis. 
technique. Lt. wont: ) 
37 |Jan. 22, 1935.| Both RÈ "30. — — — Died Lumbar sinus present and palpable 
sis 12. Lt. (conc. ) May 6. lump in kidney region. P.M. Rt. 
Lowsley’s 5. pyonephrosis. 
technique. 
30 Dec. 28, 1934.) Poth | Rt. y onc.) — Lt. hydro- — Killed | Lt. kidney small. Section shows areas of 
Lt., 24. 24. nephrosis. Mar. 28, dilatation of tubules as in hydro- 
Lowsley’s Lt. nil. 1935. nephrosis and some areas of fibrosis 
technique. and some pyelitis. 
35 |Jan. 15, 1935.) Both — — No Rt. 5and| Killed. | Rt. kidney half size of lt., scarred and 
Rt., 15. definite | delayed.| Apr. 23. adherent to liver but on section there 
Lowsley’s abnor- Lt. 35 is plenty of normal looking tissue left. 
technique. mality. imme- 
diate. 
36 |Jan. 15, 1935.| Failure. | Failure. — — Rt. 10. | Killed | Lt. kidney small, scarred, and section 
Lt., Lt. nil. | May 2. shows extensive destruction of tubules 
Lowsley’s with deficient blood-supply as demon- 
technique. strated by Berlin blue injection into 
aorta. 
39 Jan. 29, 1935.) Both Rt. nil. — — — Died Rt. kidney almost complete destruction 
Rt., 17. Lt. (conc.) May 9. of cortex with a marked calcium 
Lowsley’s 3. deposit. Pyelitis present. 
technique. 


P.S.P. 


TABLE II.—SUMMARY OF RESULTS 


Technique. Marked 
Ani- | —— Hydro- Com- |diminution Slight 
mal or pyo- plete in size, |changes 
‘| Mattress} Lows- | nephrosis.| atrophy.| obvious only. 
sutures. | ley’s. deformity. 

15 + == = = — + 
16 + => = — + z4 
17 + = = + = = 
18 + — + = om == 
19 + = J= = +- — 
20) + — — — — + 
29 — + — = + = 
3) — -+ = == + za 
35 — + — — + — 
36 — + — — + — 
37 — + + — — — 
39 — + — + — — 

; 6 6 2 2 6 2 


Two had hydronephrosis ; 


2 complete atrophy ; 6 marked dimi- 
nution in size and deformity to the naked eye ; 2 changes slight. 


= phenolsulphone-phthalein. 


As a matter of interest it may be worth recording 
that one other dog developed renal calculi. This 
animal had had a preliminary nephrectomy and 
then, after an interval, hemisection of the remaining 
kidney. At cystoscopy a month later this kidney 
excreted a concentrated dye, but after another 
month the animal suddenly died. Post mortem the 
kidney, though small, looked otherwise normal, 
but on opening it many calculi were found in 
the pelvis. 

Histological Examination.—The general findings 
were arcas of tubular destruction, most conspicuous 
in the cortex. These were probably related to areas 
of deficient blood-supply. In order to investigate 
this point carmine-gelatin was injected into the 
aorta while the animals were still alive, since it 
was felt that this method would not give results 


THE LANCET] 


: 
| 
| 
| 


FIG. 1.—Kidneys of Dog 16 showing partial atrophy of right 


kidney. 


of much significance after the 
circulation had stopped. The 
carmine was blown in under 
constant pressure and then the 
circulation released as quickly 
as possible before the animal 
died. Four rabbits treated in 
the same way (hemisection of 
kidneys) were given injections 
of intravital trypan-blue several 
days prior to the carmine injec- 
tion, and in this way a com- 
bined picture of the tubular 
function and the blood-supply 
was obtained. These sections 
show an intense blue in the 
tubules of the sound. side, 
whereas on the operated side 
there is considerable deficiency 
of blue in the tubules where 
these are damaged, and here 
the carmine shows defective 
blood-supply. These appear- 
ances are interpreted as mean- 
ing that the function of the 
sound kidney has increased to 
counter-balance the damage done 
to the other side. 


FIG. 4 (Dog 18).—Hydronephrosis of right kidney. 


FIG. 


MR. J. GRAY : EXPERIMENTAL RENAL SECTION 


2 


(Dog 17).—Retrograde pyelogram 
showing partial atrophy of right kidney. 


[FEB. 15,1936 361 


FIG. 3 (Dog 17).—Destruction of tubules on right side (B); 
hypertrophy of tubules on left (A). 


SUMMARY AND CONCLUSIONS 


Among 12 dogs on which 
hemisection of a kidney was 
performed there were 4 deaths ; 
and 1 other animal showed 
atrophy of the kidney. Of the 
remaining 7, 2 can be passed 
as normal, while 5 had greater 
or lesser degrees of injury. 
Observation over three months 
suggested that the damage was 
not progressive, although the 
sound kidney was doing extra 
wolk. 

It seems clear from this in- 
vestigation that in assessing the 
anatomical and physiological 
condition of the kidneys too 
much reliance should not be 
placed on the usual tests of 
renal function as carried out 
clinically. Conclusions must be 
based for the most part on the 
naked-eye, and to a less extent 
the microscopic, appearance of 
the kidneys. In considering the 
question whether hemisection is 


eS lenny: 
rd “2 


FIG. 5 (Dog 20)).—Carmine-gelatin injection five months after 
operation. Increased blood-supply in right Kidney (B); 
decreased blood-supply in left. 


362 THE LANCET] 
worth while, it must be remembered that it falls 
into the category of exploratory operations. A 
sine qua non of such an operation is that it shall do 
little harm to the organ explored, and hemisection 
receives no justification from experiments in which 
the kidney was severely: damaged in 4 cases out of 
12 cases, and largely atrophied in another. 

Nor does it seem that Lowsley’s technique is 
noticeably less deleterious in its effects than the 
ordinary operation in which mattress sutures are 
used. 


Iam indebted to Dr. F. T. Ranson for suggesting the 
investigation, to Mr. R. V. Dent for the photographs, and 
to Mr. Henderson for the sections, and to Messrs. Davis 
and Geck Inc. for a supply of ribbon catgut. 


BIBLIOGRAPHY 


Hinman, Morrison, and Lee-Brown: Demonstration of Circu- 
lation, Jour. Amer. Med. Assoc., 1923, Ixxxi., 172. 

Lowsley, O. S.: Some New Developments in Renal Surgery, 
Southern Med. Jour., 1934, xxvii., 139. 


Mimpriss, I. W.: Splitting the Kidney, THE LANCET, 1934, 


ii., 921. 
Woollard, H.: Intravital Staining. 


Recent Advances in 
Anatomy, London, 1927, p. 114. 


Clinical and Laboratory Notes 


PERFORATED GASTRIC ULCER 
RECOVERY IN A MAN AGED 8l 


By T. St. M. Norris, M.B. Camb., 
M.R.C.P. Lond., D.P.H. 


BENIOR ASSISTANT MEDICAL OFFICER, THE ARCHWAY 
HOSPITAL (L.C.C.), LONDON, N. 


RECOVERY after perforated gastric or duodenal 
ulcer appears to be rare in the aged. Schulein ? 
describes two cases in which a man and a woman, 
both aged 76, died after operation. Speck ? records 
one case of a woman aged 69 who survived for eight 
weeks after operation and then died of heart failure ; 
he also gives statistics of eight others all over the 
age of 60, but does not mention their fate. Graves °? 
describing eight cases between the ages of 60 and 70 
had a recovery in three of them; while Gilmour and 
Saint,‘ in a series of sixty-four cases, give the age of 
five as over 60, the oldest male being 67 and the 
oldest female 69; only three of the sixty-four 
failed to recover. Read,’ Brown,® and Scotson’ 
also give statistics of perforation in patients over 
the age of 60, but they do not give information about 
the fate of individual patients. 

The case I describe seems worthy of record in 
view of the patient’s age and his uninterrupted 
recovery. 


On admission to the Archway Hospital the patient 
gave a history of dyspepsia for the past two years, but 
he had been comparatively well until the morning of his 
admission to hospital, when he had suddenly collapsed 
with severe abdominal pain while engaged in sweeping 
out his room; he had not vomited. He was an elderly 
man with severe artorio-sclerosis. The pulse-rate was 116 
and the temperature 99:2° F.: although obviously in 
considerable pain he was not severely collapsed and 
was able to give a clear account of himself. The abdomen 
moved very little with respiration ; it was rigid throughout, 
and there was no liver dullness. 

The operation under general anesthesia was begun 
nine hours after perforation. The peritoneal cavity was 
found to contain gas and free fluid, and there was a 
perforation in the anterior surface of the stomach near 
the pylorus. This was closed with interrupted stitches 
and reinforced with a piece of adjacent omentum. The 


CLINICAL AND LABORATORY NOTES 


(res. 15, 1936 


pouch of Douglas was drained by a tube through a supra- 
pubic stab wound. The patient’s convalescence was 
uneventful and the wound healed by first intention. 
On discharge home 25 days after operation the scar 
was sound and the patient walked well. When seen 
again six months later he stated that he had rapidly 
gained strength; he now looked after himself and 
frequently walked 3-5 miles daily ; he had no dyspepsia 
or inconvenience and eats a light mixed diet. 

The radiologist’s report on a barium meal reads: ‘‘ The 
stomach showed normal appearance except for some 
irregularity on its lesser curve near the pylorus. The 
latter functioned well, and on pressure the duodenal cap 
could be well filled ; no ulcer crater could be demonstrated 
either in the stomach or the duodenum.” 


A reference to the records of Somerset House 
confirms the age of the patient as 81. 


My thanks are due to Dr. C. D. Agassiz, medical superin- 
tendent of the hospital, for permission to publish this case, 
and to Dr. F. G. Nicholas for his report on the barium meal. 


REFERENCES 


. Schulein, M.: Deut. Zeits. f. Chir., 1921, clxi., 242. 

. Speck, W.: Beitr. z. klin. Chir., 1923, exxix., 537. 

. Graves, A. M.: Ann. of Surg., 1933, xeviii., 197. 

. Gilmour, J., and Saint, J. H.: Brit. Jour. Surg., 1932—33, 


xx., 78. 
. Read, J. C.: New York State Jour. Med., 1930, xxx., 591. 
. Brown, H. P.: Ann. of Surg., 1929, Ixxxix., 209. 
. Scotson, F. H.: Brit. Med. Jour., 1933, ii., 680. 


IOS) euU 


POLYSEROSITIS 


By O. K. G. GUYER, M.D. Edin. 
AND 


F. B. Smita, M.D. Camb. 


PATHOLOGIST TO THE ROYAL INFIRMARY, PRESTON 


THE subject of polyserositis is complicated by the 
confusion and complexity of nomenclature ; several 
conditions clinically similar are included under the 
same title. The term seems most suitable to describe 
a chronic hyperplastic serositis of the pleural, peri- 
toneal, and, sometimes, pericardial cavities. Some 
of the synonyms are multiple serositis, Concato’s 
disease, Pick’s disease (pericarditic pseudocirrhosis 
of the liver), diffuse chronic hyperplastic peri- 


hepatitis, chronic hyaline perihepatitis, chronic 
proliferative peritonitis, and Zuckergussleber of 
Curschmann. 


Adherent pericarditis of known etiology may end 
with heart failure, chronic venous congestion of the 
liver, oedema of the lungs, pleural effusion, and 
ascites, and yet be known by any of the above 
names, particularly Pick’s disease. It does not, 
however, show the widespread, uniform picture of 
serous hyperplasia and polyserositis described below, 
though it is not unustal to find sugar-icing of the 
liver, peritoneum, and pleura in a minor degree. 
Chronie nephritis, particularly if associated with 
arterio-sclerosis or alcoholism, may cause or be 
associated with Zucker-gussleber, and pearly spots 
on the pericardium ; but the fibrosis never approxi- 
mates to that met with in polyserositis. 

Polyserositis appears to be distinct from “‘ adherent 
pericarditis ” of rheumatic, tuberculous, or pyogenic 
origin. Its association with chronic nephritis or 
alcoholism may be fortuitous or causative, the 
xtiology of both being unknown. 
described this association was absent. 

Polyserositis is an essentially chronic disorder 
of the middle and later periods of life, whereas peri- 
carditis is usually seen in young people. The 
symptoms are insidious—namely: (1) Abdominal 


In the case 


LANCET] 


pain, due to involvement of peritoneum. (2) Recurrent 
effusions into serous cavities, requiring more frequent 
tapping than those of simple cirrhosis of the liver 
or less virulent forms of pleurisy. (3) Obstruction 
of the great veins of the trunk with oedema of the 
limbs. Despite these symptoms the patient’s condi- 
tion may remain good for as long as five or ten years. 
(4) There is also apparent glandular enlargement in 
axille and groins, due to embedding of lymphatic 
nodes in active fibrosis of connective tissue. 

Radiography may help in deciding that the heart 
is fixed, the normal movement being replaced by 
an up-and-down motion; the cardiac enlargement 
distinctive of pericarditis may be absent in poly- 
serositis. The electrocardiogram may show fixation 
of axis, due to partial or complete immobilisation of 
the heart. 

The fluid obtained from the pleural cavities is 
usually clear, yellow, cell-free, and sterile, and 
contains 3 per cent. of albumin; the ascitic fluid 
has occasionally been described as chylous. 

The fibrosis may be greater on the right side of the 
body, possibly because there are more lymphatic 
channels through the right cupola of the diaphragm 
than through the left. Death results from slow 
constriction of lungs, heart, and great vessels. 


CASE-HISTORY 


In 1929 a man, aged 38, sustained an “injury ” to the 
sacro-iliac region while at work. There wereno radiographic 
signs, but he was thenceforward unable to work and was 
given weekly compensation. In November, 1933, he was in 
hospital with pain in back; “loss of use ” and swelling 
of legs; cough, six months; sense of constriction in 
throat. He discharged himself after three days, but in 
December, 1933, was admitted to another hospital. 

Complaint: pain right chest and pit of stomach, 
especially after food ; dyspnoea ; swelling of legs ; cough. 

Physical state: cyanosis ; 
solid middle and lower lobes right lung; right clear 
pleural effusion ; fixed, firm glands in axille and femoral 
triangles ; much frothy sputum ; heart displaced to left ; 
pulse-rate 120; afebrile ; ascites absent; 
Wassermann reaction negative; no anemia; 13,600 total 
leucocytes per c.mm., 11,600 (84 per cent.) being neutro- 
phils ; X ray ? neoplasm right lung. 

Diagnosis: neoplasm right lung. 

After discharge the right pleura was tapped every two 
or three weeks. Accidental pneumothorax occurred once 
and appeared to give relief and postpone the next tapping. 


ot ee ee 
~ BAS Ey. 
‘2! z, ` I DIA Ne 


1, ET p 


aT 
w Tr 
-T 


oa ae 


` F. x d d 


oly 


ei BAC Ayi 
vE 


A 


oe 


Taek 


FIG. 1.—Fibrosis encroaching on inguinal gland. Very 
cellular, vascular, and of active growth. (x 100.) 
FIG 2.—Pleura. Features similar to Fig. 1. (x 100.) 


CLINICAL AND LABORATORY NOTES 


distended chest veins; 


tender liver; . 


[FEB. 15, 1936 563 


— +. oo - —- — -- 


ç] Tee E 
D iin a 


FIG. 3.—Subpleural fatty connective tissue ; vascularised and 
permeated by lymphoid and plasma cells. (x 200.) 


FIG. 4.—Hepatic peritoneum. Portion of acute inflammatory 
focus ; polynuclear leucocytes numerous. (xX 200.) 


There was increase of hepatic pain and tenderness, with 
cedema of adjacent anterior abdominal wall; more 
frequent acute epigastric pain and vomiting, only relieved 
by morphia, and slight ascites. In October, 1934, he was 
readmitted to hospital. There was loss of weight; 
tense abdomen, with slight ascites ; slight pleural effusion 
and pneumothorax; 70.per cent. hæmoglobin, 9200 
neutrophils per c.mm.; liver enlarged downwards and 
tender ; signs of cardiac hypertrophy and dilatation absent. 
An inguinal gland was excised for examination. The 
patient discharged himself after one week, and in 
November, 1934, at the age of 43, he died by sudden 
failure of right side of heart. 


NECROPSY 


General.—Pale; moderate wasting; upper abdomen 
prominent and tense; chest assymetrical, left side more 
prominent. anteriorly than right; varicose distension 
of superficial veins of neck and upper half of chest ; diffuse 
swellings, apparently glandular, in both groins and both 
axille. 

Thorax.—Back of sternum only detached from peri- 
cardium and mediastinum by cutting dense, white, rather 
elastic tissue, which spreads laterally over anterior borders 
and surfaces of both lungs. Large, slightly hemorrhagic 
pleural effusions (bilateral). Left lung compressed by 
pleural effusion; substance cedematous and congested ; 
lung free except on medial aspect, where the pleura fuses 
with general mediastinal mass of dense, white tissue ; 
lateral and posterior left pleura normal. Right pleural 
sac partly obliterated by loculi of yellow, gelatinous 
exudate; right lung much collapsed, encased in dense 
coat of “‘ sugar ice,” with pitted surface, and 2 to 7mm. 
thick; upper lobe removed by incision through large 
areas of fusion of visceral and parietal pleura; right 
parietal pleura, where free, is 5 to 8mm. thick; this 
sclerosis penetrates upper intercostal spaces on both 
sides, infiltrates the axillary spaces and embeds groups of 
lymphatic glands of normal appearance; sclerosis lacks 
defined limits and resembles mediastinal tissue. Anterior 
part of pericardium thick and adherent to back of sternum 
and anterior surface of heart. Heart distorted by antero- 
posterior compression, showing atrophy of muscle and 
marked dilatation of right side. 

Abdomen.—White, dense sclerosis covers both surfaces 
of both sides of the diaphragm, upper surface of liver, left 
perirenal tissue, and whole of prevertebral tissue, so that 
a solid mass embeds aorta, inferior vena cava, duodenum, 
and pelvic portions of ileum and colon. In front of the 
spine this mass is 20 to 30mm. thick. Lower border of 
liver is at level of umbilicus; left lobe adherent to anterior 


364 THE LANCET] 


abdominal wall; liver weighs 1-9 kg. (plus 20 per cent.). 
Spleen adherent to stomach and diaphragm. Sclerosis 
involves both iliac sets of main vessels, penetrates to the 
femoral triangles where lymphatic glands are embedded, 
asin axille. Lateral peritoneum of the pelvis is very thick, 
burying the nerve-roots to the lower limbs. Skull and 
spinal column, central nervous system, and remaining 
viscera normal. 

Microscopical.—Rather than hyaline lamination, the 
features of the fibrosis are cellularity, vascularity, and 
active growth, suggesting active infection, though micro- 
organisms could not be demonstrated in sections. The 
penetration of the fibrosis to the axillary and inguinal 
spaces appears unrecorded in the literature. 


Polyserositis should be considered, therefore, in 
the presence of any or all of the following symptoms : 
mediastinal or abdominal venous obstruction, 
recurrent effusion into serous cavities, adherent 
pericardium, and enlargement of the liver—even if 
these are associated with apparent glandular enlarge- 
ment. In the case described the pericardial lesion 
was an embedding of the heart and great vessels 
rather than adhesion between the parietal and 
visceral pericardium. Thus it follows that poly- 
serositis should be considered as an 
diagnosis to mediastinal neoplasm, Hodgkin’s disease, 
adherent pericarditis, and cirrhosis of the liver. 


We wish to thank Dr. A. E. Rayner for his permission 
to record this case which was under his charge, and 
Mr. H. C. Taylor for the photomicrographs. 


BIBLIOGRAPHY 


Becke, C. ant Cushing, E. H.: Jour. Amer. Med. Assoc., 1934, 
cii., 1543. 

Becke and Moore, R. L.: Arch. of Surg., 1926, xi., 550. 

Boyd, W.: Pathology of Internal Diseases, London, 1931. 

Edelston, B.: Brit. Med. Jour.. 1928, ii., 570. 

Kelly, A. 0. J.: Amer. Jour. Med. Sci., 1903, exxv., 116. 

Rolleston, H., and McNee, J. W.: Diseases of the Liver, Gall- 
bladder. and Bile-ducts, Edinburgh, 1912. 

Rothstein, Jacob L.: Arch. of Pediat., 1934. li., 219 and 288. 

Tidy, H. Letheby : Synopsis of Medicine, London, 1930. 

White, P. D.: Heart Disease, London, 1931, p. 516. 


HISTAMINE IONISATION 
IN RHEUMATISM AND ALLIED CONDITIONS 
ANALYSIS OF ONE HUNDRED CASES 


By F. SEVERNE MACKENNA, M.B. Dub. 


HON. PHYSICIAN TO THE ROYAL BRINE BATHS CLJNIC AND 
PHYSICIAN TO THE HIGHFIELD HOSPITAL FOR 
RHEUMATISM, DROITWICH 


ALTHOUGH the series of consecutive cases reviewed 
here is somewhat short, an analysis of the results 
may be of value in showing how histamine can 
be used in the routine treatment of rheumatism. 
The total number of applications was 2496—an 
average of 25 per patient—and it was usually found 
that at least 12 were required for any permanent 
improvement. Apart from an insignificant number 
who were found to be constitutionally unsuited for 
balneological treatment, all the patients received 
concurrently some form of brine bath, and often 
massage in addition. 

The method of treatment employed is essentially 
the same as that already described,! with the notable 
addition of a preliminary preparation of the area 
with multiple punctures and scratches produced by 
a special scarifier. This procedure is based on that 
recommended by Vas,? and is now finally considered 
beneficial. In most cases the histamine was given 
daily and it is considered important that baths or 


1 Mackenna, F. S.: TUR LANCET, 1934, i., 1228. 
? Vas, 5.: Deut. med. Woch., 1932, Iviii., 1009. 


CLINICAL AND LABORATORY NOTES 


alternative- 


[FEB. 15, 1936 


other additional treatment should follow and not 
precede its administration. 

In the accompanying Table the various groups 
have not been subdivided and the nomenclature is 
based on the recommendations, of the Arthritis 
Committee. 

Clinical Analysis 


t 


Traumatic arthritis .. 


w a! 3 5 ; 
a| S 29| $| al ¢ 
2 3 gol 2 | OzZ| i 
= | fa} S178) 

9 =| 
A| 2 Sg E © | > 
Fibrositis oa bite 18 | 29 11 | — 2 
Neuritis A 2 6 4 2| — | — 
Osteo-arthritis ae 9 4 9 4 | — 
Rheumatic arthritis .. 1 2 1 2! — 
Villous arthritis 3 | 20 8| — 1 
Spondylitis : — 2| — | — 


In this Table only the disabled parts that received 
treatment are considered : where there was a mixed 
condition the remaining disabilities are ignored. 


NON-ARTICULAR CONDITIONS 


Fibrositis—The majority in this group had lumbar 
and shoulder-girdle fibrositis. Of the 47 cases, 
7 were passed as clinically cured; all except one 
showed very great or great improvement, and in 
most of them it was believed that sufficient treatment 
would have completely removed the disability. The 
greater number had massage in addition to baths. 
The two cases which are reported as worse were 
complicated by an erratic ‘“‘ psyche” which pre- 
cluded the possibility of relief from any ailment, and 
treatment, was not persevered with. 

Neuritis—In this group are included cases of root 
and trunk sciatica, and brachial neuralgia. Of the 


10 patients treated, 7 were discharged and have 


remained free from pain. Improvement was unsteady 
in all and there were occasional recrudescences, each 
less severe than the one before. One fell short of 
complete recovery because the patient persisted in 
taking forbidden exercise. 


CIIRONIC JOINT CHANGES 


Osteo-arthritis —Of the 13 cases, 9 showed improve- 
ment; 6 of these were of the hip, 2 of the knee, 
and 1 of the shoulder-joint. There was a steady 
lessening of pain and usually an increase of move- 
ment after the first application. Of 4 patients that 
returned only 1 had become worse in the interval 
(seven months). In 4 the improvement lasted only 
a few hours. 

Rheumatoid Arthritis.—Only 3 patients were treated, 
and of these 1 alone showed definite improvement. 

Villous Arthritis.—The knee was affected in each 
of the 23 cases, and there was almost always a 
very gratifying result, with loss of pain and greatly 
increased movement. Massage was given in every 
ease. In this group again 1 patient failed to respond 
or persevere. 

Spondylitis.—The 2 cases treated were both of the 
osteo-arthritic type, the patients being men of 35 
and 38. There was much improvement in posture, 
with a great lessening of pain, and this progress had 
continued in one of the patients who returned after 
34 months for a second course. Plaster shells were 
fitted for night use, and baths and massage were 
also given. 


TRAUMATIC CONDITIONS 


Both the patients in this group had “ badminton 
elbow ” and recovered rapidly and uneventfully with 


THE LANCET] 


CLINICAL AND LABORATORY NOTES 


[FEB. 15, 1936 365 


five and seven administrations each. No other forms 
of treatment were used. 


COMPLICATIONS AND INTERCURRENT DISEASE 


Collapse.—There were three cases in which hista- 
mine treatment caused collapse. . 

Case 1.—Female, aged 49. Fibrositis. Menopause 
at present; extremely neurotic. This patient did 
moderately well until the seventh treatment, but suddenly 
collapsed about a minute after beginning the eighth ; 
the pulse disappeared at the wrist and there was slight 
vomiting. She gradually recovered after some hours, but 
had hysterical prostration afterwards. No remedy beyond 


the ordinary was employed. 

Case 2.—Female, aged 68. Sciatica and fibrositis. 
She was very neurotic and began to show signs of collapse 
after the third treatment, on the appearance of the facial 
flush. Ephedrine (lc.cm.) was injected, with rapid 
improvement and complete recovery in about eight 
minutes. Subsequently five more treatments were success- 
fully given and there was considerable improvement, but 
the patient became more “nervy,” refused all treatment, 
and departed. 

CasE 3.—Female, aged 73. Fibrositis and brachial 
neuralgia. This woman was very sensible and vigorous, 
and a first course of 42 treatments resulted in complete 
cure of the neuralgia and an improvement in the old- 
standing lumbar and gluteal fibrositis. A second course 
was started five months later but at the third treatment 
there was a dramatic and severe collapse. Rapid relief 
was obtained from ephedrine, and the patient afterwards 
declared that she felt better than for many years and that 
all the backache had gone. Further treatment was given 
to the lumbar region and there has been no return of pain 
after eight months. 


With the exception of hysteria, which was con- 
spicuously absent in the third patient, there was 
nothing remarkable about any of these cases, nor 
was the collapse due to an overdose in the usual 
sense. The onset of symptoms was sudden and not 
preceded by any visible signs, nor did the patient 
notice anything unusual. The most careful inquiry 
subsequently into diet, &c., failed to produce a 
solution. The collapse presumably bears some 
relation to the (so far unexplained) variation in 
histamine tolerance shown by each patient from 
day to day. Ephedrine appears to be an efficient 
antidote. 

Intercurrent Diseases.—In 5 cases the systolic 
pressure was over 200 mm. Hg, and showed not only 
the customary post-histaminal fall of several milli- 
metres noted by Bisset and Woodmansey,? and 
Shanson and Eastwood,‘ but also a definite downward 
tendency throughout the course. This was, however, 
never greater than a total of 15mm. Two cases of 
chronic asthma and bronchitis were included and 
appeared to be unaffected either temporarily or 
permanently by the drug; in other respects they 
progressed normally. Gross valvular and myocardial 
lesions were rejected, but those with less advanced 
disease that were suitable for bath treatment were 
accepted and took the histamine successfully. 


CONCLUSIONS 


It is to be regretted, for the purposes of this 
analysis, that other forms of treatment could not be 
excluded, but it is noteworthy that many patients 
who have taken a course of baths for several years 
are emphatic in their statements that histamine has 
greatly increased the benefit received ; undoubtedly 
it also increases the rate of recovery. It may be said 
to fail in cases of the rheumatoid type, where the 


joints are swollen and ‘“‘doughy”’ and the skin 
3 AT A. A., and Woodmansey, A.: THE LANCET, 1933, 
ii., 10 18. 
Shanson, B., and Eastwood, C. G.: Ibid., 1934,i., 1226. 


clammy, but in all others, and particularly in 
villous arthritis, fibrositis, and neuritis, its value is 
unquestionable. | 


NON-TRAUMATIC SURGICAL 
EMPHYSEMA 
IN ASSOCIATION WITH ACTIVE PHTHISIS 


By Davip N. Dossi, M.B. Edin. 


RESIDENT MEDICAL OFFICER, BIRKENHEAD MUNICIPAL 
HOSPITAL 


SURGICAL emphysema occurring in a phthisical 
patient is usually superficial and due to faulty 
artificial pneumothorax technique. Interstitial 
emphysema, though it is not a very uncommon 
complication of broncho-pneumonia and whooping- 
cough, is rarely met with in pulmonary tuberculosis, 
presumably because of the fibrotic changes taking 
place in advance of the active lesion. When it 
does occur it generally follows an unusually severe 
bout of coughing which ruptures an alveolus and 
allows air to escape into the interstitial tissue of the 
lung, and so, by way of the hilum, to the mediastinum. 
From here the air passes to the subcutaneous tissue 
of the neck, face, and chest, thus establishing a 
“ surgical °” emphysema. This condition is believed 
to be rare enough to warrant the publication of 
the following case. 

A man, aged 26, was admitted to Birkenhead Municipal 
Hospital on Nov. 12th, 1935, having a history of chest 
trouble of at least six years’ standing. He was extremely 
emaciated and complained of asthenia and cough; the 
temperature was remittent, and sweating was profuse. 
Clinical examination revealed scattered patches of con- 
solidation in both lungs, with fairly extensive cavitation 
at the right apex. Tubercle bacilli were present in the 
sputum. 

No improvement took place during the next five weeks ; 
emaciation became more obvious, and the cough assumed 
a paroxysmal character. On Dec. 19th, at 10.30 A.M., 
the patient complained of slight dysphagia and a bilateral 
swelling of the neck was noticed. By midday the neck 
had become increasingly swollen and crepitus was elicited 
on pressure. The superficial tissues of the chest wall and 
lower jaw became involved, and on the following day 
the face, particularly on the left side, was greatly swollen 
and disfigured, with massive involvement of the tissue 
of the lower eyelids. The patient was very dyspneic and 
becoming cyanosed. Sweating was profuse. On Dec. 21st 
the surgical emphysema had spread to the anterior abdo- 
minal wall and flanks, and was encroaching on the lower 
limbs. Breathing now became exceedingly embarrassed 
and death took place at 8.20 r.m., 58 hours after the onset 
of the acute symptoms. 

On post-mortem examination both lungs were found 
to be studded with tuberculous foci with considerable 
cavity formation. No collapse was present on either 
side, The mediastinal tissues were ballooned up with 
air, and this could be traced to the subcutaneous tissues 
behind the clavicles. 


There was no history in this case of artificially 
induced pneumothorax, nor did the post-mortem 
examination reveal any evidence of spontaneous 
pneumothorax. 

I wish to thank Dr. R. A. Grant, medical superintendent, 
for permission to publish these notes. 


RoyaL MASONIC HOSPITAL, LONDON.—The figures 
for this hospital for the last half of 1935 show an excess 
of expenditure over income of £7141, against £9425 in 
1934, although the patients resident on daily average have 
been 125 against 113. Lord Marshall, in submitting the 
treasurer’s report at the annual general meeting on 
Jan. 29th, stated that when the nurses’ home was complete 
and ready for occupation the average costs would be 
further reduced and the position considerably improved. 


366 THE LANCET] 


[FEB. 15, 1936 


MEDICAL SOCIETIES 


' 


ROYAL SOCIETY OF MEDICINE 


SECTION OF SURGERY 


AT a meeting of this section on Feb. Sth, with 
Mr. SAMPSON HANDLEY, the president, in the chair, 
a discussion on 


Sterilised Surgical Catgut 


was opened by Sir WELDON DALRYMPLE-CHAMPNEYS. 
He said that the occurrence recently in rather rapid 
succession of a number of cases of post-operative 
tetanus, either certainly or probably due to the use 
of what might be termed ‘“‘home-cured’”’ catgut, 
made it important to emphasise the dangers of 
inelliciently sterilised material; though control 
under the Therapeutic Substances Act had raised 
the general standard of sterility of surgical catgut 
on sale in this’ country. The raw material from 
which catgut was prepared was the small intestine 
of the lamb, and was heavily infected with micro- 
organisms of many kinds, including pathogenic 
spore-bearing anaerobes. On reaching the manu- 
facturer the raw material was either thawed out 
(if frozen) or washed free from salt (if this had been 
used as a preservative) or, if dried, soaked in dilute 
alkali to make it soft and pliable. Even if not 
dried it usually received this soaking. The gut was 
next split into ribbons longitudinally and then 
scraped to remove the inner and outer layers, leaving 
only the submucosa. The ribbons were measured 
and spun, two or more ribbons being twisted together 
to form a string. The gauge of the finished gut 
depended on the number of ribbons spun together. 
Sometimes the ribbons were partially sterilised 
before spinning by soaking in disinfectant solution. 
The strings were dried under tension and polished 
with pumice or emery, and then graded by measuring 
their calibre with a gauge. It was important that 
the gauge of any individual] string should vary only 
very slightly at different points in its length. If 
hard slowly absorbed gut was required the strings 
at this stage were immersed in a chrome bath. Gut 
partially sterilised before spinning was often sold as 
‘internally sterile ” or “ partially sterilised ’’ catgut 
and, as it was not calléd ‘‘ sterilised surgical catgut,” 
did not come under the control of the Therapeutic 
Substances Act. Purchasers of such catgut were 
apt to assume that the product required less sterilisa- 
tion than raw catgut, and some of the wound infections 
following the employment of catgut sterilised by 
hospitals for their own use were, he believed, attribut- 
able to this erroneous assumption. 

Heat was the most reliable sterilising agent, provided 
the physical properties of the gut could be preserved 
unimpaired. The heating of catgut rapidly in air to 
a temperature sufficient to destroy anaerobic spores, 
if it did not actually burn it, rendered the gut as 
hard as wire and extremely brittle. Methods had 
been devised for overcoming this difficulty, and some 
had proved completely successful, but there was a 
temptation to reduce the temperature or time of 
heating below the safety point if the tensile strength 
of the gut was found to be unsatisfactory. Iodine 
had been used for sterilisation of catgut because of 
its penetrating power. Owing to its colour, the 
degree of penetration of iodine could be verified by 
examining a cross-section of the gut. Excess of 
iodine must be removed at the end of the process 
because prolonged action rotted the gut, reducing 


its tensile strength. The value of mercurial salts 
for sterilisation of catgut had been overrated ; they 
were bacteriostatic only, though they had some 
disinfectant action on the exterior of the gut. 
Hydrogen peroxide was an efficient sterilising agent, 
but as it caused spun gut to swell it was never used 
alone, but employed for treating the wet gut as a 
preliminary to the action of iodine. Essential oils 
had a negligible action on spore-bearing bacteria, 
and it was difficult to account for their popularity 
among hospitals sterilising their own gut. 

After sterilisation, the gut was introduced into 
containers, together with a filling solution. The 
principal types of container were sealed glass tubes ; 
glass tubes closed with a rubber cork and metal 
screw cap; similar tubes containing several reels 
of gut, the ends of which were drawn out through 
side tubes, closed in the manner described; waxed 
cardboard cartons ; and finally multiple sealed paper 
envelopes each containing a single coil of dry gut. 
Any packing which allowed repeated extractions of 
portions of gut from the same container must be 
regarded as highly unsatisfactory. Filling solutions 
should only be regarded as useful for killing organisms 
on the outside of the gut which had got there during 
packing. Tubes were sealed in the ordinary way in 
the flame of a blowpipe. 

Catgut might become recontaminated : 


(1) By handling before it was put into the container. 
Sterilisation inside the container was therefore desirable. 

(2) By air-borne organisms, from dust or the breath of 
operatives, entering the container before sealing. This 
source of contamination might be avoided by the use 
of metal boxes with sliding lids to hold the containers. 
rubber gloves, face masks, and a glass shield over the 
sealing table. | 

(3) By the use of unsterile containers. 

(4) By the use of unsterile stoppers in the interval 
between filling and sealing. 

(5) By the use of unsterile filling solutions. Even 
solutions containing so-called antiseptics might provide 
such a source of contamination if they were incapable of 
killing the spores of anaerobes. 


The examination of a reasonable length of any 
batch of catgut by sterility tests could not ensure 
that the whole of the batch was sterile. A licensee 
under the Act was required to carry out sterility 
tests on not less than 1 per cent. of the material 
constituting a batch. ‘The control tests carried out 
by the licensing authority were identical with those 
which the licensee was required to perform as a 
routine. | 

In February, 1933, Dr. R. O. Clock, of New York, 
had published the results of bacteriological examina- 
tions of gut sterilised by different methods. He had 
concluded that “‘ heat sterilisation properly controlled 
was the only safe and positive method for sterilising 
surgical catgut sutures.” In afurther paper published 
in December, 1934, he had given results of the exami- 
nation of 1204 sutures emanating from Great Britain, 
France, Germany, Japan, and Spain, and had found 
that 4 of the 8 British brands, 1 of the 4 French brands, 
5 of the 6 German brands, 2 of the 4 Spanish brands, 
and both of the 2 Japanese brands were non-sterile. 
His tests, however, were tests of absolute sterility 
and could hardly be regarded as practical for every- 
day control. Prof. T. J. Mackie, of Edinburgh, 
had found that ethyl alcohol, oil of cloves, oil of 
eucalyptus, phenol, and lysol had httle action on bac- 
terial spores. Formalin was more effective but 


THE LANCET] 


acriflavine and crystal-violet brilliant-green mixture 
were ineffective, and biniodide of mercury failed to 
kill spores after they had been exposed for 82 days 
to a 1: 1000 alcoholic solution. He had confirmed 
Bulloch’s unfavourable report on perchloride of 
mercury. Silver nitrate had proved lethal to spores, 
and so had boric acid, but both tended to damage 
the physical properties of the gut; the same applied 
to iodine trichloride. He had found iodine water 
to be effective, again confirming Bulloch’s earlier 
findings. A combined hydrogen peroxide and iodine 
water method gave a sterile gut with good physical 
properties. Little was known about the factors 
which governed the fate of catgut in the living body, 
but Dr. V. D. Allison’s recent work had shown 
extreme variation in resistance to tryptic digestion 
in vitro of commercial catgut. Mackie had reached 
the following conclusions in regard to the presence 
of Bacillus tetani in catgut: (1) the presence of the 
bacillus in the raw material was irregular and vari- 
able; (2) only certain batches of any commercially 
sterilised catgut might be contaminated; (3) bac- 
tericidal processes, even if not entirely effective, 
might destroy the majority of the spores; (4) sur- 
vivors might be scanty and irregular in distribution ; 
(5) the thickness and amount of catgut left in the 
tissues might determine the multiplication of the 
bacillus ; (6) other factors might be involved, includ- 
ing perhaps factors affecting the power of spores to 
germinate in the tissues. 


Certain cases of post-operative tetanus had lately 
come to the notice of the Ministry, one group from 
a hospital in the north and another group from 
a hospital in the south. In the northern group, 
two cases had followed operations for inguinal hernia, 
and the patients had recovered ; the third, following 
nephrectomy, had proved fatal. The catgut used 
was bought raw and sterilised at the hospital by 
boiling in xylol for half an hour and then storing in 
spirit. Samples of gut similar to that used at the 
operations were examined and found to be heavily 
infected with aerobes and spore-bearing anaerobes, 
but B. tetani was not demonstrated. Some of the 
dry catgut before sterilisation, however, was found 
to contain the bacillus. Four cases occurred in the 
southern group, of which two ended in recovery and 
two were fatal. Both commercially sterilised cat- 
gut and catgut sterilised at the hospital were in use 
here, but the theatre sister thought it probable that 
hospital-sterilised gut had been used in the second 
fatal case, and might well have been used in the 
others. The method of sterilisation employed was 
immersion of the gut in oil of cloves for 14 days 
followed by storage in absolute alcohol for 8 days. 
Post-mortem material from the second fatal case 
and specimens of both kinds of catgut were examined, 
but B. tetani could be isolated only from the appendix 
stump. The tetanus spores might have been present 
in the patient’s intestine and have infected the 
appendix stump, or she might have acquired her 
infection from the catgut. It was unlikely, however, 
that B. tetanit was present in the bowel of all four 
of the cases affected, and moreover in two of them 
the bowel had not been interfered with at operation. 
The method of sterilisation employed at the hospital 
had been shown experimentally to be ineffective in 
killing tetanus spores, and altogether, although proof 
was lacking, the evidence indicated the conclusion 
that the infection came from the “ home-cured ”’ 
catgut. He appealed to surgeons to inquire into the 
methods employed for the sterilisation of the catgut 
they used at operation. 


ROYAL SOCIETY OF MEDICINE: SURGERY 


- 


(FEB. 15, 1936 367 


DISCUSSION 


Prof. W. BULLOCH said that biniodide of mercury 
was perfectly useless. He had infected small hanks of 
sterilised silk ligatures with Bacillus ruber and had 
placed them in a solution of 1 per cent. biniodide. 
He had tested this material 40 times over a period of 
ten years and had obtained a pure culture of the 
bacilli on every occasion; what they lived on he 
could not say. He thought there were only two 
methods of sterilising catgut effectively: either by 
immersion in iodine solution for eight days or by 
heat. He believed that tetanus in catgut was a bogy. 
In 17,420 samples of catgut which he had examined 
he had never once found tetanus. 

Prof. JAMES McINTOSH said that all surgeons had 
encountered cases of post-operative tetanus. Tetanus 
bacilli could be isolated from the wound in such 
cases; in the last one he had examined, however, no 
tetanus had been obtained from the wound, but the 
wood-wool used to pack the splint had been found to 
be heavily infected with the organism. He thought 
we had yet to go a long way to prove that catgut 
was a source of post-operative tetanus infection. 

Prof. PauL Fmprs agreed that if too much 
attention was directed to catgut surgeons might 
overlook other important sources of tetanic infection. 
In his work he was often called upon to find the 
tetanus bacillus in sites where it was present—and 
he did find them ; if he failed to find them elsewhere, 
therefore, it might count, he thought, as useful 
evidence that they were absent. And though he had 
found the bacillus in every one of 40 cases of tetanus 
he had never once found it in surgical catgut. He 
described a case of pyonephrosis in which excision of 
the kidney was followed by tetanus; the wound at 
post-mortem was swarming with tetanus bacilli, but 
though he examined 50 reels of catgut of the same 
brand as that used at the operation he had found no 
tetanus. In another case the knee-joint was excised 
for tuberculosis and the leg put up in a plaster splint. 
Three months later the patient developed tetanus 
and died. The whole operation area was excised 
and cultured but no tetanus bacilli were grown ; but 
in the wood-wool used as dressing tetanus spores were 
found. He was convinced the infection of some slight 
abrasion from thedressing was responsible for the symp- 
toms. He thought that more cases of post-operative 
tetanus occurred than were reported, and he hoped that 
every surgeon who encountered a case would put the 
facts on record so that they could be properly sifted. 

Dr. Joun BEATTIE said that the impregnation of 
catgut with silver salts gave a sterile gut with sufficient 
tensile strength for surgical purposes. This method 
might, it has been suggested, act merely by encasing 
the spores in silver, but if they were effectively 
imprisoned it did not matter whether they were 
living or not. The smaller hospitals often used 
unsuitable methods of sterilisation, and these 
must be replaced by a good method which was both 
simple and cheap. They could not all afford catgut 
which was sterilised under rigid conditions. He 
thought that tetanus in catgut was a bogy only as 
far as the London Hospital was concerned. Post- 
operative tetanus and wound infections due to 
catgut were much commoner at hospitals where 
catgut was not prepared so efficiently. 

Dr. V. D. ALLISON said that he had been using 
trypsin to digest and soften catgut so that any 
organisms embedded in it might be induced to grow. 
He had found catgut digested in this way to be 
teeming with organisms—staphylococci, streptococci, 
spores, and vibrios, mostly dead. He had also tried 


injecting extracts of catgut into animals and had 
once got tetanus from a sample of catgut requiring 
to be sterilised before use, but never from catgut 
declared to be ready for surgical use. A substitute 
for catgut was most desirable and a new material 
made from horseflesh was stated to be sterile, flexible, 
readily absorbed, and of good tensile strength. lt 
was time new experiments were carried out to decide 
how long different catgut ligatures tock to absorb. 
The rates of digestion with trypsin were very variable. 


Lord HORDER remarked that the bacteriologists 
did not seem to confirm the responsibility of catgut 
for post-operative tetanus. Might the same arguments 
apply to gas-gangrene ? He would also like to know 
to what extent surgical technique was dependent on 
catgut as against other forms of ligature. Was 
absorbability the great virtue of catgut determining 
its use ? 


Mr. W. M. DICKIE said that three areas where out- 
breaks of post-operative tetanus had occurred were 
areas in which heavy grades of catgut were commonly 
used. Such grades were hard to sterilise and per- 
sisted for a long time in the tissues. If the lightest 
possible catgut was used there was less likelihood, 
he thought, of getting tetanus. 


The CHAIRMAN said that he rarely used catgut 
unless he was forced. He found that unabsorbable 
sutures, provided they were thin enough and sterilised 
just before use, were rarely attended by the dis- 
advantages usually attributed to them. 


Mr. CARWARDINE urged all surgeons to prepare 
their own ligatures and handle them in person 
until the last minute. He had always sterilised 
his own catgut by the xylol method, and he had 
never seen any tetanus. 


Sir WELDON, in replying, said that the thesis that 
tetanus in catgut was a bogy had not been proved. 
The discussion had shown the need for further research. 
He trembled to think what would happen if all 
surgeons prepared their own catgut; not all of them 
could be trusted to perform the task as carefully and 
successfully as Mr. Carwardine. 


SECTION OF LARYNGOLOGY 


A MEETING of this section was held on Feb. 7th, 
with Mr. LIONEL COLLEDGE, the president, in the 
chair. 

Mr. MAXWELL ELLIS read a paper on the mechanism 
of the 


Bronchial Movements and Naso-pulmonary 
Reflex 


He said that his interest in the subject had first been 
aroused when he was working in Dr. Chevalier 
Jackson’s bronchoscopie clinic and noticed the 
movements in the bronchi of certain asthmatics. 
This led him to an attempt at recording these move- 
ments. He briefly described the muscular structure 
of the bronchial tubes, and pointed out that the 
muscle extends as a continuous network from the 
trachea to the air sacs. The fibres run neither 
circularly nor longitudinally, but obliquely, in 

“geodesic” lines, as depicted by William Snow 
Miller, enclosing lozenge- shaped spaces. They end 
at the mouths of the atria, surrounding these openings 
almost in the manner of a sphineter. It had been 
deduced from the structure of the bronchi that they 
elongate with inspiration, shortening during expira- 
tion, but different opinions had been “expressed about 
the nature of the alterations in calibre. 


368 THE LANCET] ROYAL SOCIETY OF MEDICINE: LARYNGOLOGY [FEB. 15, 1936 


Mr. Ellis said that none of the experimental methods 
of measuring and recording these movements did 
this direetly. The classical investigations of Dixon 
and Brodie in 1903 consisted in measuring the changes 
in volume of a lobe of alung. By other methods the 
variations in intrapleural or intratracheal pressures 
were recorded. It was doubtful whether these 
measurements were reliable records of variation 
in intrabronchial capacity, particularly as the 
experimental animals were in an abnormal condition, 
and usually kept alive by artificial respiration. 
Mr. Ellis said that his method of recording changes 
in calibre in the larger bronchi of the dog was a 
direct one involving the use of the bronchoscope. 
A specially devised hollow instrument carrying a 
rubber balloon which could be inflated through a 
separate tube was inserted through a bronchoscope 
into the right bronchus. The balloon was loosely 
inflated and connected with a Brodie bellows capable 
of registering clearly changes in volume of one-tenth 
of a cubic centimetre. Respiratory exchange in the 
lung distal to the balloon was carried on through the 
lumen of the instrument and changes in calibre were 
thus directly recorded. Mr. Ellis showed tracings 
obtained in this manner, in one of which the bronchial 
contraction produced by pilocarpine and the relaxa- 
tion produced by adrenaline were seen. He pointed 
out that synchronously with the respiratory move- 
ments are rhythmic alterations in calibre—inspiratory 
dilatation and expiratory narrowing—which had 
been commented upon by Fletcher Ingals and 
Chevalier Jackson some years ago as a result of their 
bronchoscopic observations, but not previously 
recorded by a direct method. The means of produc- 
tion of this rhythm was of interest: (1) it could be 
produced by impulses travelling in the vagi; (2) it 
could be an intrinsic property of the bronchial tubes, 
or(3)a mechanical effect of the respiratory movements 
of the thoracic walls. The first two hypotheses 
demand rhythmic contractions of smooth muscle 
at the rate of at least 15 a minute, and this behaviour 
of smooth muscle was not seen elsewhere in the 
body. He showed a tracing from a bronchus before 
and after bilateral vagotomy in which the bronchus 
narrowed to an even greater extent after it had been 
deprived of its constrictor nerve-supply than 
previously, which seemed to be evidence against the 
first hypothesis. In numerous experiments the bron- 
chial movements had followed exactly the respiratory 
movements. Mr. Ellis thought that during the 
inspiratory phase of respiration the increase in 
thoracic volume tended to create a decrease in 
pressure in the lung substance, which in turn caused 
air to flow into the bronchial tubes, dilating them. 
The flexible structure of the tubes would permit of 
this. He considered that the network arrange- 
ment of fibres in the myoelastic layer explained how 
shortening and narrowing of the tubes go hand in 
hand during the expiratory-phase (decrease in lung 
volume’. He believed that the maintenance of tone 
is the function of the bronchial muscle. 


He went on to discuss the question of peristalsis 
in the bronchi. Yandell Henderson’s work on the 
“dead space ” and its occasional rhythmic variation 
was the best available evidence about this fanction 
and was supported by Lewis’s demonstration of 
contraction waves in tissue-culture preparations of 
bronchial tubes from chick embryos. In his own 
experiments Mr. Ellis had never witnessed rhythimie 
relaxation followed by contraction which would 
indicate the possible existence of peristalsis, but he 
had occasionally observed variations in tone. For 


THE LANCET] ROYAL SOCIETY OF MEDICINE: TROPICAL DISEASES AND PARASITOLOGY ([FEB. 15,1936 369 


a true demonstration of the phenomenon records 
from two fixed points in a bronchus were necessary, 
and these had not been obtained. A certain amount 
of work had been done on the influence on respiration 
of reflexes from the nose, but nothing convincing 
had been published on the effects of such reflexes 
onthe bronchi. Mr. Ellis showed tracings of bronchial 
reactions produced by stimulation of the septum with 
a moderate faradic current and of the right nasal 
cavity with dilute ammonia vapour. Bronchial 
constriction occurred often but not invariably. 
Such stimuli were stronger than those which occur 
in normal life and might evoke pain and defence 
reflexes which obscured the picture; clear-cut 
results were not easy to obtain. This might perhaps 
be explained by the different functions of the canine 
and human nose. The principal function of the 
former was olfaction, and of the latter respiration, 
and the microscopic structure of the mucous 
membranes indicated this difference. The human 
nose might be more sensitive to stimuli, but he had 
had no opportunity of carrying out experiments on 
man and had no objective evidence to offer. On 
stimulating his own septum with an electric current, 
he received no subjective sensation of constriction 
in the chest, but he had no idea how much bronchial 
constriction was needed to convey such a sensation. 
He felt convinced, however, that the tone of the 
bronchial muscle could be influenced reflexly from 
the nasal mucous membrane, although he was not 
prepared to be dogmatic as to the precise mechanism. 
Finally, Mr. Ellis pointed out that it was essential 
to know more about the normal dynamics of the 
bronchi in order to understand the abnormal 
mechanics of asthma and other spasmodic respiratory 
diseases. 

Dr. G. Ewart MARTIN mentioned observations 
that he had made on patients during bronchoscopy. 
Blowing cold air down the bronchoscope resulted 
in a closure of the bronchus which relaxed on the 
introduction of warm air. 

Mr. T. A. CLARKE asked whether Mr. Ellis had 
made any observations on the subject of homolateral 
reflexes between the nasal cavity and bronchial 
tree. He had read descriptions of such reflexes. 

Mr. H. V. Forster mentioned that in some 
patients in whom the larynx had been excised move- 
ments of the diaphragm were unequal on the two 
sides. He wondered if this affected the lung by 
promoting unequal bronchial dilatation and, perhaps, 
lung expansion. 

Mr. A. R. TWEEDIE recalled a case where the patient, 
during the performance of a nasal operation, suddenly 
went into an asphyxial spasm. He passed a broncho- 
scope and saw what appeared to be a complete 
closure of the secondary bronchi by swollen mucosa. 


In reply, Mr. ELLs said that theoretically he would 
expect the bronchial muscle to react to stimuli 
applied locally to the overlying mucous membrane. 
He had not yet investigated this aspect of reflex 
behaviour. He doubted the validity of the work quoted 
by Mr. Clarke. On theoretical grounds, as the sensory 
are ended in the medulla, spread to both sides was 
almost inevitable, and both vagal nuclei would 
almost certainly be affected. He had on several 
oceasions observed effects on the right bronchus 
resulting from stimulation of the left nasal cavity. 

In the case quoted by Mr. Tweedie he thought an 
extreme form of bronchial muscle spasm had occurred. 
The bronchial mucous membrane contained no 
erectile tissue, and did not convey the impression 


that it could suddenly swell several millimetres. 
He thought it likely that for some unknown reason 
the bronchial muscle in this patient was unusually 
irritable and was reflexly stimulated by the nasal 
operation to extreme tonic contraction. 

A number of cases were exhibited and discussed 
at some length. 


SECTION OF TROPICAL DISEASES AND 
PARASITOLOGY 


AT a meeting of this section on Feb. 6th, with Dr. P. 
Manson-Banur, the president, in the chair, Prof. R.T. 


- LEIPER presented a demonstration on the 


Crustacea as Helminth Intermediaries 


This took the form mainly of lantern slides illustrating 
the life-histories of the dibothriocephalus tapeworms, 
the Guinea worm, and Gnathosioma spinigerum, 
all using species of cyclops as intermediate hosts, 
and the life-history of the lung fluke which uses 
certain fresh water crabs and crayfish as second 
intermediaries. He said that the life-history of the 
guinea worm had been correctly deduced, on the 
analogy of that of a very different worm in fish, 
from the close similarity of theirembryos. Gnathostoma 
spinigerum, normally parasitic in the stomach wall 
of cats and dogs, had been found several times 
subcutaneously in man. The lung fluke, parasitising 
man and some other mammals in the Far East, 
and dogs in Venezuela, had recently been reported 
from a child in West Africa. It was very important 
that regional collections of crustacea should be made 
so as to ascertain the distribution of intermediaries, 
but in that connexion it had to be remembered that 
the entomostraca were also intermediaries for a 
number of helminths not parasitising man. Among 
these were several tapeworms of the same group 
as dibothriocephalus, some species of the four- 


. suckered tapeworm genus hymenolepis, and many 


acanthocephala. Caution was therefore needed in 
interpreting the discovery of helminth larvie in 
crustacea. 


Dr. B. G. PETERS followed with a paper on some 
recent 
Developments in Helminthology 


which dealt with certain biological aspects of 
parasitism, mainly among the cestodes. Normal 
life-histories, he said, were occasionally departed 
from, as when larvæ of Dibothriocephalus mansoni or 
Mesocestoides, fed to dogs, continued to live as larvæ 
in the peritoneum instead of becoming adults in 
the intestine. De Waele’s work tended to show 
that tapeworm embryos and larve resisted intestinal 
digestion only because the surrounding egg-shell 
and cyst wall, respectively, protected them froin the 
host’s gastric juice. The adult cestodes appeared 
to have an anaerobic metabolism in which glycogen 
was decomposed to furnish energy, and fatty acids 
and carbon dioxide were excreted as metabolic 
products. So-called “age immunity ”’ in helminths 
was a form of innate Immunity. Acquired immunity 
could be most fully illustrated from Miller’s numerous 
experiments on the larval stage of the cat tania. 
These had revealed active immunity, both natural 
and artificially induced, and also passive immunity, 
both inherited and induced. Of immunological 
reactions employed in diagnosis, the Casoni skin 
test for hydatid was a group reaction among the 
tenias. Intradermal and precipitin reactions appeared 
to have been established as valuable methods for the 
diagnosis of trichinosis, both in man and in the pig. 


370 THE LANCET] 
Dr. N. HAMILTON FAIRLEY said that most 
helminthic immunological reactions were of a group 
nature, probably owing to the existing crude methods 
of preparing antigens. It was usually easier to 
detect fixed antibodies, as in skin tests, than free 
antibodies concerning which there was less knowledge. 
Major-General W. P. MACARTHUR said that in 
cysticercosis the complement-fixation reaction varied 
in intensity along with eosinophilia; both were 
high in early stages, then tended to disappear, and 
finally to reappear with the death of the cysts. 


In reply to a question whether, in view of the spread 
of the ‘‘ mitten crab’’ in Europe, some local mollusc 
might not serve as first intermediary to the lung 
fluke in place of melania, 

Prof. LEIPER said that he thought this unlikely. 
Trematodes were more specific as to first than as to 
second intermediaries. Moreover, both the lung 
fluke itself and the habit of eating raw crab would 
also have to be introduced before this parasite could 
spread in Europe. 


MIDLAND OBSTETRICAL SOCIETY 


A RECENT meeting of this society, held at 
Birmingham, was devoted to a discussion on 


Eclampsia and Pre-eclamptic States 


Mr. S. W. MASLEN JONES (Wolverhampton) said 
that since the Obstetrical Congress of 1922 there 
had been a general adoption of purely medical treat- 
ment in eclampsia as opposed to active obstetrical 
interference. The essentials in treating eclampsia 
and pre-eclampsia were similar—namely, (1) rest; 
(2) starvation, giving nothing but water for 24—48 
hours, and then adding fruit juice, carbohydrates, and 
milk; (3) intestinal lavage and saline purgation ; 
and (4) free intake of alkaline fluids. In eclampsia 
nursing in the left lateral position was essential, 
because it allowed escape of blood and mucus from 
the mouth and air-passages ; lavage of stomach and 
colon should be done as a routine leaving magnesium 
sulphate in the stomach. In unconscious patients 
fluid should be given per rectum ; if this was returned, 
intravenous or even submammary salines might be 
necessary. Fluids should never be “‘ pushed,” how- 
ever, before the bowels were acting freely, since there 
was a danger of waterlogging the patient. The value 
of drugs was disputed: morphia in a dose of up to 
gr.4 was useful for controlling restlessness during 
labour, but it often failed to stop fits, and was not 
entirely safe in cases with pulmonary wdema. Induc- 
tion of premature labour was not done often enough 
in eclampsia: if there was no conspicuous improve- 
ment in the patient’s condition, and no sign of 
spontaneous onset of labour, after 24 hours’ medical 
treatment labour should be induced by aspiration 
of liquor amnii with the Drew Smythe catheter. 
In severe pregnancy toxemia, without fits, the use 
of induction called for much discrimination. After the 
36th week he advised induction in severe cases which 
had responded to treatment, whereas before this 
time medical treatment should be continued unless 
the patient was getting worse, since the viability 
of the child was of importance; but in the latter 
type of case it must be remembered also that intra- 
uterine death of the child was common. 

Mrs. BERTRAM LLOYD agreed that it was dangerous 
to give too much fluid in the early stages of treat- 
ment ; she advised induction in cases of pre-eclampsia 


MIDLAND OBSTETRICAL SOCIETY 


[FEB. 15, 1936 _ 


if medical treatment produced no improvement 
within three weeks. In her experience eclampsia 
was rare in hospital cases. At the Birmingham 
Maternity Hospital there had been 87 cases in the 
past six years. Delivery was spontaneous in 56 
cases ; forceps were used in 19; Csesarean section 
was done once. In 4 cases labour was induced, and 
6 patients died undelivered. The maternal death- 
rate was 25 per cent. and the fetal 47 per cent. 


Mr. ALFRED DANBY said that as the primary cause 
of the pre-eclamptic state was still unknown, all 
forms of treatment for this disease (or syndrome) 
must be empirical. Recent experimental work in 
America suggested that some of the untoward 
symptoms of eclampsia were due to ‘“‘ water intoxica- 
tion,” and he wondered whether this suggestion would 
have any influence on the fetish for forcing fluids 
to dilute the ‘“‘toxins.”” The three cardinal signs 
of pre-eclampsia were raised blood pressure, cedema, 
and albuminuria, of which the last-named was 
probably the least important. It was now known 
that water retention could occur without visible 
cdema, and any undue gain in weight in the last 
trimester of pregnancy was suggestive of this so-called 
“hidden cedema.’’ The generally recognised fact 
that free diuresis was usually followed by rapid 
improvement in the general condition seemed to 
indicate a functional rather than organic derange- 
ment of the kidneys. In this connexion Mr. Danby 
was particularly interested in the work of Hoffmann 
and Anselmino (1931) who were able to demonstrate 
that the blood of eclamptics contained two components 
of the posterior lobe hormone—namely, the anti- 
diuretic and the pressor. These factors were not 
present in the blood of normal women, pregnant 
or otherwise. Goodall (1933), commenting on this 
work, which was done upon rabbits with controls, 
considered that it showed a consistent uniformity 


. of reaction that placed the antidiuretic content of the 


blood of these patients beyond doubt; the pressor 
Substance was present only in cases of high blood 
pressure, 180 systolic or over. It appeared, however, 
that Hoffmann and Anselmino’s observations had 
not yet been confirmed by other workers. Whilst 
the physiology and pathology of water metabolism 
was still imperfectly understood, the speaker felt 
that it had a considerable bearing on the subject 
under discussion. During the past few years he had 
treated a number of cases of pre-eclampsia showing 
edema by fluid limitation and dehydration—a 
method modified from that of Arnold and Fay (1932). 
The results had been excellent as far as they went, 
but the cases were specially selected. In many 
instances the change in the external appearance of 
the patient and the reduction in weight due to loss 
of fluids was very striking. Although the diet 
contained over 50 grammes of protein, including 
meat, he had seen no ill-effects from its use; but 
most of the patients complained of thirst. In 
eclampsia he was convinced that the injections of 
hypertonic solutions had given improved results, 
probably through dehydration and diuresis. He 
usually employed a 25 per cent. solution of glucose 
intravenously, but occasionally intramuscular 
injections of 25 per cent. magnesium sulphate were 
given in addition. The free use of sedatives, including 
Sodium Luminal hypodermically, were part of the 
routine treatment, and all forms of interference— 
such as colon wash-outs, rupture of the membranes, 
and application of forceps—were done under chloro- 
form anesthesia. The objection to the use of small 
quantities of chloroform was in his opinion more 


THE LANCET] 


MIDLAND OBSTETRICAL SOCIETY 


[FEB. 15, 1936 371 


academic than real. As regards Cesarean section, 
although he admitted there might be an occasional 
case where it should be done, he had never had 
occasion to perform the operation for eclampsia. 


Mr. H. L. SHEPHERD said that in Bristol eclampsia 
was becoming less common; during the past ten 
years he had seen 80 cases, with 9 deaths, whereas 
before the war the average was 15 cases per annum. 
He believed that eclampsia and pre-eclampsia should 
be treated on different lines; for although the 
primary toxin was undoubtedly formed in the placenta, 
the fits were caused by absorption of toxic products 
from the bowel. The greater number of deaths in 
eclampsia were due to intracranial hemorrhage, a 
direct result of the high blood pressure and the 
fits. Hence the most important part of the treat- 
ment of eclampsia was to reduce the blood pressure 
and contro] the fits, which he thought could best 
be done by free venesection and the use of morphia. 
Subsequently the usual eliminative treatment of the 
bowel should be adopted and protein omitted from 
the diet with the idea of sparing the liver and giving 
it every chance to recover. He considered it 
dangerous to allow too much fluid. Pre-eclampsia, 
he believed, was always associated with constipation, 
which led to the higher breakdown products of 
proteins being absorbed unchanged. Constipation 
should therefore be treated energetically. The value 
of induction of labour lay mainly in the relief of intra- 
abdominal pressure ; hence the fact that withdrawal 
of liquor amnii through catheters gave better results 
than bougies. Calcium, both by mouth and intra- 
venously, was of value at all stages. 

Mr. WENTWORTH TAYLOR, speaking of the Dublin 
method of treatment, said that it did not consist in 
a fixed and unalterable régime. While the basic 
principles of Tweedy’s treatment were still generally 
applied, each case was dealt with on its own merits. 
To some extent he had been impressed with the 
efficacy of the treatment, and in his personal 
experience of 62 cases he had only had 9 deaths ; 
in all the fatal cases post-mortem examination had 
revealed some gross failure of the human organism 
such as cerebral hemorrhage or massive necrosis 
of the liver or kidneys, which no form of treatment 
could be expected to influence. Pregnancy toxemia 
could be classified broadly into four separate types. 
(1) Pernicious vomiting should be treated in the 
first place by securing a proper action of the bowel 
and by correcting any malposition of the uterus. 
If this preliminary attack failed the patient lost 
weight rapidly, continued to vomit, and developed 
jaundice and acetonuria. In these circumstances 
delay was dangerous and the uterus should be emptied 
by abdominal hysterotomy in the sure knowledge 
that rapid improvement would follow. Evacuation 
by insertion of tents was too slow. (2) In the pre- 
eclamplic state starvation need seldom be carried 
beyond two days and never beyond four. If there 
was no improvement after this time, labour should 
be induced. Hysterotomy might be necessary in 
severe cases before the 25th week. (3) In eclampsia 
he advised an initial dose of morphine gr. 4—4. If 
this failed to control the fits a major cerebral lesion 
was probable, and no further morphia should be given. 
Venesection was not popular in Dublin, since eclamptic 
patients were in any case anemic during the puer- 
perium. Cesarean section at or near term was never 
necessary since it was easy to stimulate the uterus 
to empty. (4) In toric antepartum hamorrhage 
treatment by plugging the vagina was seldom 
attempted now. It was preferable to treat by 


puncturing the membranes, allowing the waters to 
escape and the uterine cavity to close down, after 
which spontaneous delivery was the rule. 


Mr. T. C. CLARE (Leicester) was not convinced that 
toxemia was the right descriptive term for the 
condition under discussion. He was now converted 
to Paramore’s mechanical theory of origin of eclampsia. 
The essential in treatment was to stop the fits. The 
results published by Stroganoff were so remarkable 
that he felt that the danger of using chloroform for 
this purpose was less than generally believed. He 
personally used spinal anesthesia to lower the blood 
pressure, and regarded it as safer than venesection. 
It could be repeated if necessary.. He asked 
whether Evipan had been tried for control of the 
fits. He thought that oxygen played an important 
part in treatment. i 


Prof. MILES PHILLIPS (Sheffield) said that eclampsia 
was rare in treated cases. It was important that the 
honorary surgeon should see cases of pre-eclampsia 
at least three times in the 24 hours. At Sheffield 
they had used the Stroganoff method of treatment 
since 1922. Induction of labour should be done when 
a pre-eclamptic patient became worse, and it was 
important to listen to the fcetal heart twice daily. 
He thought that Veratrone and venesection were 
both of value, but that it was easy to overdo the 
administration of fluids. He mentioned that eclampsia 
was extremely rare in Holland—a fact attributed 
to the salt-free diet. 


Prof. H. J. Drew Smy7He (Bristol) believed in 
giving large doses of morphia in eclampsia. He 
said that a pre-eclamptic required protein to reduce 
cedema. a5 


Mr. C. L. SOMERVILLE (Leicester) said that in the 
treatment of eclampsia he advised immediate vene- 
section followed by intravenous anesthesia, preferably 
with Pernocton in a dose of from 3—4 c.cm. There 
was no risk of damage to the liver. The patient 
slept for 5-7 hours, and was not restless on waking. 
Fits were rare after this. The effect of evipan was 
too transient for its use in eclampsia. He believed 
in giving pilocarpine to produce sweating. 

Prof. D. C. RAYNER (Bristol) advised rupture of 
the membranes as soon as possible in eclampsia. 
If pilocarpine was used there was a danger of drowning 
the patient. 


RoyaL MEDICAL BENEVOLENT FUND.—At a recent 
meeting of the committee 9 new applicants were 
assisted and 54 grants were renewed. In all the 
sum of £1680 was voted. The following are particulars 
of a few cases helped. 


Widow, aged 28, of M.B. who died in May, 1935. Both 
her parents died when she was a child leaving only sufficient 
money to insure the child’s education. In July, 1932, she 
married, but in May, 1935, the husband died leaving the widow 
at the age of 28 with two infant children, and a capital sum of 
£380. The fund and its auxiliary, the Ladies’ Guild, will do 
what is possible to help. 

Widow, aged 78, of M.R.C.S. who died in 1890, was found 
to be living on a yearly income of £66. The fund granted £25 
thus raising the income to £91, which is the limit allowed for 
retaining the State old age pension of £26. 

Daughter, aged 37, of M.R.C.S. who died in 1908. After 
her father’s death she was educated from 9 to 15 years at Dr. 
Barnardo’s Home. She then had to earn her own living and 
went into domestic service. As she is a dwarf she is unable 
to do any strenuous work and her power of earning is limited. 
It is estimated that her earnings for the last month at odd. 
jobs was only £2. The fund voted her an allowance of £26. 


As this is the centenary year of the fund a special 
appeal is being made for new subscribers to carry on the 
work begun a hundred years ago and for donations towards 
the centenary fund. Cheques should be sent to the hon. 
treasurer of the fund, 11, Chandos-street, London, W.1. 


372 THE LANCET] 
MEDICAL SOCIETY OF LONDON 


Prof. G. E. GASK, the president, took the chair at 
a meeting of this society on Feb. 10th, when a 
discussion on the 


Treatment of Sterility 


was opened by Mr. C. S. LANE-RoBERTs. Absolute 
sterility in the female, he said, could often be corrected 
nowadays by plastic operations on the adnexa, and 
one should seldom give up hope of conception. Most 
couples should be allowed to go on from twelve to 
eighteen months without investigation unless an 
obvious cause was present. The investigation at 
the Meaker clinic for sterility in Boston was amazingly 
thorough. The team consisted of a urologist, a 
gynecologist, an internist, an endocrinologist, and a 
clinical pathologist. The basic routine study required 
a full week and consisted of six steps: the medical 
histories and examinations of husband and wife; 
the gynecological history and abdominal examination ; 
examination of the semen; endocrinological studies 
of husband and wife; transuterine insufflation ; 
and further necessary medical or surgical procedure. 
Meaker’s nine major headings for the causes of 
sterility were : deficient spermatogenesis ; obstruction 
and occlusion in the male genital tract; hostility 
of prostato-vesicular secretion; faults of delivery 
and reception of semen; hostility of endocervical 
secretions; ‘‘ uterine blockade ”?” ; tubal obstruction 
and occlusion ; impassability of ovario-tubal hiatus ; 
deficient odgenesis. Constitutional disorders impaired 
fertility, and success might be achieved by combating 
general debility, endocrine dysfunction, metabolic 
disturbance, and chronic intoxication. The urological 
examination must be very thorough, but a well- 
balanced outlook must be maintained. Perhaps the 
American workers laid too much stress on endocrine 
disturbance. In an American series of 4000 cases the 
large bulk of the males were said to have shown 
anterior pituitary dysfunction with faulty spermato- 
genesis, some with thyroid deficiency and some 
with disturbance of the islets of the pancreas. In 
some cases of male genital hypoplasia it was claimed 
that the injection of prolan gave promising results. 
Many cases of sterility were due to inability to perform 
the sexual act, and simple and direct advice would 
often be successful. 


On the female side, the sooner an external 
dyspareunia was dealt with the better. Spasm 
of the pelvic floor muscles was common, and easily 
and quickly remediable. It was usually neither 
necessary nor advisable to perform plastic operations 
on the vagina. Huehner’s work on post-coital 
examination in cases where intercourse failed to 
produce cervical insemination had led to the conclusion, 
among others, that the normal alkaline endocervical 
mucus was an environment favourable to spermatozoa, 
and that the acid vaginal moisture was hostile. 
The significance of premature ejaculation was there- 
fore obvious. Marked anteversion of the cervix, 
so that the external os was covered by the anterior 
vaginal wall, often went with hypoplasia, scanty 
periods, an undersized uterus, an elongated cervix, 
and a pinhole external os. Chemical hostility of the 
endocervical secretion and serological hostility were 
probably not very important, and bacterial hostility 
might be grossly exaggerated. Excessive viscosity 
in the cervix might, however, be due to bacteria, 
and a mechanical viscosity to poor cervical drainage ; 
this could be treated by dilatation and draining 


MEDICAL SOCIETY OF LONDON 


[FEB. 15, 1936 
for a few days. A douche of dilute hydrogen 
peroxide or sodium bicarbonate shortly before 
coitus was useful. Endocervicitis should be 
thoroughly treated, either by linear cauterisation 
or by diathermy with the burr or cutting loop. 
Retention cysts should be dealt with. Curettage of 
the endocervix and chemical antiseptics seemed quite 
useless. Chronic passive congestion might be cured 
by correcting such faults as coital excess or habitual 
excitation of the female without proper orgasm. 
The correct treatment of chronic constipation and 
uterine retrodisplacement also helped. A deficiency 
of the precoital secretions demanded instruction 
for the husband. There were only two indications 
for artificial insemination: imperfect ‘“‘ delivery- 
reception,’ and hostile endocervical secretion. 
Uterine blockade mostly implied the deformity of 
the uterine cavity or obliteration of the tubal lumen 
by fibroid tumours. A carefully done myomectomy 
with meticulous hæmostasis was often followed by 
pregnancy. The mildest gonorrhæœalsalpingitis caused 
damage to the tubal mucosa. Puerperal and post- 
abortive infections might cause adhesions and occlude 
the tubal ostia. 


Of recent years lipiodol salpingography had been 
almost universally adopted. Ordinary insufflaticn 
methods were of help when the tubes were found 
closed at laparotomy. The best time for tube 
testing was immediately after a period, when the 
epithelium was at its lowest. Only a very chronic 
case was suitable for salpingostomy. Any proposed 
plastic operation should be thoroughly explained 
to the couple. In 366 cases treated by Bethel 
Solomons with tubal resection, 8 per cent. became 
pregnant and 18 per cent. either became pregnant 
or showed tubal pregnancy. Adhesions and folds 
should be dealt with and a prolapsed ovary might he 
stitched up. Some workers reported success in 
cases of sterility with mid-menstrual pain by bursting 
the follicle under anwsthesia, and others by shaving 
off the surface of the ovary to facilitate the rupture 
of the follicle. Small X ray dosage was sometimes 
used for odgenic dysfunction. 


Of the constitutional causes, chronic intoxication 
should be excluded. The diet should be regulated 
and vitamin E and protein given. Slimming and 
obesity would both cause sterility. Lack of exercise, 
over-work, nervous fatigue, and anemia could be 
treated by change of habit and scene. 


ENDOCRINE FACTORS 


Mr. Lane-Roberts summarised Knaus’s work on the 
physiology of ovulation, but set against Knaus’s 
theory of “safe periods” following and preceding 
menstruation the results published by Dickinson. 
who found that impregnation could take place at 
any part of the cycle, including the period itself. 
He discussed in some detail the endocrine causes of 
sterility, in relation to the use of cstrogenic and 
gonadotropic hormones. Thyroid, he said, might 
be employed with great advantage, even with a 
normal basal metabolism. Progestin was remarkably 
useful in threatened or habitual abortion; in the 
treatment of sterility it should be given in association 
with cstrin in the last third of the menstrual cycle 
in order to prepare a suitable premenstrual nidatory 
phase. In some cases of primary ovarian failure, 
10 units of insulin before breakfast and dinner 
improved genital function. Out of 150 cases of 
functional sterility treated by hormones, dilatation 
and diagnostic curettage, and low-dosage radiation 
of the pituitary and ovaries, 53 per cent. had become 


THE LANCET] 


MEDICAL SOCIETY OF LONDON 


[FEB. 15,1936 373 


pregnant and 42 had carried to full term. In the 
vast majority of cases the infertility factors would 
be gradually sifted out by general and local physical 
examination of husband and wife, with appropriate 
treatment; Huehner’s post-coital examination of 
spermatic fluid; tests for tubal patency; and 
special measures such as endometrial examination 
and tests of the basal metabolism. 


DISCUSSION 


Mr. A. C. PALMER said that by far the commonest 
cause of sterility in woman was some degree of genital 
imperfection or under-development, which included 
acute anteflexion. This displacement could not, 
of course, stop one spermatozo6én, but would stop the 
fluid which carried the sperm cells, especially if it 
was abnormally viscous. Salpingitis sometimes did 
not damage the tubes, but filled the pelvis with 
adhesions which did not necessarily close the 
abdominal ostium, and yet somehow by their presence 
prevented the sperm from reaching the ovary. Their 
simple removal was sometimes followed by pregnancy. 
Tiny fibroids or fibromyomata and adenomyomata 
in the isthmus might block a tube so that gas did 
not pass at 200mm. Hg, and laparotomy might be 
justified. He was working on a technique of cutting 
out the growth together with a large part of the 
isthmus, making an incision in the top of the fundus, 
cutting a big channel in the uterus and embedding 
the ampullary portion of the tube. This had 
appeared to lead to patency, but its value had still 
to be proved. 


Mr. V. B. GreEN-ARMYTAGE said that anovular 
menstruation was a far commoner cause of sterility 
than was generally appreciated. If a very fine 
curette were passed just before the period and a 
cheese-paring were taken from the endometrium 
at the top of the uterus, hypoplasia would be found 
with no secretory phase. Out of 7 of his patients 
treated for the first two weeks after the period with 
100,000 units of Œstroform twice a week, and with 
three doses of 30 rat units of Progynon during the 
last ten days of the cycle, 4 had become pregnant 
after three months, one with twins. Greater stress 
should be laid on the value of lipiodol injections, 
which apart from their diagnostic value were thera- 
peutic in at least 20 per cent. of cases. This procedure 
was apt to be neglected in London, to the discredit 
of London gynecologists. The insufflation test was 
more or less useless; he had known clubbed or 
phimotic tubes to be declared patent on the strength 
of this test. It was a mistake to use catgut, which 
was easily absorbed, for uterine implantation ; silk- 
worm gut gave far better results. 


Dr. Witt1am Moopie drew attention to the 
psychological factors which might cause sterility 
in apparently normal couples, some maladjustment 
or imbalance preventing successful coitus. A faulty 
attitude to sex, the married situation, and life 
generally explained many such troubles. Mental 
causes might have actual physiological repercussions, 
and mental and physiological readjustment must 
proceed together. A person might be sterile with 
one partner and fertile with another. 


Mr. W. McK. McCurLacu said that he could not 
understand why lipiodol should pass through a tube 
if gas could not. Patients surprisingly often became 
pregnant when their tubes were not patent to 
ordinary gas. The tubes might open some days 
after an unsuccessful insufflation. Fear probably 
had an influence in sterility; a certain veterinary 


-was fertile or not by semen examination. 


surgeon had owed his great reputation for the 
successful mating of horses to. his practice of 
thoroughly startling the mare first by chasing her 
round the yard with a whip. The speaker claimed 
48 per cent. of successful results with insufflation 
in a series of 50. Impregnation might be achieved 
by stopping the husband’s tobacco, ordering a 
seaside holiday, or giving thyroid and calcium, which 
latter increased sexual desire in females. 


Mr. GREEN-ARMYTAGE answered that Rubin had 
established that carbon dioxide caused spasm of the 
tube whereas lipiodol did not; moreover, the gas 
had therapeutic value in only 10 per cent. of cases 
as against the 20 per cent. of lipiodol. 


Mr. JOHNSTON ABRAHAM suggested that better 
results might be obtained if the husband was always 
sent to a urologist. Sterility due to the male was 
far higher than the 12 per cent. mentioned by 
Mr. Palmer, and it was easy to see whether a man 
In a 
case of double epididymitis, implantation of the 
vas into the top of the epididymis might cure the 
sterility. Recent gonorrhea did not sterilise a man, 
but chronic prostatitis would thicken the spermatic 
fluid and impede the action of the spermatozoa. 
Many men were impotent though quite fertile, and 
in these cases artificial insemination might be 
performed. 


Dr. HENNING BELFRAGE laid stress on the 
importance of diet and the necessity of correcting 
vitamin imbalance, especially in city-dwellers. 


Mr. Horr CARLTON inquired about the incidence 
of sterility in men after operation for neoplasm of the 
prostate. If the enlargement was of the whole 
prostate, he suggested, fertility would probably 
be destroyed, but an adenomyoma might leave it 
unimpaired. Young’s operation had become popular 
in America because it was believed not to cause 
sterility. The closure operation by the Harris 
technique was said to allow the spermatozoa to 
pass without being lost in the bladder. 


THE FOTHERGILL TESTIMONIAL FUND 


THE following is the second list of subscriptions 
received in response to the letter published in the 
British Medical Journaland The Lancet of Jan. 18th : 


Amount previously acknowledged, £262 14s. 6d. 

Lord Dawson of Penn (London), £5; R. Langdon-Down 
(Teddington), £10 10s.; G. T. Willan (Hove) and G. C. Trotter 
(London), each £1 1s.; J. C. Loughridge (Belfast) and J. Arm- 
strong (Ballymena), each £1; W. W. Shrubshall (Burgess Hill), 
£2 2s.; T. Brice Poole (Hove), £3 3s.; J. Manson (Warrington), 
£2 2s.; H. 5. Souttar (London), C. O. Hawthorne (London), 
and Bolton Local Medical and Panel Committee, each £5 5s. ; 
J. Mills (Ballinasloe), Isle of Wight Local Medical and Panel 
Committee, G. Morgan (Brighton), and Mid-Cheshire Division, 
Aen each £1 18.; Portsmouth Division, B.M.A., £5 oe ; 

. C. Chaffey (Hove), £2 2s. W. Gosse (W imborne). £5; 
Henderson (Glasgow), £2 2s. 'E. Kaye Le Fleming (W A 
£5 Os. Halifax Panel Committee, £2 2s. Sir Humphry 
Rolleston (Haslemere), £5 58. Shropshire and Mid-Wales 
Branch, B.M.A., £2 Os. 6d.; S. Watson Smith (Bournemouth), 
£2 2s. H. C. Jonas (Barnstaple), £5; J. B. Miller (Bishop- 
briggs) and B. E. A. Batt (Bury St. Edmunds), each £1 1s.; 
R. G. Gordon (Bath), £3 3s. ; Berks Panel Committee, £5 5s. ; 
W ost Suffolk Panel Committee, £10 10s.; L. Kilroe 2 (Rochdale), 
£5; C. L. Batteson Londan ‘J. C. Ly th (York), A . Smith- 
Shand (York), and W. W. A. Kelly (York), each £1 rae ; Wake- 
field, Pontefract, and Castleford Division, B.M.A., £3; H. E. 
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H. S. Beadles (Romford), £5 5s. Total £386 7s. 


Cheques should be made payable to the Fothergill 
Testimonial Fund, and addressed to the treasurer, 
Fothergill Testimonial Fund, British Medical Asso- 
ciation, B.M.A. House, Tavistock-square, London, 
W.C. 1. 


374 THE LANCET] 


[rEB. 15, 1936 


REVIEWS AND NOTICES OF BOOKS 


The Natural History of Disease 


By Joux A. Rye, M.A., M.D., F:R.C.P., Regius 
Professor of Physic in the University of Cam- 
bridge; Consulting Physician to Guy’s Hospital. 
London: Humphrey Milford, Oxford University 
Press. 1936. Pp. 438. 165s.° 


To Dr. Ryle’s many friends—colleagues, pupils, 
patients—his new title of Professor must still sound a 
trifle strange. It carries with it a faint suggestion 
of intellectual detachment, of academic as distinct 
from broadly human attitude, which are no part of 
his character and work as they are known. He has 
long stood high in the esteem of the English medical 
world as a general physician—“ albeit with an abdo- 
minal bias,” as he puts it. That is a greater achieve- 
ment than the industrious ascent of a specialist 
ladder, and the method and the philosophy that lie 
behind it are to be gathered from this series of his 
papers assembled from the medical journals of the 
. past decade. Ten of them, representing the bias, 
deal with gastro-intestinal subjects, and another score 
or so with other diseases or symptoms. What do 
I know about this condition? In what sorts of 
patients have I met it? In what circumstances ? 
What course does it follow? How precisely can its 
manifestations be described ? What then can I infer 
about its cause, or its significance, or its later 
behaviour ? 

Such questions as these seem to have been the 
starting point of each essay, and the next step 
every time was to bring out the writer’s own case 
records and examine them. ‘“‘ Full notes, frequently 
perused, are the essence of clinical education.” 
There emerges a clinical description, or a discussion 
of relationships, that is usually simple and direct, 
yet in some way illuminating, setting matters 
in a better perspective. The method so exemplified 
is frankly preached in the opening paper and in one 
or two at the end of the book. It is the method of 
the field naturalist, who watches—pencil and note- 
book in hand—the play and interplay of natural 
forces and the behaviour of living things. It demands 
quick and full and accurate observation, immediate 
and correct recording, and a close examination of the 
facts in search of sequences and relationships. Dr. 
Ryle’s belief is that this method, old as Hippocrates, 
is by no means outworn; there are many facts yet 
to be observed by watching different diseases in 
different men, and much useful knowledge to be had 
from studying them. The newer experimental 
method, applied directly in man to the problems of 
disease, has its own value and its own field, but the 
whole future does not lie with it. Medicine, as both 
art and science, will be not only well practised but 
also carried forward by the physician with the touch 
of the naturalist in him, gaining a wide experience 
and using it wisely and critically. This is sound 
philosophy. It denies nothing to the experimental 
method except monopoly. It needs emphasis to-day, 
not because the experimental method challenges it, 
but because the development of specialisation, the 
advent of numerous physical and chemical methods, 
and commercial enterprise in the therapeutic field 
have combined to foster in the clinician a neglect of 
his peculiar opportunity, and a narrow and uncritical 
attitude. 

No one can be in a better position to oppose 
those tendencies than the professors of medicine, 
and it is significant that Dr. Ryle, on becoming one 


of them, should re-emphasise the value in medicine 
of a broad basis of experience and a closer observation 
of the natural history of disease. 


The Minor Medicine of General Practice 


By L. V. SNowman, M.A., M.B. Cantab., M.R.C.P. 
Lond., Physician to the Eastern Dispensary ; 
Assistant Pediatrician, Jewish Maternity Hospital. 
London: John Bale, Sons and Danielsson, Ltd. 
1936. Pp. 104. 2s. 6d. 


PATIENT and doctor will continue to disagree 
about what constitutes minor medicine so long 
as the former thinks in terms of discomfort and 
the latter in terms of prognosis. Although Dr. 
Snowman’s little book, despite its title, discusses 
a number of morbid conditions which will be regarded 
as minor by neither patient nor doctor, for the 
most part his comments on their causation and 
treatment will be found apposite and useful. In 
the chapter on coryza, though rightly condemning 
central heating as a predisposing factor, he advocates 
the use of watery douches in the treatment of nasal 
obstruction where many nowadays prefer oily sprays. 
He says, rather surprisingly, that it is rare for a 
respiratory infection in a well-nourished individual to 
cause a true bronchitis and omits to mention a rapid 
pulse as an early, and often solitary, physical sign of 
phthisis. The point that unexplained pain, labelled 
faute de mieux rheumatic fibrositis, often turns out 
to be due to herpes zoster is well taken, and if borne 
in mind may do much to enhance a doctor’s reputa- 
tion. Dr. Snowman believes that children must be 
hardened to our inclement weather if rheumatism is 
to be prevented, and he is eminently sane on the bogy 
of constipation. In the dietary advised for simple 
diarrhoa he makes no mention of weak tea, the 
astringent action of which has much to commend it. 
In the chapter on cardiac disorders he perhaps lays 
undue stress on the height of the systolic blood 
pressure and too little on that of the diastolic, and he 
claims that the ‘‘trained finger’? can diagnose 
hypertension—a debatable point. His remarks on 
so-called depressor substances are, however, sensible 
and timely. 

Altogether a well-written and sound little book. 


Notable British Trials 


Trial of Alma Victoria Rattenbury and George 
Percy Stoner. Edited by F. TENNYSON JESSE. 
London and Edinburgh: Wm. Hodge and Co. 
1935. Pp. 298. 10s. 6d. 


THE sixty-fourth volume in the series of Notable 
British Trials contains the proceedings against 
Mrs. Rattenbury and George Stoner for the murder 
of the former’s husband at Bournemouth less than a 
year ago. The masterly handling of the trial by 
Mr. Justice Humphreys would alone make the book 
worth study. If the Court of Criminal Appeal found 
it merely “a sordid and squalid case,” Miss Tennyson 
Jesse rehabilitates romance in a pleasantly provocative 
Introduction. 

Stoner, aged 18, was engaged as chauffeur by 
Mrs. Rattenbury, aged 38, and her husband, aged 67. 
Within two months she gave him a bedroom inside 
the house and became his lover; within six months 
her elderly husband was discovered dying with his 


THE LANCET] 


REVIEWS AND NOTICES OF BOOKS 


[FEB. 15, 1936 375 


head battered in. A doctor, hastily summoned late 
at night, found Mrs. Rattenbury in a state of drunken 
excitement, with a gramophone playing and all the 
lightson. She kept saying she had killed her husband 
and, when formally charged, said ‘‘ I did it deliberately 
and would do it again.” She was tried jointly with 
Stoner on an indictment for murder; she would have 
been guilty in law if she had counselled or advised the 
deed even if she had not been present when the 
blows were struck. She went into the witness-box, 
denied her guilt without casting any blame on Stoner, 
and was acquitted. Stoner, who had told the police 
that he struck the blows, did not go into the box 
and was found guilty. It was said for him that the 
Rattenburys were going on a visit, that he was 
morbidly jealous at the prospect of his mistress 
resuming marital relations with her husband, and 
that he hit the husband to give him some hurt which 
would stop the visit rather than to kill him. It was 
a hopeless defence. There was also a curiously 
fugitive suggestion that young Stoner was a cocaine 
addict, suffering from insane hallucinations. His 
counsel asked the jury to say Stoner was either 
‘*‘ guilty but insane ” or else guilty of manslaughter 
and not of murder. The judge told them he saw 
no ray of evidence to support insanity. Stoner’s 
counsel had said ‘“‘he does not deny that it was his 
hand that struck the blow.’’ As the judge observed, 
counsel cannot properly make an admission in a 
criminal case when the client is not put in the box. 
Three days after Stoner’s conviction and her own 
acquittal, Mrs. Rattenbury committed suicide with 
remarkable determination, stabbing herself in the 
breast six times with a knife (three of the wounds 
penetrated the heart) on the bank of a stream whence 
her body fell into the water. Stoner’s appeal was 
dismissed, but he was reprieved. Somewhere he is 
alive, not yet 20, and with his story and his portrait 
in this book ready to help the public not to forget 
him when he is free. Is this quite fair? 


The Gallic esprit of Miss Tennyson Jesse scores 
several points against our insular prejudices. She 
derides the Anglo-Saxon attitude of contemptuous 
condemnation towards the man and woman (and 
especially the woman) unlucky enough to be found 
out in sexual delinquency. If Mrs. Rattenbury 
suffered from nymphomania, the fact was not admir- 
able but neither was it blameworthy. Another 
Anglo-Saxon trait is attributed to the judge when he 
stigmatised the husband as a “mari complaisant, 
not a nice character’’; Mr. Rattenbury’s indifference 
was ‘‘not necessarily a despicable attitude.” Worst, 
and most Anglo-Saxon of all, is the idea that Mrs. 
Rattenbury, being older, dominated the much younger 
man. The truth is, says the Introduction, that 
no woman is so completely dominated by her lover 


as the elderly mistress of a very young admirer. 


In support of this thesis Miss Tennyson Jesse prints 
a singular letter by Benjamin Franklin to a young 
man on the advantage of choosing an elderly mistress. 
It is frank enough to bring a blush to the marble of 
his statues in Philadelphia and other transatlantic 
towns where the inscriptions credit him neither with 
cynicism nor with sophistication. The Introduction 
criticises the reiteration by judge and counsel of the 
words ‘‘adulterous intercourse.” The assize court, 
it reminds us, is a court of law and not of morals. 
But the law, having to assess the truthfulness of a 
witness, considers itself entitled to take into account 
the witness’s character. And the prosecution was 
inviting the jury to consider whether a woman might 
not be so lost to decency that, to gain her ends and 


particularly for sexual gratification, she would stop 
at nothing, not even at murdering her elderly 
husband—especially if she had not to strike the blow 
herself. Miss Tennyson Jesse’s lively advocacy 
of Mrs. Rattenbury rebuts the,suggestion and makes 
an interesting study of character. 


The Patient and the Weather 


By Wuria{Įm F. PETERSEN, M.D. Vol. I., Part I. 
The Footprint of Asclepius. Michigan: Edward 
Bros., Inc. 1935. Pp. 127. $3.75. 


THE second and third volumes of this voluminous 
work have already been reviewed in THE LANCET, 
when it was stated that there was inevitable delay 
in producing the first volume. And now that the 
first volume arrives it is described as Part I., so that 


' the general introduction is not yet complete. What 


we have now is an interesting essay on Greek medicine 
with its different approaches to medical problems, 
while an able summary of Hippocratic arguments 
leads up to detailed information as to the influence 
of the weather in relation to particular diseases. 
here racial differentiation is taken into considera- 
tion, although this side has been dealt with in another 
section. These chapters are profusely illustrated 
with maps showing the percentage distribution of 
the “old-age group ” (55-75 years) in the United 
States, and the distribution of this group for the 
coloured races, the information being obtained from 
the U.S. census of 1930. Other maps figure the 
distribution in various States of under-height, under- 
weight, myopia, defective hearing and teeth, mor- 
tality of infants from malformation, distribution of 
various forms of insanity, and suicide rates. The 
general suggestion in these chapters may be fairly 
summed up by considering that variations of disease 
based on environment may be mainly referred to 
climate and the mutations of weather. One such 
generalisation may be quoted: ‘‘ Wherein lies the 
difference in the European environment and the 
American? Wherein the energizing effect? What 
can cause the increase in autonomic dysfunctions ? 
I believe the explanation is a relatively simple one. 
While it is true that Europe has a typically cyclonic 
climate, the cyclonic disturbances are neither as 
frequent nor as violent as those in America. In 
Europe the rate of travel of the storms is only about 
half that of the speed that they attain in America. 
Very rarely does the degree of barometric fluctuation: 
reach the amplitude that we find so common along 
our storm tracks. It is the abruptness of the auto- 
nomic adaptation demanded by these changes that 
is of greatest moment.” 


The completion of Vol. I. has still to appear, and 
it is not quite clear in how many parts that will be 
issued. Sono attempt can be made toestimate definitely 
the value of this large and far-reaching production 
until the remainder comes under review. It seems 
likely that part two of Vol. I., announced as shortly 
forthcoming, may not prove the conclusion of the 
work. Enough has been published to show that 
Dr. Petersen is supplying the medical profession, 
and the public, with a compendium which must 
prove a useful book of reference. The second and 
third volumes were reproduced by lithoprinting so 
that a considerable saving of expense was brought 
about. In the first volume the ordinary method of 
production has been followed, and both the type 
and the definition of the illustrations may be 
commended. 


346 


THE LANCET] 


REPORT OF THE 
DEPARTMENTAL COMMITTEE ON 
CORONERS 


THE departmental committee appointed by the 
Home Secretary in February, 1935, to inquire into 
the law and practice relating to coroners, and to 
recommend what changes are desirable and prac- 
ticable, has brought in its report (H.M. Stationery 
Office. Cd. 5070. 1s. 3d.). The committee was made 
up of Lord Wright (chairman), Sir Archibald Bodkin, 
Sir Farquhar Buzzard, M.D., Mr. Digby Cotes- 
Preedy, K.C., Sir Arthur Hazlerigg, Mr. George A. 
Isaacs, Mr. W. Rutley Mowll, Mrs. Margaret Win- 
tringham, with Mr. A. Johnston, of the Home Office 
(secretary). The committee held 19 meetings and 
examined 68 witnesses. Its main recommendations 
are summarised for reference as follows :— 


The office of coroner should be retained, the 
coroner’s jurisdiction being limited to the investi- 
gation of the facts how, when, and where the death 
occurred and this investigation of facts being clearly 
distinguished from any trial of lability, whether 
civil or criminal. 

In cases of suicide the press should be prohibited 
from publishing an account of the proceedings at the 
inquest ; though the inquest should be held in public, 
as at present. All that the press should be allowed 
to publish is the fact that an inquest has been held, 
the name and address of the deceased, and the 
verdict that the deceased died by his own hand. 


The verdict of felo de se should be abolished, and 
the verdict in cases of suicide should simply be that 
the deceased died by his own hand. 

No inquiry into the state of mind of the deceased 
should be made in cases of suicide save in so far as 
it might throw light on the question whether he took 
his own life, and no reference should be made in the 
verdict to the state of mind of the deceased. 


The coroner should no longer have the power to 
commit any person for trial on the inquisition on a 
charge of murder, manslaughter, or infanticide ; and 
the inquisition should not name any person as guilty 
of one of these offences. 

In any case in which questions of criminality are 
involved the laws of evidence should be observed ; 
and where a person is suspected of causing the death 
he should not be called and put on oath unless he so 
desires, and should not be cross-examined. 


A coroner should be obliged to adjourn an inquest 
for 14 days, if requested to do so by a chief officer 
of police on the ground that he is investigating the 
circumstances of the death to determine whether he 
should proceed for an indictable offence; and the 
inquest should be adjourned for further periods of 
14 days if the chief officer of police repeats his request. 


Coroners’ courts should be prohibited from dealing 
with questions of civil liability. , 

Verdicts, or riders to verdicts, of censure or 
exoneration should be prohibited, but this prohibition 
should not extend to recommendations of a general 
character designed to prevent further fatalities. 

The coroner should have a discretion to dispense 
with the holding of an inquest in the case of deaths 
due to simple accidents, or to chronic alcoholism, 
and likewise in the case of deaths under an anexs- 
thetic or during an operation. He should be obliged 
to hold an inquest in cases of suspected industrial 
disease. 

Arrangements should be made to ensure that 
post-mortem examinations in cases of deaths due to 
anesthetics are carried out expeditiously. 

Post-mortem examinations ordered by coroners 
should, save in exceptional cases, be made by 
pathologists whose names appear on a list to be Kept 
by the Home Office. In compiling the list, the Home 


DEPARTMENTAL COMMITTEE ON CORONERS 


(FEB. 15, 1936 


Secretary would be advised by an expert advisory 
committee. There should be a special list of patho- 
logists competent to conduct post-mortem examina- 
tions in certain cases of industrial disease. 

The coroner, if so requested by a chief officer of 
police before the conclusion of an inquest, should 
direct a post-mortem examination to be made. If 
an inquest is not being held, or an inquest has been 
concluded, the chief officer of police should have 
power to order a post-mortem examination subject 
to the approval of the Director of Public Prosecutions 

Steps should be taken to secure the provision of 
better mortuaries and of places for post-mortem 
examinations. 

A Rules Committee should be established to make 
rules for the conduct of inquests and the procedure 
to be followed by coroners generally. The com- 
mittee should consist of persons appointed to repre- 
sent the Lord Chancellor,. the Home Secretary, 
Coroners Society, General Council of the Bar, Law 
Po British Medical Association, and general 
public. 

A Disciplinary Committee, similarly constituted, 
should þe created to deal with complaints about the 
conduct of coroners. 

Coroners should give, where practicable, reasonable 
notice of the time and place of inquests, especially in 
cases of industrial disease. 

The coroner should have a discretion to view or 
not to view the body. 

The London County Council should be empowered 
to prepare a scheme for the approval of the Home 
Secretary, setting out the areas to be served by each 
coroner’s court provided by the council. 

The provisions of Section 84 of the Coal Mines 
Act, 1911, in regard to the notification of inquests 
and representation of interested parties, should be 
extended to all industrial cases. 

Coroners should keep adequate records of the 
evidence taken before them at inquests, and copies 
should be available to any person who shows proper 
cause on payment of a fee. 

In these cases in which the coroner has at present 
a discretion to dispense with a jury, he should in 
future sit without a jury, unless there are reasons 
which appear to him to render the presence of a jury 
desirable. 

In jury cases the coroner should be empowered to 
hold a preliminary sitting of the inquest where 
desirable without the presence of a jury, for the 
purpose of receiving evidence of identification and 
issuing a burial order. 

Juries should be drawn from the jury list and, 
where a jury is empanelled in an inquest on a woman, 
child, or infant, at least two women should serve on 
the jury. 

Steps should be taken, whenever practicable, to 
merge the smaller coroners’ jurisdictions in larger 
areas. 

In future, only solicitors or barristers should be 
appointed as coroners, but, whenever possible, they 
should have had experience as deputy coroners and 
should have a knowledge of forensic medicine. 

Coroners should not act in their professional 
capacity as solicitors in matters which have been 
the subject of investigation at inquests held by them 
as coroners. 

Deputy coroners and assistant deputy coroners 
should be appointed and paid by the same authority 
as appoints the coroner, after consultation with the 
coroner to whom the deputy is being appointed. 

A coroner’s officer should in all cases be a serving 
police officer. 


Legislation will be required to give effect to most 
of these recommendations. The report is signed by 
all the members of the committee except Mr. Mowl), 
who submits a minority report. Sir Archibald 
Bodkin signs subject to reservations set out in a 
memorandum. Comment is made in a leading 
article on p. 377. 


ee ioe ee i A 


THE LANCET] 


THE LANCET 


LONDON : SATURDAY, FEBRUARY 15, 1936 


THE FUTURE OF THE CORONER 


Unanimity is a cardinal virtue in a Royal 
Commission or Departmental Committee. The 
Committee on Coroners is unanimous on one point 
only—namely, that the abolition of the coroner- 
ship is neither practicable nor desirable. It has 
examined the Scottish system of private investi- 
gation of unnatural deaths by the procurator 
fiscal and does not find its adaptation to England 
to be feasible. The reason is that the procurator 
fiscal’s inquiries in Scotland are part of his 
ordinary duties in the prosecution of criminal 
offenders on behalf of the Crown. As has been 
pointed out in these columns, there is no such 
exclusively official scheme of prosecution in 
England where the proportion of indictable 
offences undertaken by the Director of Public 
Prosecutions is much less than one per cent. of 
the total. The conclusions of the Committee’s 
report (Cmd. 5070. H.M. Stationery Office. 
ls. 3d.) are printed on another page. Some of 
them, as we shall see, involve fresh legislation. 
But it is noteworthy that one experienced legal 
member of the Committee, Mr. W. RUTLEY 
Mow, found himself unable to sign his colleagues’ 
report, while Sir ARCHIBALD BODKIN, who speaks 
with almost unique authority on the administra- 
tion of the criminal law, signs it subject to weighty 
comments and reservations. It may well be, 
therefore, that a Coroners (Amendment) Bill will 
not be introduced immediately. 


Several of the current complaints of coroners’. 


practice and procedure, declared by the Com- 
mittee to be well founded, are criticisms which the 
More judicious coroners escape. They are points 
in which the high level of the best of these tribunals 
could be uniformly attained by all if attention 
were drawn by Home Office circular to what needs 
to be avoided. Coroners ought to know, for 
instance, that the law courts condemn the employ- 
ment of the same persons as jurors at inquests 
again and again. The decision in R. v. Divine, 
ex parte Walton in 1930* left no doubt about this ; 
yet the Committee is told of a town where the 
eoroner’s jury regularly consists of the inmates of 
the workhouse. Such a practice is a scandal; 
the Committee recommends legislation to secure 
that inquest jurors be chosen from the ordinary 
jury list and that at least two women jurors be 
summoned where the inquest concerns a woman, 
child, or infant. Another indefensible impropriety 
is the making of irrelevant animadversions upon 
the conduct of persons who are in any way brought 
before the tribunal. The Committee cites an inquest 
upon a girl of 19 who was said to have had sexual 


2? THE LANCET, 1930, i., 426. 


THE FUTURE OF THE CORONER 


[FEB. 15, 1936 377 


relations with a much older married man. Medical 
evidence entirely disproved an allegation that he 
had been responsible for her death ; yet the coroner, 
at the request of the jury, went outside his province 
and censured the man for his relations with the 
deceased. Other coroners, the Committee says, 
use their public position to attack the beliefs held 
by Christian Scientists or to criticise the adminis- 
tration of a hospital, the status and competence of 
its medical staff, and the specific method of a 
patient’s treatment. Thus an individual finds 
himself condemned without redress or right of 
appeal. The Committee insists that this practice 
must stop. It desires also to prohibit coroners’ 
juries from bringing in riders imputing responsi- 
bility (even where moral blame is disclosed) or 
purporting to exonerate. The only permissible 
riders, it insists, are those which contain pro- 
posals for limiting the recurrence of fatalities. 
Interested parties are all too fond of turning an 
inquest into a skirmish over civil liability, groping 
for admissions which may later be useful in the 
county court or High Court and wasting time over 
minor allegations of negligence which are outside . 
the plain issue before the coroner. The purpose of — 
an inquest is, after all, made clear by Section 4 
of the Act of 1887. The inquisition is to elucidate 
three matters—first, the identity of the deceased ; 


secondly, how, when, and where he came by his 


death ; and thirdly, if he came by his death by 
murder or manslaughter, the persons (if any) whom 
the jury find to have been guilty. 

Hitherto we have mentioned criticisms which, 
if all coroners had been blessed with the wisdom 
of Solomon, no Committee need have been con- 
stituted to meet. We come now to the Com- 
mittee’s proposals for altering the law in directions 
where the best of coroners could take no step 
unless Parliament first decides the policy. The 
Committee recommends that the third of the 
above-mentioned statutory purposes of an inquest 
be cancelled, that the inquisition should no longer 
name anyone as guilty of murder, manslaughter, 
or infanticide, and that the coroner should no 
longer have power to commit persons for trial. 
If questions of criminality arise, the laws of 
evidence are to be observed; if a person is 
suspected of having caused the death, he is not 
to be called and put on oath unless he so desires, 
and he is not to be cross-examined. Already, 
under Section 20 of the Act of 1926, inquests 
are adjourned as soon as criminal proceed- 
ings are launched before the magistrates. It is 
unnecessary and inconvenient to have two con- 
current investigations, and the coroner stands aside 
when the ordinary procedures of prosecuting an 
offender are definitely taken. In future, the 
Committee proposes, the coroner will adjourn at 
the request of the police on their mere assurance 
that prosecution is possible. The coroner is also 
to direct a post-mortem examination, if the police 
so desire, before an inquest is ended. If an inquest 
is not held, or if it is already over, the police are 
to have power to order a post-mortem examination 
subject to the approval of the Director of Public 
Prosecutions. These proposals are evidently based 


378 THE LANCET] 


_ on two ideas—the unfairness of a coroner plying 
a suspect with questions, and the uselessness of 
the inquest as an aid to the police in the detection 
of offenders. On this latter point the experts 
differ. The majority report of the Committee 
assumes that the inquest ‘can contribute little, 
even in poisoning cases. A witness from Scotland 
Yard declared that the private questioning by the 
police of possible witnesses or possible suspects 
was more likely to elicit information than the 
proceedings at an inquest. Moreover, witnesses 
who represented the police forces outside London 
disclaimed any desire to use inquests as a means 
of extracting incriminating information. But 
there may still be old-fashioned folk who fear 
that private questionings by the police can be 
as grave an abuse as public interrogations by a 
coroner. Sir ARCHIBALD BODKIN points out that, 
if essential witnesses refuse to disclose their know- 
ledge to the police, and if there is consequently 
not’ enough evidence to justify an arrest, the 
present system of the inquest is the only other 
method of compelling disclosure. He regards the 
coroner’s powers in such cases as valuable adjuncts 
to the present administration of the criminal law. 

There will probably be less controversy over the 
Committee’s recommendations as to cases of 
suicide. Until modern times the law lagged 
behind the public intelligence. It dealt with self- 
murder (felo de se) by forfeiting the dead man’s 
goods to the Crown and by burying his body at 
the cross-roads without religious ceremony and 
with marks of infamy in order to mark the ecclesi- 
astical condemnation of his offence. The verdict 
of unsound mind became popular to mitigate 
these harsh consequences. It has outlived the 
conditions which were thought to justify it, and, 
if it were taken seriously, it would confuse the 
national statistics of crime and insanity. If the 
law applied to suicides the same tests of criminal 
responsibility as are insisted upon in the criminal 
courts, few persons who have taken their own 
lives would be found of unsound mind. To 
remedy this curious convention of insanity at 
inquests, the Committee boldly proposes (as did 
the Chalmers Committee on Coroners in 1910) to 
abolish the verdict of felo de se in the coroner’s 
court ; it will no longer be his duty to attribute 
felonious responsibility ; the verdict will simply 
be that the deceased died by his own hand. 
Further, to prevent the imitative suicide and the 
publicity which relatives must find so painful, the 
_press is to be prohibited from giving an account of 
inquests on suicides. The inquest is still to be 
held in public but the newspapers are to publish 
only the fact of the holding of the inquest, the 
name and address of the deceased, and the bare 
verdict that he died by his own hand. This will 
involve legislation on the lines of the Judicial 
Proceedings (Regulation of Reports) Act, 1926, 
which was passed to suppress unsavoury details, 
especially in divorce cases. The proposal will 
encounter not only the opposition of the journalists 
but also the practical difficulty of the coroner, 
who cannot announce that the case is one of suicide 
until the verdict is returned. The Committee 


THE FUTURE OF THE CORONER 


[FEB. 15, 1936 


suggests that he should state at the outset that a 
verdict of suicide is possible, whereupon the press 
would be forbidden to publish any account till 
the verdict was ascertained. If the law eliminates 
from inquest verdicts all reference to the deceased’s 
state of mind in cases of suicide, coroners will no 
longer need to read in court letters and other 
intimate documents written by him which are 
often painful and harmful to living persons. It 
may still be necessary to inquire into the state 
of a dead person’s mind in order to decide whether 
he took his own life; suicide may still remain 
self-murder in law; but a great reform will have 
been achieved if the Committee’s proposal receives 
effect. 

Other recommendations are important to the 
medical profession. It is proposed that post- 
mortem examinations, ordered by coroners, be 
made by pathologists whose names are on a 
national panel constituted by the Home Office 
with the guidance of an expert advisory com- 
mittee. A special panel would be available for 
cases of industrial disease, and it is suggested 
that the Coroners Acts be amended to include 
among unnatural deaths any death believed due 
to illness or disease (including poisoning by gas, 
vapour, or fumes) resulting from the nature of an 
employee’s work. In recognition of the higher 
standard required of pathologists on the Home 
Office panels it is proposed that the post-mortem 
fee be raised from two to three guineas and that 
travelling expenses and a fee for attendance at the 
inquest be allowed. At the same time it is 
suggested that the ordinary medical attendant of 
the deceased should be entitled to an appropriate 
fee for supplying a report on the case or attending 
an examination. It is often important to collate 
the clinical and the post-mortem evidence. A 
further recommendation that better provision be 
made for mortuarics and places for post-mortem 
examinations was long overdue. A few important 
miscellaneous recommendations remain to be 
mentioned. It is proposed that the coroner 
should have discretion to dispense with an inquest 
where deaths are due to what the Canadian laws 
call “‘ mere accident or mischance,” or to chronic 
alcoholism or where death occurs under an anzs- 
thetic or during an operation. It has long been a 
matter of comment that in one coroner’s district 
a major operation resulting in death becomes the 
subject of an inquest, while in another district a 
similar case is not even investigated by the coroner. 
Some coroners hold inquests only where death 
actually occurs on the operating-table, others 
whenever death occurs: before the patient regains 
consciousness. The previous Committee, which 
reported in 1910, recommended that all deaths 
under an anesthetic should be reported to the 
coroner, that he should have a discretion as to 
holding an inquest, and that the hospital or other 
public institution concerned should hold a scientific 
investigation. The Minister of Health took up 
this proposal in 1920, but it has been difficult for 
hospitals to take action inasmuch as the dead body 
comes under the control of the coroner. 

Lastly, we come to the proposals affecting the 


THE LANCET] SALT AND 


coroner’s office. The recent report does not press 
for whole-time coroners, but it has embodied the 
suggestions of the Bar Council to the effect that 
in future only barristers or solicitors should be 
appointed. It is doubtful whether there is any 
public demand for this limitation. The inquest in 
South Dorset on Mr. JEFFERYS ALLEN, an old 
gentleman of 86 who was found dead with his 
head against a coal fire, is singled out for prolonged 
comment by the Committee and indeed is possibly 
the cause of the Departmental Committee having 
been constituted a year ago. That inquest was 
not held by a medical coroner. There are at 
present in England 268 coroners who are barristers 
or solicitors, 37 who are medical practitioners, 
and 4 who have no professional qualifications at all. 
While it is proposed to eliminate the medical 
coroner here, it is worth noting that in New York 
the coroner has been replaced by medical examiners 
who, since 1918, have sole charge of the medical 
investigation of sudden, violent, and suspicious 
deaths. Doubtless in England the influence of 
the Lord Chancellor makes for a preference for 
legal coroners. This legal influence it is now 
proposed to extend by giving the Lord Chancellor 
fresh powers of removing unfit coroners and by 
creating two new committees. A Rules Com- 
mittee is to make rules for procedure at inquests. 
Naturally much will depend on the nature of the 
rules. A power to make rules was given to the 
Lord Chancellor by the 1926 Act and he has made 
little use of it. The second committce is to be a 
Disciplinary Committee, apparently on the lines 
of the tribunal which, under the Solicitors Acts, 
takes up the grievances of clients and enforces 
standards of professional conduct. Coroners will 
be haled before this body {or censure. There is no 
such tribunal where members of the public can 
obtain redress when annoyed by the behaviour 
of judges, recorders, or magistrates. If the coroner 
is worth keeping at all, he should remain as an 


` independent judicial officer who can do his work 


fearlessly withovt the risk of being harassed by 
disgruntled witnesses or unsuccessful advocates. 


SALT AND THE SUN 


Ir is difficult for the European to understand 
the prominence given to salt in the phrase and 
fable of the East. Here, where its lack is 
improbable, it ranks merely as one, perhaps the 
highest, among the condiments: there, it 1s one 
of life’s necessities ; the salt of the earth is second 
only to the water of life—indeed, the gods, in 
Egypt for example, have been worshipped as 
“ givers of bread and salt.” With animals it is 
of even greater importance; big game can be 
induced to forsake an ancient drinking pool 
simply by moving a block: of rock salt, and no 
herd of cattle is without its Jicking-stone. In 
temperate climates this need for salt is not apparent 
because there is ample in the food to balance excre- 
tion. In the tropics, however, its value is shown 
when it is realised that in the least oppressive 
circumstances a man may lose by sweating alone as 
much salt as he normally absorbs from his diet. The 
average volume of sweat in the hot weather in 


THE SUN [FEB. 15, 1936 379 


India is seven litres a day, containing about 20 g. 
of sodium chloride, and this is the amount in the 
normal diet; as the daily requirements in these 
circumstances are at least 32 g. there is a consider- 
able deficit to be supplied by the tissues. 
It was to this that, in a letter to our columns,! 
Lieut.-Colonel O. R. McEWEN attributed the vague 
ill-health and loss of efficiency so common in the 
white inhabitants of hot countries. Though differ- 
ing in degree, this state is similar to that giving 
rise to the severe miner’s cramp described by 
Prof. K. N. Moss, when the fluid lost by excessive 
sweating is replaced only by water. Referring 
to Colonel McEwen’s theory, Sir WALTER 
‘Lancpon-Brown later drew attention ? to another 
and severer form of the condition in the tropics 
known as functional hypo-adrenalism. He 
compared it with Addison’s disease which is very 
similar in its great salt excretion, its symptoms 
of asthenia, lassitude, insomnia, anorexia, and 
achlorhydria, and its response to sodium chloride. 
He thought that this knowledge should diminish 
the zest with which salt-free diets were often 
prescribed, especially in asthenic states. The 
effects of a severe deficiency of sodium chloride 
were described on Jan. 30th at the Royal Society. 
Dr. R. A. McCance had given a diet with the 
least possible sodium chloride, collecting all the 
excretions and estimating the sodium in the body. 
Fluids were not restricted and the low protein was ` 
augmented by “ashless”’ casein. It was found 
that there was a deficiency of 25-35 per cent. of 
the body sodium, with symptoms of weakness, 
fatigue, and muscular cramps; the blood showed 
a rise in the cell count, viscosity, hæmoglobin, 
protein, and urea. Health was regained when 
sodium chloride was restored to the diet. This 
action does not seem to be purely that of any 
electrolyte, for E. H. DERRICK found? that 
ammonium chloride was ineffective in relieving 
miner’s cramp; the sodium is at least as important 
as the chloride. These observations show that a 
large proportion of the indefinite, if not the serious, 
effects of torrid climates can be avoided, with 
the intelligent coöperation of the cook, by greatly 
increasing the salt intake. 


The growth of industry and settlement in the 
tropics has made the whole subject of the effects 
of great heat one of increasing importance, but 
as usual ignorance of their nature is betrayed by 
the confusion in nomenclature. The different types 
are vaguely and variously called heat prostra- 
tion, heat exhaustion, heat-stroke, sunstroke, and 
miner’s, stoker’s, and fireman’s cramp, though the 
clinical syndromes themselves may be well defined, 
and there is no better inclusive title than “the 
effects of heat.” The prevention of these is 
simple, but inventive science seems to have stopped 


‘short at punkahs, long drinks, and short shifts. 


Climate is treated with the same casual tolerance 
shown to the other states dismissed as being 
beyond man’s control, and even in the last decade 
the construction of refrigerated offices in Calcutta 
suffered the editorial scorn of a London newspaper. 


1THE LANCET, 1935, i., 1015. ? Ibid., p. 1069. *Ibid., p. 38. 


380 THE LANCET] PURIFICATION 


The human body, however, can adapt itself to 
conditions with great extremes of temperature, 
from exploring the Poles to mining in the tropics ; 
it is only when mechanisms fail, which in ordinary 
emergencies are enough to protect the organism, 
that illness occurs. Almost always this is due to 
purely physical changes in the internal fluids, 
CLAUDE BERNARD’sS milieu intérieur, upon the 
delicate adjustment of which depends the life of 
every cell. LEE 4 has divided the effects of heat 
into four groups: heat cramps, dehydration, heat- 
stroke in the nervous system, and heat exhaustion 
in the circulatory ; the first two are due directly to 


‘Lee, Douglas H. K.: Trans. Roy. Soc. Trop. Med. and 


Hyg., 1935, xxix., 7. 


OF THE HEMOPOIETIC FACTOR 


[FEB. 15, 1936 


changes in the water-salt balance, and the others to 
the high temperature. Experiments upon miners on 
the Rand ° and in the Urals ® have shown that the 
great majority of casualties can be prevented by 
carefully estimating the heat tolerance of recruits 
and then by acclimatising them with graded work. 
By such simple measures as good ventilation, 
light clothing, suitable drinking fluids, and careful 
training, this type of disease can be limited until 
it becomes merely the penalty for negligence, 
instead of a danger to a large part of the population 
at home and abroad. 

$ Dreosti, A. O. : Proc. Transvaal Mine Med. Officers’ Assoc., 
1934, xiii., 32. 


*Starkov, P. M., and Jikesh, J. V.: Jour. Indust. Hyg., 
1935, xvii., 247. 


ANNOTATIONS 


PURIFICATION OF THE HAMOPOIETIC 
FACTOR 
PROGRESS towards identification of the hemopoietic 


(blood-forming ) substances in liver has been curiously 
slow and discouraging. There are two reasons for 


the delay: first, experience has shown that most. 


of the chemical methods which would otherwise 
be appropriate result in inactivation of the product ; 
secondly, it is hard to find suitable clinical cases for 
testing the activity of isolated extracts. Lately, 
however, there has been an outburst of successful 
activity in widely scattered laboratories. Dakin 
and West in New York last year prepared a substance, 
to which the name Anahexmin has been given, which 
appeared capable of inducing a remission when given 
in doses as small as 80 mg. A few weeks later 
Strandell and his colleagues in Sweden reported that 
they had been able to obtain from 100 g. of liver 
a substance so highly purified that 2 mg. would 
induce a remission. Two papers published in our 
present issue record the further progress made in 
this country, and our readers will agree that the 
Medical Research Council has performed a useful 
service in supporting these investigations and in 
arranging for anahæmin to be submitted to clinical 
trial under the supervision of acknowledged experts 
working in conditions which permit of exact control. 
Prof. Davidson, Dr. Ungley, and Prof. Wayne 
emphasise the difficulty of assessing potency in tests 
limited to a small number of cases, but are able to 
conclude that anahxmin is highly active for blood 
regeneration ; indeed, in their experience no other 
liver extract given in such small amounts has produced 
such striking results. Preliminary observations 
indicate also that this highly purified fraction may 
prove to be equally potent in the treatment of the 
nervous manifestations. The English preparation 
seems rather less active than the original fraction 
described by Dakin and West, since 80-150 mg. 
of the latter usually induced a maximal response, 
whereas the observations of Ungley and his colleagues 
suggest that only rarely is an average dose of 359 mg. 
maximally effective. Dr. J. F. Wilkinson likewise 
confirms the value of the new methods of fractiona- 
tion introduced by Dakin and West; he found that 
58-120 mg. of a fraction similarly prepared were 
maximally effective. But he has carried purification 
even further, and gets maximal responses with total 
doses of only 18-36 mg., representing an original 
amount of 660-1332 g. of fresh liver. IT*urther 


analysis of the chemical nature of this fraction will 
be eagerly awaited. 

Though treatment with the less highly purified 
preparations already available for parenteral injection 
is extremely satisfactory if properly carried out, these 
recent attempts to purify the effective principle are 
of great theoretical importance; for it is only when 
the chemical constitution of the effective principles 
in liver and stomach are known that the complex 
relationship of these substances will be understood. 
Castle’s original hypothesis that the effective factor 
in liver is formed by the action of an extrinsic factor 
(present in beef muscle) with an intrinsic factor in 
gastric juice has recently been questioned, and an 
alternative explanation of the observed experimental 
results is put forward by Greenspon,! who suggests, 
on the strength of experiments at present rather 
incompletely reported, that it is unnecessary to 
assume tho existence of any extrinsic factor at all. 
He believes that the hemopoietic factor in gastric 
juice is normally inactivated by pepsin; the beef 
(or other source of extrinsic factor), when incubated 
with normal gastric juice, binds pepsin and prevents 
it from inactivating the anti-anzemic principle, but 
does not provide any other essential principle. The 
arguments and experiments with which this suggestion 
is supported are stimulating, but they leave many 
important points which are more adequately explained 
by Castle’s hypothesis. The answer to these important 
theoretical problems lies in the hands of the chemists, 
working in close collaboration with the clinicians, 
as has been done in carrying out the work reported 
in our columns to-day. 


EXPERIMENTAL HYPERTENSION 


THE repercussions of renal disease upon the cardio- 
vascular system are still a subject of lively debate. 
On the one hand is the incontestable supervention 
of arterial hypertrophy and persistent high blood 
pressure upon a primary Bright’s disease. On the 
other hand is the fact that experimental ablation of 
one or both kidneys has, on the whole, demonstrated 
that mere reduction of renal tissue will not of itself 
initiate a rise of blood pressure, though there is 
reason to believe that gradual reduction of renal 
tissue, either by excision or by lgaturing vessels, 
will lead to a rise of pressure when the borderline 
of the amount of tissue necessary for life is approached. 
Puzzling and apparently irreconcilable is the occasional 
finding, in children, of an advanced stage of chronic 


1 Greenspon, E. A.: Jour. Amer. Med. Assoc., January, 1936, 
p. 266. 


THE LANCET] OXYGEN DEBT AND 
Bright’s disease without accompanying cardiovascular 
hypertrophy. 

The present impracticability of reproducing in 
animals a nephritis comparable with Bright’s disease 
in man may be responsible for most of the negative 
results of attempts to establish an experimental 
hypertension by means of known irritants. Con- 
siderable interest therefore attaches to the claim of 
Dr. W. M. Arnott and Dr. R. J. Kellar,’ working in 
Edinburgh, to have produced hypertension in rabbits 
by intravenous injection of sodium oxalate. The 
difficulty of estimating the blood pressure was over- 
come by a modification of Van Leersum’s technique, 
in which a loop of the carotid is brought to the surface 
and enclosed in a tubular strip of skin. It is note- 
worthy that the observed rise of pressure, which 
appears to be statistically significant, was not main- 
tained for longer than twelve days after which there 
was ‘‘a pronounced instability.’ Further experi- 
ments * were carried out by the same workers on a 
large series of rabbits in order to elucidate the 
mechanism of the hypertension. They found that 
the blood pressure tended to fall after bilateral 
nephrectomy, and that administration of oxalate 
to such animals shortened the survival period but 
did not influence the level of the blood pressure. 
When one kidney only was removed the usual hyper- 
tensive response was obtained with oxalate. Arnott 
and Kellar therefore concluded that the hypertension 
was of renal origin. Their view was strongly sup- 
ported by a further experiment, on a series of 18 
animals, in which one kidney was removed and the 
other denervated. Thirteen animals survived and 
were then given a course of oxalate injections; no 
hypertension was observed. The inference from this 
is that the mechanism of oxalate hypertension in 
rabbits is of the nature of a nervous reflex. In 
attempting to assess the importance of these observa- 
tions it should not be forgotten, first, that oxalate 
nephritis is essentially a tubular nephritis without 
demonstrable lesions in the glomeruli; secondly, 
that the hypertension produced by these experi- 
ments appears to be of short duration. In these 
respects there is a wide gulf between this experi- 
mental condition and the nephritic hypertension of 
man, but the demonstration of a nervous mechanism 
in any form of hypertension is a progressive step. 


OXYGEN DEBT AND CHEST MOVEMENT 


In the search for methods of assessing the efficiency 
of the respiratory apparatus more than one worker 
has attempted to arrive at some way of using oxygen 
consumption under fixed conditions as an easily 
measured test for respiratory efficiency. The use of 
“oxygen debt” as such a test has certain super- 
ficial attractions and, according to a preliminary 
account? by H. C. Jacobaeus, G. Nylin, and B. 
Almberg, may be of some value. Oxygen -debt is 
defined as the amount of oxygen used after cessation 
of a period of exercise in excess of the resting oxygen 
utilisation for the same length of time and, although 
the mechanism is by no means simple, this pheno- 
menon is closely related to lactic acid formation 
during the exercise. Nylin already claims to have 
shown that, with a measured amount of work, 
patients with heart disease have an increased oxygen 
debt when cardiac failure occurs. In the present 
study patients suffering from pulmonary disorders, 
especially advanced silicosis, were found to have 


1 Brit. Jour. Exp. Path., 1935, xvi., 265. 
* Jour. Path. and Bact., January, 1936, p. 141. 
3 Acta med. Scand., 1935, Ixxxvi., 455. 


CHEST MOVEMENT [FEB. 15, 1936 381 

values for oxygen debt in excess of expectation. It 
was decided to see whether this finding could be . 
connected with diminished movements of the chest 
wall, and a series of ten subjects were examined 
with and without constriction of the thorax by 
means of a stiff belt. This had the effect of reducing 
an average vital capacity of 4'5 litres to 2'4 litres. 
The effect of the belt was reflected in the oxygen 
debt which was always materially increased, in cer- 
tain instances resembling the type of increase found 
in severe heart failure. The authors conclude that 
the mobility of the thorax plays a more important 
part in the cardio-respiratory functions than had 


_ been hitherto accepted. Further investigation which 


is In progress might well include a study of what is 
happening in the blood as regards' lactic acid and 
carbon dioxide. The depletion of bicarbonate 
during exercise has to be made good and interference 
with respiratory movements must affect the amount 
of carbon dioxide blown off as well as the oxygen 
taken in. The links between movements of the 
thorax and the chemistry of muscular exercise are 
many, and a wide survey will be needed before it can 
be assumed that oxygen debt affords a simple test 
of cardiac or pulmonary efficiency. 


EPIDEMIOLOGY OF TUBERCULOSIS 


THERE are still some who believe that adult tuber- 
culosis is due to the reawakening of a focus acquired 
in childhood, and perhaps more who do not admit 
that the disease is infectious, at all events to a degree 
which should forbid the association of a patient with 
other individuals under ordinary conditions of living. 
Anyone entertaining these beliefs will have them 
severely shaken if he studies a series of papers 
recently published ! by F. M. McPhedran and E. L. 
Opie, which record the latest results of a study of 
tuberculosis, with the earlier stages of which many 
of our readers are familiar. These authors have for 
years past observed tuberculosis in a large section of 
Philadelphia, not merely as it affects individuals, 
but as it attacks families, and their chief conclusion 
may best be stated in their own words. ‘‘ The 
spread of tuberculosis occurs in large part by long 
drawn-out family or household epidemics, in which 
the disease is slowly transmitted from one generation 
to the next.” 

The evidence on which this statement is based is 
voluminous, detailed, and closely analysed. The 
criteria used to determine the existence of the 
infection are the intradermal tuberculin test, the 
skiagram, and clinical examination. For purposes 
of deduction, families are divided into those in 
which a member has tubercle bacilli in the sputum, 
those including a member with tuberculosis but 
without discoverable bacilli in the sputum, and those 
with no known contact with the disease. The 
frequency of a positive tuberculin reaction during 
early years, and of manifest tuberculosis both then 
and in later years is, in different degrees and at 
different ages, unmistakably or even overwhelmingly 
greater in the first two of these categories than the 
last. It is to be inferred that the absence of tubercle 
bacilli from the sputum on such occasions as those 
when it was examined does not mean that they had 
at no time been present. Findings of this kind have 
been recorded before; we may recall a report ? 
edited by Dr. G. Lissant Cox on the fate of young 
children in tuberculous households of Lancashire. 
What is perhaps more interesting and more contro- 


1 Amer. Jour. Hyg., 1935, xxii., 539, 565, G44. 
* See THE LANCET, 1920, i., 1201. 


382 THE LANCET] 


versial is the argument used to sustain the thesis 
that pulmonary tuberculosis in the adult is acquired 
by recent contact, and does not result from the 
renewed activity of a focus acquired in childhood. 
Among the ingenious methods of analysis and presenta- 
tion by which the authors’ extensive data are 
utilised to this end is the unusual device of the 
three-dimensional diagram. The whole argument is 
incapable of condensation, but one item of evidence 
can be stated quite briefly: it is that among indi- 
viduals exposed to infection for the first time after 
15 years of age nearly 10 per cent. develop manifest 
tuberculosis, a frequency exceeding that in the 
general population to much the same extent as that 
among child contacts in contrast with the children of 
healthy families. Throughout these studies a clear 
distinction is drawn between findings in whites and 
negroes; the different behaviour of the disease in 
coloured races is hence no reason for refusing to 
apply their conclusions to any white population. 

The authors would have us recognise that pul- 
monary tuberculosis is an infectious disease, differing 
from other infectious diseases and concealing its real 
nature only by the fact that its incubation period is 
often reckoned in years. Those concerned with the 
care of the tuberculous should study these papers 
carefully ; it is much to be hoped that similar studies 
may be pursued in this country by those to whom 
the opportunity is available. 


CATGUT AND TETANUS 

SEVERAL cases have recently been reported in this 
country of tetanus following surgical operation 
in which catgut has been used as a ligature materia}, 
and the question has arisen whether the catgut may 
not have been the source of infection. The Thera- 
peutic Substances Regulations of 1931 placed the 
commercial production of sterilised gut under expert 
control by the Ministry of Health, and since then 
the risk of non-sterile catgut reaching the hands of 
surgeons is lessened, if it has not been actually 
eliminated. An American investigation 1 has suggested 
that catgut, prepared by commercial firms in several 
countries of the world, is still often non-sterile. It 
seems fairly clear, however, that such British material 
as was used in this investigation dates from the 
period before the application of Government control. 
But this control only applies to catgut as it is 
offered for sale and not to gut prepared in hospitals 
or by surgeons for use in institutions or private 
work. From the discussion (see p. 366) last week 
at the Royal Society of Medicine it is evident that 
grave risk is being run from the use of catgut prepared 
under inadequate control. The dry unsterilised gut, 
used as raw material by some of the smaller hospitals 
which prepare their own ligatures, teems with micro- 
organisms—anaerobes and aerobes with their spores— 
to deal with which demands efficient processes of 
sterilisation, scientific rather than traditional. As 
W. Bulloch showed in 1929 it is possible under ideal 
conditions of manufacture, with the use of heat and 
certain chemical substances, to prepare catgut which 
satisfies routine bacteriological investigation. Whether 
such material will still be proved sterile after it has 
been subjected to digestion in the tissues remains 
to be seen; but the clinical experience of hundreds 
of surgeons, in thousands of cases where standard 
commercial catgut has been used, suggests that the 
risk is extremely small. What has been done so 
successfully in some hospitals should be feasible 
in others, and the time has come when the sterility 
of every brand of catgut used by surgeons should 


2 Clock, R. O. ; Surg., Gyn., and Obst., 1934, lix., 899. 


CATGUT AND TETANUS 


[FEB. 15, 1936 


be controlled by standardised investigation. It is 
urgently necessary that some cheap and efficient 
method of sterilisation should be placed in the hands 
of the smaller hospitals and private surgeons who 
sterilise their own catgut, which, if rigidly followed, 
would remove a risk which, if numerically small, is 
yet a very terrible one. Where catgut is employed, 
as it generally is, because it is absorbed by the tissues, 
obviously the interior of the catgut must be as sterile 
as the exterior ; and digestion methods in the bacterio- 
logical laboratory afford the only means of checking 
this. When delayed absorption is the aim the surgeon 
should satisfy himself that the 20, 40, and 60-day 
catgut is really absorbed within a few days of the 
time specified on the containers. 


A REMEDY FOR VAGINAL INFECTIONS 


DEVEGAN is the manufacturers’ name for a combina- 
tion of 4-oxy-3-acetyl-amino-phenyl-arsinic acid with 
boric acid in a carbohydrate vehicle. The arsenical 
constituent is, therefore, identical with the arsenical 
derivatives, Stovarsol, Spirocid, and Orarsan, which 
are widely used in the oral therapy of syphilis. The 
compound is made in the form of tablets for insertion 
into the vagina and for some time has been available 
to the medical profession in this country. The 
advantages claimed by German writers are that 
it causes vaginal discharges—particularly those 
associated with the flagellate protozoén Trichomonas 
vaginalis—to diminish in satisfactory and often 
remarkable fashion; and that much inconvenience 
and expense are saved to patients owing to the ease 
with which self-treatment can be carried out. The 
unpleasant and sometimes harmful practice of regular 
vaginal douching can thus be dispensed with. 

It is inevitable that a new preparation which is 
relatively inexpensive and easy of application and 
produces a fair proportion of excellent results should 
be employed somewhat indiscriminately when its 
advantages are first appreciated. Accordingly, it 
is useful to have Hauptstein’s! review of results in 
185 cases of vaginal discharge treated with devegan 
at the gynecological clinic of the University of 
Freiburg (Breisgau) during 1933-34. By far the 
best results, he says, were obtained in those whom 
it was possible to treat as in-patients; among out- 
patients the results were less encouraging, while 
the effects of self-treatment at home were regarded 
as quite unsatisfactory—a result attributed to lack 
of coöperation. As. many as 48 per cent. of this 
last group failed to remain under observation and 
it was decided not to proceed with the investiga- 
tion in this series. Among in-patients, the procedure 
adopted varied according to the severity of the 
infection and the amount of discharge. All self- 
douching was prohibited. Where conspicuous inflam - 
matory changes of the vagina wall were noted the 
earlier insertions of devegan were preceded by vaginal 
douche of silver nitrate 3-5 per cent. or 1 per cent. 
corrosive sublimate, or both, and this was continued 
until the local condition showed improvement. 
One to four tablets of devegan were inserted high 
in the vaginal fornices, at first twice daily (if this 
was considered necessary), and then at lengthening 
intervals until finally the treatment was given just 
after the menstrual periods only. In more than 
two-thirds of the cases the desired result was produced 
within two weeks to two months. Some patients 
complained of the thick unpleasant discharge of 
unaltered masses of devegan, but this difficulty was 
overcome by the insertion of vaginal plugs of cotton- 


1 Hauptstein, P.: Med. Welt., Dec. 21st, 1935, p. 1345. 


THE LANCET] 


wool, which the patients themselves could remove 
after 24-36 hours. The criteria of success were the 
absence of recurrence of discharge long after dis- 
continuance of the treatment, the absence of the 
trichomonas flagellate on microscopic examination 
of the vaginal secretion after menstruation, and the 
presence of normal vaginal flora including the lactic 
acid bacillus. Impressions of the treatment were 
definitely favourable, both in trichomonas infections 
and those which were believed to be non-specific. 
Complete disappearance of discharge or substantial 
improvement occurred in all but a small proportion 
of cases (about 8 per cent. of the trichomonas 
infections and about 4 per cent. of the non-specific). 
Hauptstein regards the results as definitely superior 
to those obtained with the various antiseptic douches 
formerly in vogue, and he puts down relapses and 
partial failures to irregular attendances or indiscretions 
on the part of the patients, though the possibility of 
residual infection in urethra, rectum, or uterus, 
causing reinfection, is mentioned. A small number 
of patients showed toxic symptoms which were 
believed to be the result of the treatment: in 1 case 
there was nausea, in 9 there was local discomfort 
or pain of an itching and burning type, and in 1 
there was cdema of the labia. 

In this survey no mention is made of gonococcal 
infections, and it should be emphasised that there 
is as yet no evidence that devegan is effective in 
eradicating the gonococcus from its usual haunts. 
The practice of applying this treatment before full 
investigation to exclude gonococcal infection has 
been carried out must be condemned unreservedly, 
since it is likely to make the subsequent isolation 
of the causative organism difficult or impossible. 
Moreover, it should be noted that the method of 
self-treatment is usually unsatisfactory, even where 
the coöperation of the patient is assured, because 
of the mechanical difficulty of placing the tablets 
high in the vaginal fornices. Dr. Collis,2 who reports 
from Birmingham that all but 7 of 47 patients were 
clear of trichomonas infection after three months— 
and 5 of the 7 had an associated gonorrhea—points 
out that “all the patients were treated at the clinic 
as it was found that the tablets were more effectively 
inserted by an experienced person.”’ . 


‘ANAESTHETICS IN THORACIC SURGERY 


NoT many years ago lobectomy was a rare operation 
only to be witnessed at special chest hospitals. It 
is now a commonplace in these institutions and is 
likely before long to be included in the routine list 
of operations performed at large general hospitals. 
In an address to the section of anesthetics of the 
Royal Society of Medicine on Feb. 7th Dr. I. W. 
Magill commented on the diversity of methods of 
securing anesthesia for this operation. His own 
preference appears to be for cyclopropane, although 
‘this is admittedly contra-indicated when diathermy 
is used, and for spinal analgesia, the advantage of 
which according to Dr. Magill is becoming more and 
nore obvious in thoracic surgery. The fear that 
respiratory paralysis may supervene when spinal 
anesthesia is administered to patients with already 
limited respiratory capacity is apparently not 
confirmed by clinical experience. No doubt, said 
Dr. Magill, the explanation les in the fact that the 
motor roots are so much less affected by tle injection 
than the sensory that good analgesia is obtainable 
without corresponding depression of respiratory 


2 Collis, J. L.: Jour. Obst. and Gyn. Brit. Emp., February, 
1936, p. 387. 


FOR THOSE ABOUT TO MARRY 


[FEB. 15,.1936 383 


movement. This explanation was accepted by 
Dr. Langton Hewer, who in the course of the discussion 
voiced his general preference for nitrous oxide and 
oxygen which does not, he claimed, imply cyanosis. 
He recommends in severe chest operations the early 
insertion of a rectal tube through which glucose should 
be given towards the close of the operation. Dr. Magill 
disapproves of premedication by any drugs with 
prolonged action. He employs some of the barbiturates, 
which are quickly metabolised, and believes that one 
will still be discovered better than any yet available. 
In many of the thoracic operations it is necessary 
to employ suction of the bronchi in association with 
intubation, and it is often a great advantage to 
block off other portions of the lung. He showed an 
ingenious apparatus which he has devised and uses 
for this purpose. Mr. J. E. H. Roberts thought that 
diathermy was almost essential in lobectomy and 
precluded the use of any inflammable anesthetic. 
He did not like nasal intubation, and he drew attention 
to the very small amount of lung with which respira- 
tion could be effectively performed. Mr. H. P. 
Nelson likes cyclopropane for the quiet respiration 
it secures in the patient, but a disadvantage is that 
it increases the bleeding. In his view cyclopropane 
seems to lead the field for mediastinal dissections. 


FOR THOSE ABOUT TO MARRY 


THE scheme for voluntary prenuptial health 
examinations issued by the Eugenics Society this 
week ! is constructed on such a broad foundation that 
it may well develop into a service of national 
importance. The scheme differs from those established 
in certain European countries in many respects, 
of which the most important is that it is designed 
only for those who themselves seek information and 
advice before contemplating marriage and indeed 
could not be worked on a compulsory basis. More- 
over, the examination is not intended solely to serve 
the purpose of preventing dysgenic marriages or of 
checking the fertility of undesirable stocks—it has 
the further aim of improving the prospects of a 
successful and happy marriage. The distinguishing 
features of the scheme are that the applicant deals 
only with a doctor of his choice, through whom alone 
he can receive the schedules to be filled up. If the 
doctor is in doubt about the significance to be attached 
to the answers to the questions, or to his own findings 
on physical examination, he can seek the opinion of 
a consultant; or if it is a problem of heredity that 
puzzles him the Eugenics Society will be prepared 
to help in its solution through the good offices of a 
board of specialists. It is recognised that some 
doctors who are especially interested in the subject 
will have formulated their own questions and methods 
of physical examination. But in view of the 
infrequency of the demand hitherto it is likely that 
others may have little experience of such examina- 
tions and may be glad to use the pattern of pre- 
marital health schedule here provided. 

It consists of three parts of which the first relates 
to the applicants family history—notably con- 
sangwinity of proposed partners, the ages and causes 
of death of near relatives, and, more important, the 
incidence in near and distant relatives of diseases 
and defects (specified) which are thought to be 
hereditary. The second part of the schedule is 
divided into three sections, A, B, and C, in which 
questions are asked about (A) physical diseases, 
(B) psychological abnormalities, and (c) sexual 


'Obtainable from the general secretary 
at 69, Eccleston-square, London, S.W.1. 


of the society 


ae 


384 THE LANCET] THE ACTION OF POSTERIOR 
problems. The questions on physical diseases have 
been framed in accordance with the experience of 
insurance companies; those on possible nervous 
troubles bear the stamp of wise psychological advice ; 
while the third section is skilfully planned to enable 
the applicant to indicate the sexual problems pre- 
occupying him by the simple deletion of the words 
yes or no in answer to non-committal questions. 
These questions should cause little or no embarrass- 
ment to those who, having become engaged, develop 
anxiety about their future sex life which makes 
them highly sensitive to any direct attempt to probe 
their difficulties. A quiet chat some time after they 
have said “yes”? to any such general question as 
whether the subject of sex is at all repugnant or 
whether there are any worries: about past or future 
sex life that they would like to discuss, is likely to do 
much to reassure them. The third part of the 
schedule—giving space for results of physical examina- 
tion—is in the form of leaves that can be used 
separately and should be retained by the doctor, with 
some confidential notes for his guidance. He is 
reminded that among the reasons for which a health 
examination may be sought before marriage are: 
the anxiety of parents; misgivings about hereditary 
diseases or defects; present abnormalities such as 
heart disease, glycosuria, and so forth ; past diseases, 
often venereal; desire for specific reassurance of a 
general nature; and desire to break an engagement. 
Most doctors have had experience of the neurotic 
who develops ailments which serve the purpose 
of postponing a marriage which is not really desired. 
A man has even been known to ask to be examined 
and to draw attention to some real or imaginary dis- 
ability in order to get out of an action for breach of 
promise. 

It is clear that the Eugenics Society in issuing these 
schedules is in no way trying to override the functions 
of the practitioner, who is in fact made the central 
agency through whom they will be distributed. 
The society will not communicate with individual 
applicants and indeed will come into the picture 
only when its help is needed on a genetic problem. 
We believe that family doctors who have not hitherto 
given much attention to these problems will welcome 
assistance in dealing with them. 


THE ACTION OF POSTERIOR PITUITARY ON 
| THE COLON 


In 1909 the late Prof. Blair-Bell observed violent 
peristalsis and expulsion of feces in rabbits after 
pituitary extract had been injected intravenously, 
and recommended its use in man in conditions of 
intestinal stasis. It has since been widely employed 
in clinical practice. Further observations on animals, 
however, threw doubt on its power of increasing 
intestinal movements, and in the intact unanzs- 
thetised dog it seems clear that movements are 
inhibited. Since the separation of pituitary extract 
into ‘‘ pitressin ” and ‘‘ pitocin ” it has been suggested 
that many of these discordant results may be due 
to a difference in the actions of the two principles 
on different animals. In this connexion observations 
on the action of pitressin and pitocin on the human 
colon are of especial interest. Macdonald and 
Settle? have recently studied the action of the 
separated principles by inserting a balloon into. the 
proximal colon of patients with colostomies. Intra- 


1 Gruber, C. M., and Robinson, P. I.: Jour. Pharmacol., 
1929, xxxvi., 203, 

? Macdonald, A. D., and Settle, H. L.: Jour. of Physiol., 
1936, lxxxvi., 8 P. 


PITUITARY ON THE COLON 


[FEB. 15, 1936 


venous injection of 1-2 units of pitressin were found 
to produce peristalsis in 2-3 minutes, usually 
accompanied by loss of fæces or flatus. Pitocin was 
usually ineffective, but it did not inhibit the action 
of pitressin as it does in dogs.* Similar results were 
obtained when the drugs were given while X ray 
examinations were being made. It is noteworthy 
that subcutaneous or intramuscular administration 
of pitressin gave a response which was always 
delayed, and often feeble in intensity, and this raises 
a point of practical importance. Pitressin has been 
shown to cause constriction of the coronary vessels,* 
and if administered indiscriminately might well give 
rise to dangerous reactions. On the other hand 
experience seems to show that pituitary extract 
given intramuscularly is usually clinically satisfactory 
in the treatment of post-operative intestinal distension, 
or where it is desired to remove gas from the colon 
preparatory to X ray examination of the renal 
tract. It would nevertheless be of interest if 
alternative drugs for this pupose, such as eserine, 
Prostigmin,® prostigmin plus pituitrin, or acetyl- 
choline 7 were more widely used and reported upon, 
so that their relative merits could be more fully 
assessed. 


Sir Thomas Barlow has been elected a member of 
the French Academy of Medicine. 


THERE is universal sympathy with Sir Humphry 
and Lady Rolleston in the tragic death of their only 
remaining son during an émeute in Zanzibar. The feel- 
ing will be specially present in the medical profession, 
where Sir Humphry Rolleston, in private as well as in 
many important public positions, is regarded with 
such real respect and affection. 


On Feb. 17th and 26th and March 2nd the 
Lettsomian lectures of the Medical Society of 
London will be delivered by Dr. Philip Manson- 
Bahr in the Society’s house in Chandos-street at 
9 P.M. He will speak on the differential diagnosis 
of diseases of the colon (dysentery and colitis) and 
their complications. 


Sir Herbert Cooke, whose death occurred on 
Feb. 6th in St. George’s Hospital as the result of an 
accident, was a distinguished soldier with a great 
Indian record: behind him. Also he was a practical 
philanthropist and a worker in an important medical 
cause. Retired as a lieutenant-general while still 
comparatively young and full of energy, he adopted 
as a hobby the London Children’s Gardens Fund 
and during his connexion with the movement secured 
a greatly increased support for the valuable project 
of securing for London’s poorest slum children the 
joy of possessing a garden, and in this work he found 
the health of the children an efficient argument for 
soliciting support. Recently he had taken charge 
of the activities for securing the money for the 
rebuilding of St. George’s Hospital, and his work had 
already borne fruit, the results of his capacity and 
ingenuity in planning becoming evident. He 
regarded that work as only initial to larger develop- 
ments, and his sudden death is a great loss to a 
charitable cause into which he had thrown himself 
with enthusiasm. 


3 Elmer, A. W., and Ptaszek, L.: Compt. rend. Soc. de biol., 
1930, civ., 540. i; 
* Goldenberg, M., and Rothberger, C. J.: Zeits. f. ges. exper. 


Med., 1931, Ixxvi., 1. 
è Cannon, W. B., and Murphy, F. T.: Jour. Amer. Med. 
Assoc., 1907, xlix., 840. f 
* Carmichael, E. A., Fraser, F. R., McKelvey, D., and Wilkie, 
D. P. D.: THE LANCET, 1934. i., 943. 
? Abel, A. L.: Ibid., 1933, ii., 1247. 


THE LANCET] 


[FEB. 15, 1936 385 


PROGNOSIS 


_ A Series of Signed Articles contributed by invitation 


LXXXVIII.—_ PROGNOSIS OF FRACTURES 
OF THE UPPER END OF THE FEMUR 


FRACTURE of the upper end of the femur is fre- 
quently followed, within a few weeks or months, by 
the death of the patient. Of 615 patients who were 
admitted during twenty years to Lambeth Hospital 
166 died without leaving the hospital, and of the 
remainder a large number were left with a disability 
that materially reduced their enjoyment of life. 
This high mortality and grave disability is, however, 
not so much due to the injury itself as to the fact 
that it is an injury that occurs much more frequently 
among the old than the young, among the feeble 
than the strong. The average age of the patients 
mentioned above was 69 years, and in many cases 
the fracture was an incident in their final illness, 
hastening the end little, if at all. 


Factors to be Considered 


In giving a prognosis in any particular case several 
factors must be considered. 


AGE OF THE PATIENT 


The older the patient the more chance there is of 
death occurring directly as a result of the injury. 
Old people are much less able to put up with the 
discomforts attendant upon the treatment of even 
minor injuries than are the young, and any attempt 
to submit them to an unpleasant régime may bring 
about fatal complications. 


CARDIOVASCULAR DISEASE 


A large number of patients who sustain this injury 
are suffering from cardiovascular disease, and many 
of them have had a cerebral thrombosis or other 
disabling complication. Indeed the reason why this 
fracture mainly occurs late in life is because it can 
only happen when bones have been rendered brittle 
and muscles have lost their tone. It is for this 
reason that the mortality of the injury is so high. 
In this connexion it is interesting to note that there 
are two different periods after the fracture at which 
death tends to occur in feeble patients: (1) those 
who die within about fourteen days, being unable to 
adapt themselves to the altered circumstances which 
the injury produces; and (2) those who live for eight 
or ten weeks and make an apparent recovery only to 
die when the first attempt is made to get them out 
of bed. In the latter group are patients whose 
hearts are only strong enough to keep them alive 
when at rest and are unable to stand the strain of 
movement. A large proportion of patients who die 
after this injury fall into this second class. 


SITUATION OF THE FRACTURE 


For the purposes of prognosis only three situations 
need be considered: (a) fracture through the neck ; 
(b) fracture through the great trochanter ; (c) fracture 
immediately below both trochanters. As regards 
mortality there is little difference between these 
three situations. 
patients, 24:5 per cent. of the fractures of the neck, 
29°3 per cent. of the fractures through the great 
trochanter, and 25 per cent. of the sub-trochanteric 
fractures died without leaving hospital, but there is 
a great difference between the prognosis of the three 
types in regard to functional results. 


Among the above-mentioned 615, 


Fractures through the neck, when they occur in 
young people or in people who are healthy enough 
to undergo severe operations or prolonged and trying 
treatment, have a very good chance of getting bony 
union in moderately satisfactory positions and of 
being restored to almost full functional use of the 
limb. Treatment by a Whitman’s plaster without 
open operation but with manipulation under an 
anesthetic, or by the insertion of a Smith-Petersen’s 
pin, the position of the fragments being determined 
by open operation, both give good results in the 
hands of experienced workers. It is probable that 
Whitman’s method is applicable to a larger number 
of patients but Smith-Petersen’s pin shortens some- 
what the time during which treatment is necessary. 
For those who are unable to stand either of these 
methods of treatment a strong fibrous union can 
generally be secured by fixing the patient on an 


_ extension frame with both lower limbs suspended 


and widely abducted. If this position be retained, 
without interruption, for ten weeks a firm fibrous 
union will form and the patient can then walk about 
with the help of a calliper splint, which should be 
worn for a period of one or two years. Movements 
of the hip in these patients with fibrous union are 
generally painless over a very small range of move- 
ment, but cause pain when the patient is fatigued 
or when any extended range of movement is attempted. 

Fractures through the great trochanter, while having 
the same mortality as fractures of the neck for 
reasons given above, should cause very much less 
disability if they are properly treated. They prac- 
tically never fail to join firmly by bony union, and 
if properly disimpacted and placed in good position 
in an extension frame with both legs abducted the 
union will generally be firm in eight weeks, and 
the patient afterwards will walk with but little dis- 
ability. If the fracture is firmly impacted and the 
patient is very feeble it is sometimes tempting to 
allow the impaction to remain, with the bones in 
bad position, and to let the patient walk about as 
best he can within two or three weeks of the fracture. 
Such a method is sometimes, though rarely, suc- 
cessful; more often the patient’s disability is so 
great that his feebleness is increased by the added 
effort of moving with a deformed limb. It is prob- 
ably always better to disimpact if it is at all possible 
to give the patient an anesthetic. The operation 
should never be done without an anesthetic. 

Sub-trochanteric fractures occur in patients whose 
bones are unusually brittle, and frequently in those 
bones which are the seat of neoplasm. The prognosis 
in this case is that of the disease and not of the 
fracture. 


THE TIME WHEN TREATMENT IS FIRST APPLIED 


To get the best results in fractures of the femur 
the patient must be cared for by skilled nurses with 
experience in this class of injury.’ Unless steps are 
taken to reduce deformity, and to secure such apposi- 
tion of the fragments as is possible, within about 
forty-eight hours of the fracture, there is ttle like- 
lihood of a good result being obtained. During the 
first two or three days after the fracture there is a 
great danger that the feeble patient may be worn 
out by pain and acquire bedsores, thus preventing 
subsequent effective treatment. It is surprising 
with what rapidity bedsores may form during the 


386 THE LANCET] 
first few hours in these cases, and the best way to 
prevent them is to apply, as a first aid, a simple 
axial extension by means of a Buck’s stirrup to both 
legs and to place them on a frame by a counterpoise, 
thus lifting part of the weight of the helpless limbs 
off the bed. The practice of placing the damaged 
limb between sandbags as a first-aid measure cannot 
be too strongly condemned ; the only effect of such 
sandbags is to make sure that any movement of the 


TEA AND COFFEE 


[FEB. 15, 1936 


patient’s body, occurring while the leg is held still, 
will take place at the site of the fracture, causing 
pain to the patient and further laceration of the 
damaged tissues, and materially lessening the prospect 
of a satisfactory recovery. 


GEORGE F. STEBBING, M.B. Lond., 
F.R.C.S. Eng. 
Surgeon Specialist, Lambeth Hospital. 


SPECIAL ARTICLES 


TEA AND COFFEE 


A PHARMACOLOGICAL DISCUSSION 


AT a combined meeting of the Society of Public 
Analysts and other Analytical Chemists with the 
Society of Chemical Industry (Food Group), held 
at the Chemical Societies Rooms, Burlington House, 
Piccadilly, on Feb. 5th, the chair being occupied 
by Mr. JoHn Evans, M.Sc., F.I.C., president of 
the first-named society, a discussion on tea and 
coffee, with special reference tò their tannins and 
alkaloid, was opened by Dr. G. RocHE LYNCH, 
analyst to the Home Office. It was, he said, 
geherally assumed that the pharmacology of tea 
and coffee could be stated in terms of caffeine— 
which he very much doubted. He understood it 
to be agreed that tea contained, on the average, 
24-41 per cent. of caffeine, and coffee 0:5-1:5 per 
cent. of caffeine. The action of caffeine on the body 
could be divided into three groups: its effect on the 
central nervous system, its action on muscular tissue 
(including heart muscle and that controlling the 
intestines), and its diuretic action or promotion of the 
flow of urine. 


THREEFOLD ACTION OF CAFFEINE 


The action of caffeine on the central nervous system 
was almost entirely in tlYe form of a psychical function, 
i.e., on the higher centres of the brain. If it were 
taken in toxic doses, it might exert an effect on the 
spinal cord similar to that of strychnine, namely, 
in producing convulsions. In the course of its 
action on the central nervous system caffeine 
facilitated the perception of sensory stimuli and the 
association of ideas, so that consciousness became, 
under its influence, more acute. One of the results 
of that was a condition of wakefulness or increased 
alertness, and so any tendency to drowsiness or 
fatigue was made to disappear or was much less 
pronounced. A corollary to this was that interpreta- 
tions of sensory stimuli received by the brain from 
various external sources became more perfect and 
accurate. Even more important was the fact that 
these stimuli were correctly placed in relation to 
each other. In this latter respect there was a 
profound difference between the effect of caffeine 
and that of cocaine, for in the case of the latter, in 
addition to the increased perception of the higher 
centres, enhanced impressions from the lower centres 
were also received, and the impressions were not 
so perfect as in the case of caffeine. Thus with 
cocaine the tendency was for the judgment to be 
impaired ; with caffeine the accuracy of the judgment 
was enhanced. Caffeine also caused a constriction 
of the musculature of the blood-vessels, leading 
to a rise in blood pressure, and respiration was 
stimulated. The centres controlling these functions 
were situated in the lower part of the brain, and that 


was an additional fact in the pharmacology of caffeine. 
If a person took a very large dose of caffeine, the 
process just described was intensified, and the result 
was a confusion of thought, and disorders of sensation, 
which were associated with flashes of light in the 
eyes and noises in the ears, so-called tinnitus. If 
extreme doses were given, this excitation proceeded 
to restlessness and the receiver became tremulous, 
and might develop convulsions, as followed strychnine 
poisoning. 

With regard to the action on muscle tissue, he 


reminded his hearers that from the medical point 


of view muscle was divided into three kinds: 
voluntary muscle, the working of which was controlled 
by the will; cardiac muscle, a specialised farm ; 
and the involuntary muscle, such as that in the 
intestines and the _ blood-vessels, not under the 
immediate control of the will. Although not definitely 
known, it was believed that caffeine acted directly . 
on the muscle-cells, not on the nerve-cells; and the 
muscular work performed by the person taking 
caffeine could be increased without that person 
feeling fatigued in correspondirg degree. Here arose a 
difficulty, as it was impossible to say whether or not 
the abolition of the feeling of fatigue was due to an 
effect of the drug on the muscles or on the central 
nervous system. As would be expected from what 
he had said, caffeine was a factor in producing 
contraction of blood-vessels and intestines, and 
their more vigorous action. There occurred also 
in those who had taken caffeine a general acceleration 
of the heart beat, with a diminution of the diastolic 
period ; hence if the dose were large over a period 
of time the effect on the heart might be definitely 
unfavourable. In ordinary medicinal doses, however, 
the taking of caffeine seemed to have no deleterious 
effect. The cardiac state after taking large doses 
of the drug may take the form of auricular fibrillation. 
Conceivably this might lead to death, though actually 
death from caffeine is very rare. 

With regard to the diuretic action of caffeine, 
the increased flow of urine promoted by it was due 
to a greater output of water, so that the urine itself 
became more dilute than normal; but tested over 
an appreciable period, there was found to be, not 
only an increase in the total urinary output, but 
also in the total solids passed. This ehmination of 
water was among the valuable results of the medicinal 
use of caffeine, as seen in patients who were suffering 
from dropsy, hence the special value of the drug in 
heart failure or of kidney disease. This increased 
elimination of water was found to be partly due to 
the raised blood pressure, and partly to the specific 
action of the caffeine on the cells of the kidney, 


‘enabling them to excrete water and, to some extent, 


solids too, in greater amount. Some of the caffeine 
is decompesed in the body, some excreted in the 
urine in an unchanged condition, and some in a 
partly de-methylated form, i.e., mono- or di-methyl 
xanthine (caffeine is trimethyl xanthine). 


® 


THE LANCET] 


TEA AND COFFEE 


[FEB. 15, 1936 387 


OVERDOSE. ADDICTION. SLEEPLESSNESS 

Dr. Roche Lynch said he had not yet encountered 
a case in which death was definitely caused by an 
overdose of caffeine. As much as grs. 60 of the 
drug had been taken at a time, but the serious illness 
which immediately resulted was recovered from. 
After taking very large doses of caffeine the person 
manifested the form of excitation which may be 
seen in people drunk from alcohol; dizziness, a 
ringing and buzzing in the ears, trembling, sleep- 
lessness, confusion of ideas, delirium, palpitation 
of the heart, and even strychnine-like convulsions. 

He did not consider that caffeine could be included 
in the drugs which came under the heading of 
addiction. People who took it in the form of coffee 
and tea became accustomed to it, and as they looked 
forward to it and liked it they found it difficult to 
do without it. Still, as opposed to the case of cocaine 
and morphine, it could be given up without much 
mental effort or feeling of loss, and its indulgence 
did not cause the serious train of symptoms which 
followed the habitual taking of cocaine and morphine. 
In post-mortem examinations he did not believe 
that any changes in the stomach and intestines 
occurred in those who had drunk largely of the 
beverages tea and coffee that could be associated 
with such drinking. He knew of no cases warranting 
the suggestion that either caffeine or the tannin 
could produce such an effect. 

With regard to sleeplessness, he felt himself to be 
in somewhat of a difficulty, and he invited suggestions. 
All must know people who said they dare not take 
coffee after dinner, as it would keep them awake 
half the, night; some said they always took a cup 
of tea instead, while others said that if they wished 
to do writing late at night this was made easier by 
taking a cup of tea. On the other hand, when 
people had narcotic poisoning, coffee administered 
per rectum was a common remedy employed. That 
the association of these beverages and sleeplessness 
may be largely psychical was suggested by the fact 
that in many cases if one gave caffeine citrate in a 
medicine unknown to the patient, there was often 
no interference with his sleep. Though he had 
pointed out various attributes of caffeine, such as 
increased stimulation, he felt there must be some 
further factor in the beverages under discussion 
which had definite effects in regard to sleep, but 
which at present could only be conjectured. 


TANNIN IN TEA 


In a paper on the tannin-content of tea, by 
Mr. P. J. Norman, F.I.C., and Mr. E. B. HUGHES, 
D.Sc., F.I.C., the authors referred to the lack of 
knowledge of the exact nature of tea-tannin, and for 
this reason they had made comparative extractions 
of tea-tannin by the more important of the methods 
employed. They pointed out that tannin is present 
in all tea, that it is an important constituent in 
that it contributes largely to those properties which 
characterise the quality of tea, and that there is more 
tannin in good leaf than in poor leaf and less in 
stalk than in leaf. The methods used for the 
comparative analyses were :— 

1. Cinchonine precipitation of the tannin ; 

2. The Löwenthal method of oxidation of the tannin by 
potassium permanganate; and 

3. The hide-powder method. 

Results obtained showed that teas of the same 
class could be compared, as regards tannin-content, 
by any one of these methods, but that there was some 
difference in results by the three methods for any 
one tea, this depending on whether the tea was a 


` teas contained 8-6 per cent. of tannin. 


black (fully fermented) tea such as Indian, Ceylon, 
China, &c., or a green (unfermented) tea (little drunk 
in this country), or Oolong (lightly fermented) tea. 
There was also some difference among black (Indian 
and Ceylon) teas which the authors considered to be 
due to the grading (by fineness) of the tea. Results 
were given for a large number of unblended teas of 
known origin, varying from 10 to 17 per cent. of the 
dry tea for black teas, and 9 to 15 per cent. for green 
and Oolong teas. The authors had also determined 
the tannin-content of a number of teas sold to the 
public as “digestive,” ‘‘invalid,” &c., teas; these 
were found to have the same tannin-content as the 
ordinary commercial teas of the same class (black 
teas of Indian, Ceylon, China, &c.). It was pointed 
out that infusions of tea, as ordinarily prepared 
for drinking, contain about two-thirds of the tannin 
from Indian or Ceylon tea and about one-half of the 
tannin from China tea. 


COFFEE EXTRACT 


Mr. Epwarp Hinks, B.Sc., F.I.C., read a paper on 
coffee extracts. A considerable proportion of the 
fluid consumed in this country as coffee must, he 
said, be reconstituted from coffee extract. The 
proper criterion of the value of an extract was, he 
thought, that its composition when reformed or 
reconstituted should be as close as possible to that 
obtained from the native article, a parallel case being 
condensed or dried milk in comparison with liquid 
cow’s milk; the loss should be only that inseparable 
from the processes of drying or condensing. His 
experience was that extracts purporting to be pure 
coffee were comparatively rare, coffee and chicory 
extracts being the commoner. But judging from the 
samples he had received the caffeine in the two classes 
did not differ much, the coffee extracts (12 in number) 
containing from 0-1 to 0-33 per cent. of caffeine 
(average 0-21), and the 45 coffee and chicory extracts 
containing from 0:05 to 0-38 per cent. (average 
0-19), though there might be some doubt about the 
designation of some of the coffee extracts. A dry 
extract he had examined contained 6-8 per cent. of 
caffeine. Taking the caffeine as a basis of evaluation, 
the poorest extracts gave a “ coffee” only of from 
one-tenth to one-fifth the strength of ordinary 
breakfast coffee made from the berry and even at 
the best they were but a poor approach to the real 
article. Why then did these beverages look so much 
like coffee? It appeared to be due to the use of 
caramel. A comparison of the costs, again on the 
basis of caffeine, gave some humorous results. In 
pure coffee at 2s. 6d. per lb. a “unit” of caffeine 
cost 7d.; in the dry extract it was 6-2d.; in a 
“ 0-22 per cent.” coffee extract it was 28d., and ina 
“0l per cent.” coffee and chicory extract it was 
found to be 41d. 

UNSUPPORTED CLAIMS 

Mr. AINSWORTH MITCHELL, D.Sc., F.I.C., read a 
communication from Mr. H. H. BAGNALL, B.Sc., F.1.C., 
city analyst of Birmingham, in which he spoke of 
the results of his analyses of a number of packet 
teas whose wrappers bore various claims, mainly 
in the direction of preventing or curing digestive. 
disorders because of the absence from the teas of 
tannin. In every case thpse claims were unsupported 
by scientific fact. In the alleged tannin-free teas 
he found from 9-9 to 16-4 per cent. of tannin, the 
average of a series being 12-5 per cent. Two China 
| One brand 
of tea was stated to contain only the tips of leaves and 
therefore to be tanninless; it had the average 
quantity of tannin and was ground fine to give the 


ee = eS SIRT TE 


388 THE LANCET] VIENNA.—SCOTLAND 


idea of tips. One brand was stated to be curative 
because of the large vitamin content, but it had 
only a trace of one vitamin—namely, E. In many 
cases a representation to the firms of the error in 
the claims made resulted in modification of the 
wording on the packets. 


Mr. A. L. Bacnaracu, M.A., F.I.C., asked whether 
caffeine could be regarded as a cumulative poison, 
and if so, was it cumulative because it was stored 
and then gradually used by the body, or because its 
adverse eifect on certain organs continued for a 
considerable time ? . 

Mr. H. H. Mann, D.Sc., F.I.C., assistant director 
of the: Woburn Experimental Station, remarking 
that he had been connected with the tea industry 
for 36 years, said there was no relationship between 
the price paid for tea and its caffeine content. Other 
things being equal, teas of high tannin-content were 
generally superior. Taste was an important factor 
in the choice of teas, and he thought an investigation 
should be made into the different forms of tannin 
which tea contained before dogmatic statements 
could be made about its effect on quality. 

Mr. L. H. Lampitt, D.Sc., F.I.C., agreed with 
Dr. Mann about the importance of taste. In making 
claims that their teas were tannin-free the proprietors 
of some packet teas were no doubt playing up to the 
public imagination of tanning the stomach. Dr. Roche 
Lynch, he recalled, could find no post-mortem 
evidence of stomach tanning. 


Dr. Rocue Lync, in a brief reply, said that any 
cumulative effect of caffeine might have was not 
from storage, as it was quickly broken down in the 
body. 


VIENNA 


(FROM OUR OWN CORRESPONDENT) 


DEATHS IN THE PROFESSION 


Tur University of Vienna has had a serious loss 
in the deaths of Prof. Maresch and Prof. Bruno 
Busson. The former, who died of bronchial cancer 
at the age of 68, first worked at the institutes of 
anatomy and pathology in Prague. When he came 
to Vienna he began to study surgery and gynwxcology 
but he soon forsook them for morbid anatomy. 
He was chief pathologist at the Rudolfs-spital and 
also in the Municipal Hospital. He was appointed 
a lecturer by the university in 1910 and in 1923 
succeeded Paltauf in the chair of morbid anatomy, 
which he held till his death. His early work was on 
the epithelial bodies and the histology of the kidney, 
and his staining methods were unique; he devoted 
his later researches to the problems of the internal 
secretions. His institute contains a splendid museum 
which is chiefly the result of his own work. He was 
an excellent teacher, and as an authority on morbid 
anatomy his reputation was international. Busson 
was director of the federal Serotherapeutic Institute, 
which controls all the vaccines and sera used in 
Austria. He graduated here and studied hygiene 
and bacteriology in Graz and Paris. During the late 
war he was in charge of the Health Commission and 
was responsible for the comparative freedom from 
war epidemics at the front and in the hinterland. 
His work was mainly concerned with immunity and 
experimental medicine especially with tetanus and 
diphtheria. 

TUE FIRST AID SOCIETY IN 1935 

The ambulance corps here, which served as a 

model for the others in Europe, has dealt in the past 


year with 26,134 emergencies, an average of 72 daily. 
The proportion of injuries to sudden illness, three to 
two, has remained constant for about eight years. 
There were 3112 traffic accidents; 1775 of these 
were due to motor-cars, 757 to pedal cycles, 419 to 
tramcars, 111 to horse-driven vehicles, and 50 to 
railway accidents. Sport and athletics were respon- 
sible for 725 casualties, 414 persons were bitten by 
animals, and 1685 were injured in factories. Members 
of the society also attended 391 women in precipitate 
labour, 2000 cases of suicide and attempted suicide, 
230 of insanity, and 180 of alcoholic excess. The 
close coöperation of police and hospital staffs with 
the society ensures an immediate response to emer- 
gency; 15 lives, for example, were saved by this 
efficiency after injuries to the heart by stabbing or 
shooting; while the patient is being hurried to 
hospital in an ambulance the surgical staff have 
already been warned and are prepared to operate at 
once. 
CORONARY OCCLUSION 


Dr. N. Landau has recently been speaking on the 
pathology and treatment of cardiac infarct. In the 
Vienna Heart Hospital there have been in the last 
three years 150 cases of sudden coronary occlusion ; 
80 per. cent. of the patients were men, 45 per cent. 
were aged 55-65, and 30 per cent. aged 45-55; but 
8 per cent. were not yet 45 and 2°5 per cent. 
were under 40. The majority (78 per cent.) had 
some previous symptoms such as dyspnea, vertigo, 
intermittent claudication, or those of hypertension. 
In 21 per cent. the precise time of onset could not 
be determined, and neither exercise nor the time of 
the day seemed to have any influence. The majority 
had had angina pectoris for about five years but in 
4 per cent. it was entirely absent; other symptoms 
were cold sweats (25 per cent.), dyspnoea (25 per cent.), 
angor animi (18 per cent.), nausea and vomiting 
(15 per cent.), and unconsciousness (10 per cent.). 
In 91 patients brought in with a recent infarct the 
clinical findings were few; 60 per cent. had weak 
murmurs, while of the 23 that had a gallop rhythm 
only 7 survived. An important sign almost constant 
enough to be considered pathognomonic was a rise 
of 1-3°C. in the rectal temperature, present in 75 per 
cent. and remaining for about a month in 30 per 
cent. Blood pressure was low in 60 per cent. and 
remained so for several weeks. A tachycardia not 
affected by digitalis was a bad sign. The electro- 
cardiogram was always abnormal; in 83 per cent. 
it was ‘characteristic of occlusion of a coronary 
branch and in 17 per cent. of myocarditis. The 
mortality was 30 per cent., of whom a third died 
suddenly, some even in convalescence; the rest 
died after getting progressively weaker in spite of 
all treatment. 


SCOTLAND 


(FROM OUR OWN CORRESPONDENT) 


TREATMENT OF LUPUS VULGARIS 
Dr. Robert Aitken, at last week’s meeting of the 


‘Edinburgh Medico-Chirurgical Society, reported strik- 


ingly good results in the treatment of lupus vulgaris 
by the use of the Finsen-Lomholt lamp. In the past 
five years, he said, 0°6 to 1 per cent. of the new cases 
seen in the skin department of the Royal Infirmary 


of Edinburgh were cases of lupus vulgaris; fifteen 


years ago the incidence of this disease was three 
times as great. He has investigated 310 patients 
and the face was affected in 77 per cent. of them. 


[FEB. 15, 1936 | 


THE LANCET] 


IRELAND 


[FEB. 15, 1936 389 


In more than half, the disease began during school 
life, and it is uncommon for it to commence after 
middle age. He stressed the frequency with which 
this condition is associated with tuberculous glands, 
and said that during the past seven years 116 cases 
of lupus with tuberculous adenitis were treated at 
his department. Until recently lupus has been a 
very intractable disease, and the results of the old 
forms of treatment were often unsightly. Dr. Aitken 
condemned, in particular, the end-results of X ray 


treatment, for the scar of the burn is disfiguring and- 


it often stimulates the development of carcinoma. 
In his opinion the diminishing incidence of lupus is 
due to the successful treatment of tuberculous glands 
with general light baths, without which many would 
have developed lupus at a later age. The general 
treatment of lupus necessitates the use of the hygienic 
and dietetic measures that apply to the treatment of 
all forms of tuberculosis. Tuberculin is the remedy 
of choice in the absence of facilities for light treat- 
ment. Excision, scraping, and cauterising are all 
unsatisfactory, and they fail to remove the disease 
from the deep skin glands; X ray treatment should 
also be given up. The original Finsen light treat- 
ment was satisfactory up to a point, but whereas 
only 15 per cent. of the radiation energy of this lamp 
could be applied to the diseased surface the corre- 
sponding figures for the new Finsen-Lomholt lamp is 
70 per cent. This increase in power has enabled the 
time required for each treatment to be reduced to 
no more than one hour, and its convenient construc- 
tion makes the application much less tiring for the 
nurse in charge. 

Dr. Aitken showed a number of beautiful coloured 
slides showing that even in an advanced state the 
disease could usually be cured in about six months. 
Reports of a large series treated in Vienna from 1914 
to 1923 show that the striking results are usually 
permanent. 


GLASGOW ROYAL INFIRMARY 


In the 14lst annual report of the managers of 
Glasgow Royal Infirmary it is stated that there were 
over 18,000 in-patients and 120,000 out-patients 
during the past year. There has been a deficit on 
the ordinary account of over £26,000; the extra- 
ordinary receipts totalled £62,000, and it was pos- 
sible to carry £28,000 of this to the capital account. 
The managers hope that the Canniesburn auxiliary 
scheme, the foundation-stone of which was laid by 
the Duke of Kent in May of last year, will be com- 
pleted by the end of 1936. These buildings will 
provide 80 beds for patients in early stages of con- 
valescence, together with 40 beds for paying patients 
of limited means. It is hoped that the provision of 
these additional buildings will reduce the number 
of patients awaiting admission to the infirmary. 


THE LATE PROF. ASHWORTH 


Edinburgh graduates who have enjoyed his teach- 
ing will feel that the university has lost one of its 
outstanding figures by the sudden death of Prof. 
James Hartley Ashworth, F.R.S., of the chair of 
natural history. It was because of his important 
work in invertebrate zoology that large contributions 
were made to the university for building the new 
zoological laboratories. He was particularly interested 
in entomology and protozoology and had conducted 
a class in this subject in the university since 1905. 
His life and energies were devoted to his science and 
to the university, in which he taught for nearly 
thirty-six years. He was everywhere popular and 
was always anxious to help his colleagues and his 
students. - 


IRELAND 
(FROM OUR OWN CORRESPONDENTS) 


THE NATIONAL MATERNITY HOSPITAL 


THE governors of the National Maternity Hospital, 
Dublin, are engaged in promoting a private Bill with 
the object of amending their charter, altering the 
name of their corporation, and effecting other changes 
in their powers and constitution. The preamble of 
the Bill has been declared proved and the Bill now 
lies on the table of the Dáil. The National Maternity 
Hospital, which is familiarly known as Holles-street 
Hospital, was founded in 1894 for the relief of poor 
lying-in women and for the treatment of diseases 
peculiar to women. In 1903 a charter under the 
Great Seal of Ireland was issued by King Edward VII., ' 
which established the corporation of governors of 
the hospital, and defined their powers and duties. 
The hospital has had a very successful career, and 
having outgrown its old premises, has recently been 
provided with a new and commodious building from 
Sweepstake Funds. Up to the present the hospital 
has been managed by a body of governors co-opted 
as vacancies occurred. It is now proposed to make 
several important changes in the constitution, and 
to bring the hospital into direct relation on the one 
hand with University College, Dublin; and on the 
other with certain general clinical hospitals. At 
present the number of governors is limited to 65, 
but if the Bill becomes law this limit will be raised 
to 100. Of these governors 3 shall be nominated 
by the corporation of Dublin, 2 shall be nominated 
by the governing body of University College, Dublin, 
and l each shall be elected by the hospital from the 
staffs of Jervis-street Hospital, the Mater Misericordiz 
Hospital, and St. Vincent’s Hospital respectively. 
Provision is made for the appointment of an executive 
committee and the delegation to it of certain powers. 
The hospital is to be designated in future ‘‘ The 
National Hospital for Women, Dublin.” It is pro- 
vided that the present master (Dr. J. F. Cunningham) 
shall continue in office until Dec. 31st, 1941. 


THE KING’S PROFESSORSHIPS IN THE SCHOOL 
OF PHYSIC | l 

On Feb. 7th the President and Fellows of the Royal - 
College of Physicians of Ireland elected Dr. David 
Smyth Torrens to the King’s professorship of the 
institutes of medicine in the School of Physic, Trinity 
College, Dublin, to fill the vacancy created by the 
death of Prof. Harold Pringle. Dr. Torrens has been 
for some time assistant professor of physiology in 
Trinity College. He was formerly lecturer in zoology 
in the Royal College of Scienċe, Dublin. At the 
same meeting the resignation of Dr. Thomas Henry 
Wilson, King’s professor of midwifery since 1910, 
was received with regret. Dr. Wilson’s health has 
not been good in recent months. 


OUTBREAK OF FIRE AT QUEEN’S UNIVERSITY, 
BELFAST 

There was a serious fire at Queen’s University, 
Belfast, on the afternoon of Feb. 7th. The part 
affected was the medical school, which is a large 
building situated close to others in the university 
grounds. The fire began in a storeroom under the 
anatomy lecture theatre, which is on the second 
floor. Students were at work in the dissecting-room 
nearby and on the ground floor a surgical lecture was 
in progress. So rapid was the spread in the few 
minutes before the brigade arrived that the building 
had to be evacuated, dense clouds of smoke pouring 


390 


from it. A strong wind was blowing and at one 
time it seemed as if the fire might spread to involve 
the whole building; but the efforts of the brigade 
were soon successful in confining it to the storeroom 
and the anatomy lecture theatre. Here the fire 
blazed furiously, the dry wood of the benches igniting 
readily, and before long flames were seen to be 
coming through the roof. In about an hour and a 
half, however, the fire was under control and subdued. 
It was feared at first that Prof. T. Walmsley’s room 


THE LANCET] 


GASTRIC ACIDITY AND ITS SIGNIFICANCE 


[FEB. 15, 1936 


and the laboratory in the tower would have been 
destroyed, but we understand that, apart from 
damage to the roof, there has been no other serious 
loss. Directly beneath the fire was the museum which 
contained a large and valuable collection of anatomical 
and pathological specimens. Though part of the 
ceiling was damaged by the fire breaking through in 
one place, it did not collapse and the contents of the 
museum were only slightly damaged. The building is 
now closed and in the hands of the salvage authorities. 


CORRESPONDENCE 


GASTRIC ACIDITY AND ITS SIGNIFICANCE 
To the Editor of THE LANCET 


Srr,—Prof. Apperly’s paper in your issue of Jan. 4th 
will have been read by many with interest, as it is 
both stimulating and provocative. By the time this 
reaches ‘you I feel sure you that will have received 
letters from others who can refute from experience 
some of the assumptions that Prof. Apperly makes 
from indirect evidence. You may, however, feel that 
my experience, in another country, is also worth 
recording. 

There must be a mass of evidence on record to 
contradict the statement that ‘‘When the former 
[the red cell content of the blood] falls to about half 
or two-thirds normal (on the average) free acid dis- 
appears from the stomach.’’? You yourself have 
made a mild protest against this statement in an 
annotation in the same issue. I will quote only 
from a series of my cases that Iam at the moment 
analysing ; in a series of fractional gastric analyses on 
33 Assam tea-garden coolies whose blood hemoglobin 
content ranged from 17 to 45 per cent., mean 32 per 
cent. (100 per cent.=13°75 grammes per 100 c.cm.), 
in 27 the maximum gastric acidity (free) was from 
25 to 90 c.cm. of N/10 hydrochloric acid per 100 c.cm., 
in 2 it was 20 c.cm., in 3 there was free acid but less 
than 20 c.cm., and in 1 case only was there achlor- 
hydria (histamine not given). In this last case at 
the beginning of treatment the haemoglobin was 29 per 
cent. (4 g.), but it improved to 80 per cent. (11 g.) 
when a trace of free acid appeared in one sample 
only (14 hours) in the fractional gastric analysis. 

Though I have always accepted the view that 
anxmia, per se, may lead to hypochlorhydria or even 
achlorhydria, recent experience adds very little 
support to this view; I will cite two cases actually 
in my wards at the moment: one is a case of hyper- 
chlorhydria (maximum 75 c.cm. N/10 HCl) with 
2°75 g. of hemoglobin (20 per cent.), and the other 
a case of hypochlorhydric microcytic anemia in 
which, though the hæmoglobin increased from 2°47 
to 16°00 g. in three months, the maximum hydro- 
chloric acid concentration only increased from 12 
to 14 c.cm. 

None of our experience in this country suggests 
that gastric acidity is diminished in a hot climate. 
The normal gastric acidity is higher than that usually 
recorded in England and North America (Napier 
and Gupta: Indian Jour. Med. Res., 1935, xxiii., 455). 
There are of course other factors to be considered, 
but all Indians do not live on the traditional highly 
spiced diet, nor is the evidence conclusive that a 
highly spiced diet leads to permanent hyperchlor- 
hydria; it may lead to gastritis, the final result of 
which is hypochlorhydria or even achlorhydria. 

Regarding the gastric acidity in asthma, there 
are many references in the literature (e.g., Hurst: 
Brit. Med. Jour., 1930, i., 1138; and Bray: ‘‘ Recent 


Advances in Allergy,” London, 1931), and it is gener- 
ally claimed that the acidity is lowered ; we (Dhar- 
mendra and Napier: Indian Med. Gaz., 1935, lxx. 
301), however, found it increased; but admittedly 
our cases were not true allergic asthma nor was the 
analysis done at the time of an attack. 

I am, Sir, yours faithfully, 


L. EVERARD NAPIER, M.R.C.P. Lond, 
Professor of Tropical Medicine. 


School of Tropical Medicine, Calcutta, Jan. 31st. 


FAMILIAL CIRRHOSIS AND TELANGIECTASIA 
To the Editor of THE LANCET 


Srr,—I was much interested in Dr. Parkes Weber's 
paper on the familial tendency to development of 
hepatic cirrhosis and more especially in his reference 
to the relationship between cirrhosis and telangiectasia 
of the Osler type. As Dr. Weber points out there 
have been many valuable papers on this disease, 
particularly by H. I. Goldstein, but it is remarkable 
how few members of the profession are familiar with 
the condition. In a letter to THE Lancet (1933, 
i., 116) Goldstein said that there are ‘‘ probably 
recorded to date about 110 or 120 families and about 
700 persons suffering from Rendu-Osler-Webers 
disease (heredofamilial epistaxis with or without 
familial hemorrhagic telangiectasia) in the entire 
available medical literature of the world.” When 
one considers that Osler’s original paper was written 
in 1901 (and a family showing epistaxis was described 
by Babbington in 1865) and, further, that cases have 
been reported from all over the world, these figures 
are undoubtedly very small if they truly represent 
the incidence of this, <aigease. From persona 
experience I have thoayht for sta time that the 
figures must be fictifiously low. Dtting the past 
six years I have pfrsonally observe-1 10 families 
suffering from this dfsease, including in. their number 
56 affected persony; all these people live in the 
West Riding of Yofkshire and as far jas I have been 
able to trace them fhe families are unfelated and hare 
not been previousfy recorded. ‘The Wealth of clinical 
material in Leedf is certainly remarkable, but it § 
very unlikely thgt about 19 per “pt of all the cases 
of familial telafeicetasia in the ‘world are living ™ 
the West Ridjae. A consideraple number of DY 
cases have shiAvn that the proféssion as a whole 8 
unfamiliar wifh the condition /and though several 
of the patient have been transfcéred to me by Dr. J. T. 
Ingram, othfrs have come af Cases of anemia 0 
unknown orjein, epistaxis, anc. even headache. l 

The assgcjation of telangiectasia with hepate 
cirrhosis isf great interest aid I agree with Dr. Weber 
that the ftelangiectasia is ; Probably a congenita! 
developméntal dysplasia o: the small blood-vesse!, 
and thatfthe cirrhosis may. be the result of associate 
developental dysbiotroy hy of the liver. At M8 
ne there can be Ro doubt that cirrhosis” 
essential feature of this disease at any of 8 


A 


! 


i 


THE LANCET] 


stages, and I have not yet seen a patient showing 
any suggestion of liver disorder. There is, however, 
a possible relationship between familial telangiectasia 
and neurofibromatosis, and I have seen a family 
suffering from the latter condition in whom there are 
several affected persons also suffering from unexplained 
epistaxis; at the same time I have not found any 
definite evidence of neurofibromatosis in patients 
suffering from telangiectasia, although I have thought 
that the incidence of skin tags, patches of pigmenta- 
tion, and other slight abnormalities of the skin is 
higher than usual in these people. If there should 
prove to be any relationship between hepatic cirrhosis 
and familial telangiectasia it is important to remember 
that the latter disease is recognised as being one of the 
most regularly inherited Mendelian dominant defects 
in man, and in my own large series of cases, with the 
exception of one or two sporadic cases of doubtful 
significance, I have found no exception to this rule. 

I have recently satisfied myself that this condition 
of telangiectasia is radiosensitive and that the 
epistaxis can probably be cured by radium. This 
will prove to be important, as the disease may, and 
frequently does, produce completely disabling anemia 
which can only be relieved when the epistaxis is 
arrested.—I am, Sir, yours faithfully, 

Leeds, Feb. 10th. HueH G. GARLAND, 


SODIUM MANDELATE IN CHRONIC CYSTITIS 
To the Editor of THE LANCET 


Sm,—A personal record of the effect of various 
urinary antiseptics upon chronic cystitis may be of 
interest to some of your readers. My catheter life 
began in 1932, at the age of 72, after an attack of 
acute retention. In spite of the most careful asepsis, 
the urine became infected with B. coli and, on the 
advice of a urologist, I dispensed with the use of the 
catheter. It was at this time that I started my 
experience of various urinary antiseptics, samples 
of urine being sent regularly for bacteriological 
examination to Mr. A. E. Parkes, F.I.C., public 
analyst for Poplar, West Ham, and Bethnal Green. 
l found that hexamine, citrates, bicarbonates, and 
sodium acetate, benzoate, and salicylate were not 
readily tolerated, but hexyl resorcinol and Pyridium 
both proved of value, the latter being very soothing 
to an irritable bladder. Organisms, however, were 
constantly present though with pyridium there were 
occasionally as few as 10 bacilli present per c.cm. 

In November, 1935, I began a course of sodium 
mandelate (3°5 g.) and ammonium chloride (1 g. 
cachet) four times a day, restricting my fluid intake 
to two pints. The immediate effect of this remedy 
was to produce a nocturnal diuresis. Despite some 
thirst, anorexia, and nausea, I persisted with the 
treatment for 13 days, and the complete disappearance 
of bacteria from the urine made the discomfort worth 
while. Five weeks later, following exposure to cold 
—I went to vote—I had another attack of cystitis 
and of acute retention necessitating catheterisation 
and the infection probably recurred. Sodium 
mandelate was again taken on Nov. 22nd and 23rd, 
but this time I decided to reduce the dose of 
ammonium chloride to 1x1 g. cachet daily, and this 
proved sufficient to make the urine acid to methyl- 
ted. Nevertheless, the treatment caused some 
strangury and after two days it was stopped. Once 
more, however, it must have proved capable of 
destroying the organisms, for a sample of urine was 
taken next day (Nov. 24th) and no B. coli could be 
grown from 1 c.cm. Now, 13 weeks later, though 
there is still two ounces of residual urine and some- 


SODIUM MANDELATH IN CHRONIC CYSTITIS 


[FEB. 15,1936 391 


times more, necessitating catheterisation night and 
morning, the urine is quite clear and bright and I am 
comfortable and practically symptom-free. (I started 
catheterisation again on Nov. 17th after 15 months 
without passing a catheter at all.) | 

Mr. Parkes carried out some experiments on the 
mandelic acid content of the urine. From one 
specimen of 10 c.cm. he extracted 20 mg. of mandelic 
acid, which indicates a concentration of 0°2 per cent., 
and he was able to show that at 37° C. a 0°1 per cent. 
solution of pH 4 of the acid in urine was fatal to 
B. coli in one hour, though a 0'007 per cent. solution 
had no effect in two hours. 

The chief lessons I have learnt are that 1 g. only 
of ammonium chloride per day is sufficient to acidify 
my urine, and that sodium mandelate taken for 
2-3 days whenever the urine becomes cloudy clears - 
up the infection. The comfort of having got rid of 
the urinary infection cannot be expressed. After 
I had spent a small fortune trying other remedies, 
sodium mandelate finally did the trick and, up to the 
present, has given me a new lease of life. 

I am, Sir, yours faithfully, 
Teddington, Feb. 9th. F. W. ALEXANDER. 


CARD PARTY FOR MEDICAL CHARITY 
To the Editor of THE LANCET 


SIR —In your issue of Feb. 8th I note you 
have a record on p. 329 of the case Wiliams v. Trevor, 
but this account does not include the final statement 
of counsel or the remarks of the judge. Will you 
please insert in your next issue that statement, 
which was as follows :— 

Sir William Jowitt said he desired to apologise for a 
mistake he made in opening the case. In all newspapers 
he was reported as having said that the card party was 
“for the benefit of the Ivory Cross National Dental 
Aid Fund of the Royal Northern Hospital.” The Dental 
Aid Fund was quite distinct from the Royal Northern 
Hospital and nobody connected with the hospital figured 
on the invitation card. 


Mr. Justice Finlay said: ‘‘ There can be no doubt 
that the president and officers of the eminent charity 
concerned knew nothing about it.” 

I am, Sir, yours faithfully, 
GILBERT G. PANTER, 
Secretary, Royal Northern Hospital. 
Holloway, N.7, Feb. 11th. 


ACETYLCHOLINE FOR PAROXYSMAL 
TACHYCARDIA 


To the Editor of THE LANCET 


SIR, —In an article in your issue of Dec. 7th, 
1935 (p. 1291), I quoted Dr. Isaac Starr Jr., of the 
University of Pennsylvania, Philadelphia, as having 
used acetylcholine in a series of cases of paroxysmal 
tachycardia. I have since received an interesting 
letter from Dr. Starr, in which he says, amongst other 
things :— 

‘“ I write to try to clear up a point which I am afraid 
may cause serious difficulty if it is not appreciated. You 
speak of me as having described the termination of 
paroxysmal tachycardia after subcutaneous injections of 
acetylcholine. This is not correct. I used acetyl-£- 
methylcholine, trade name, Mecholvl, made by E. Merck 
(Darmstadt). Given subcutaneously this is somewhere 
between ten and twenty times as powerful as acetyl- 
choline. Like vourself, I have never seen any unpleasant 
sequele after injecting acetylcholine in the dosage you 
gave. Indeed doses of this size are seldom followed by 
demonstrable drug etfect. On the other hand an injection 
of 75 mg. of acetyl-8-methylcholine to a boy of 14 would 
probably have produced enough vagus effect to stop the 
heart altogether and I would make no guarantee that it 


392 THE LANCET] 


THE SERVICES 


[FEB. 15, 1936 


would resume. I hope you will do what you can to get 
the different pharmacological effects of the many active 
choline derivatives straightened out in the minds of the 
physicians. I am very fearful that someone may use 
acetyl-8-methylcholine in the dosage proper for acetyl- 
choline subcutaneously. If so, I hope they have atropine 
ready at hand.” l 

I hope the publication of this letter will be an 
appropriate warning; and I should like to take this 
opportunity of apologising to Dr. Starr for having 
misquoted his work.—I am, Sir, yours faithfully, 


A. B. STENHOUSE. 
Radcliffe Infirmary, Oxford, Feb. 10th. 


CHILD BORN WITH A FOREIGN BODY IN 
THE HEART 


To the Editor of THe LANCET 


Sir,—We are fully aware of the incredible nature 
of this case, but feel impelled to place on record what 
we believe to be an occurrence unique in the annals 
of pathology. 

A female child was born at term to a primipara 
who had an uneventful gestation and a normal 
labour. The baby also appeared normal in every 
way, but died suddenly some hours after birth, and 
for no apparent reason. A post-mortem was ordered, 
and this was carried out with meticulous care by one of 
us (T. T. W. E.)in the presence of the other (W. M.C.), 
who was assisting and observing closely, as the case 
was his, there being no professional connexion between 
us. The mortuary attendant was also a witness. 


Nothing of importance was observed until the heart 
was removed, laid beside the body on the post-mortem 
slab, and dissected with a scalpel and a pair of surgical 
scissors, which were unplated. On opening the 
right ventricle, a small, bright object was seen lying 
free within the cavity, and was extracted under three 
pairs of curious eyes. It was a small piece of metal 
resembling brass or gilded tin, appearing to be a 
circlet of sorts, folded upon itself, with regular 
serrations along its edge, and measuring roughly 
3 by 2 mm. It looked something like the claw 
setting of a toy jewel ring such as is found in Christmas 
crackers. | 

We emphasise that there was no possibility of its 
having been dropped by one of us as we bent over the 
heart; of its having been shed by one of the instru- 
ments used ; or of its having been picked up from the 
post-mortem table. We very naturally examined 
these possibilities critically before ruling them out. 
The explanation of its presence, forced upon us by 
exclusion, seems as fantastic as the discovery itself; 
but we would welcome alternative suggestions. It 
is, that the foreign body was lying within the mother’s 
uterus at the time of conception and that the 
growing ovum enfolded it, so that it finally came to 
lie where it was found, When the placental circula- 
tion ceased and the child’s heart ‘‘ took over,’ it 
caused some momentary effect which produced 
syncope.—We are, Sir, yours faithfully, 

T. T. W. Eaton, 


Canvey Island, Feb. 8th. W. MULHALL CORBET. 


THE SERVICES 


ROYAL NAVAL MEDICAL SERVICE 


Surg. Rear-Admiral John S. Dudding, C.B., O.B.E., 
K.H.P., has been placed on the Retd. List at his own 
request on relinquishing charge of the R.N. Hospital, 
Plymouth, where he has served for three years. 
Surg. Rear-Admiral Francis J. Gowans, who in 1933-35 
was in medical charge of the hospital ship Maine has 
succeeded him. 

Surg. Comdr. W. G. C. Fitzpatrick to Vernon. 

Surg. Lt.-Comdr. V. G. Horan, M.B., to Pembroke 
for R.N. Hospital, Chatham. 

Surg. Lt.-Comdr. (D.) S. Mawer to Drake for R.N.B. 

Surg. Lt. (D.) W. J. Wolton to Hood. 

Surg. Lt. E. J. Littledale to St. Vincent. 


ROYAL NAVAL VOLUNTEER RESERVE 
Proby. Surg. Sub-Lts. to be Surg. Sub-Lts.: R. T. May, 
P. de B. Turtle, R. F. B. Bennett, C. P. Nicholas, and 
L. S. Anderson. 


ARMY MEDICAL SERVICES 
Lt.-Col. S. W. Kyle. from R.A.M.C., to be temp. Col. 
while employed as A.D.M.S., 5th Div. 
Lt.-Col. R. M. King, from A.D. Corps, to be Col. 


ROYAL ARMY MEDICAL CORPS 

Capts. G. Anderton, R. J. G. Hyde, and R. V. Franklin 
to be Majs. 

Capt. N. H. Lindsay, h.p. list, is restd. to the estabt. 

The results are announced of the examination (in written 
subjects) of officers with a view to promotion in the 
Regular Army, Indian Army, and Dominion Forces, which 
was held at stations abroad (excluding India) last October. 
Among the successful candidates were Capts. T. F. M. 
Woods and M. R. Burke, R.A.M.C., and Maj. J. E. A. 
Tessier, Royal Canadian Army Medical Corps. 


ARMY DENTAL CORPS. 
Maj. J. S. Smith to be Lt.-Col. 


TERRITORIAL ARMY 
Col. P. H. Mitchiner, T.D., K.H.S., from A.D.MLS., 
47th (2nd Lond.) Div., is attd. to the Ist Anti-Aircraft 
Div. for duty as A.D.M.S. 


Lt.-Col. W. A. Robertson, M.C., from R.A.M.C., to be 
Col. and is apptd. A.D.M.S., 51st (Highland) Div. 

Lt.-Col. and Bt.-Col. W. A. Robertson, M.C., from 
T. A. Res. of Off., to be Lt.-Col. and relinquishes the 
Brevet rank of Col. 

Lts. H. C. Stewart and P. Brookes to be Capts. 

Col. R. E. Bickerton, D.S.O., T.D., from 56th (lst Lond.) 
Div., to be Hon. Col., R.A.M.C. Units, The Lond. Div. 

The surname of Lt. J. L. Cowan, M.D., M.R.C.P. Edin., 
is as now described and not as notified in the Gazette 
of Jan. 24th, 1936. 

J. R. Dawson to be Lt. 


ROYAL AIR FORCE 

Wing-Comdr. J. Kyle to Medical Training Depôt, 
Halton, for duty as Commanding Officer, vice Group Capt. 
E. W. Craig, M.C. 

Flight Lts. J. Hutchieson and C. A. Lewis to R.A.F. 
Gencral Hospital, Hinaidi, Iraq. 

Flight Lt. J. Hill is promoted to the rank of Squadron 
Leader. 

Flying Offrs. H. L. Willcox, R. A. Cumming, and 
L. E. A. Dearberg to R.A.F. General Hospital, Hinaidi, 
Iraq; S. R. C. Nelson to Central Medical Establishment, 
London. 

Flying Offr. W. Q. S. Roberts is promoted to the rank 
of Flight Lt. 

DEATHS IN THE SERVICES 


The death occurred in London on Feb. 4th of Major 
ARTHUR EDWARD MILNER, R.A.M.C. Born in 1867 he 
was educated at Bristol and Guy’s Hospital, where he 
was Clark scholar in surgery and Saunders scholar in 
medicine. After taking the conjoint qualification in 
1892 he won the Montefiore prize in military surgery at 
Netley, and entered the Army as a surgeon lieutenant. 
He became captain in 1897, major in 1906, seeing service on 
tho N.W. frontier of India and with the Tirah Expeditionary 
Force, when he was awarded a medal with 2 clasps. In 
the South African War he took part in operations in 
Natal and at the defence of Ladysmith, gaining the 
Queen’s medal with 3 clasps. He was placed on retired 
pay in July, 1914, but a month later was recalled to the 
active list. 


THE LANCET! 


[FEB. 15, 1936 393 


PUBLIC HEALTH 


MENINGEAL TUBERCULOSIS 
EPIDEMIOLOGY AND TYPE OF TUBERCLE BACILLI 


By W. T. Munro, M.D. St. And., F.R.C.P. Edin. 
MEDICAL SUPERINTENDENT, GLENLOMOND SANATORIUM, 
KINROSS ; AND 
HAROLD Scott, M.B. St. And. 


ASSISTANT MEDICAL OFFICER AT THE SANATORIUM 


In 1932 Dr. Stanley Griffith } reviewed the relative 
incidence of human and bovine tubercle bacilli in 
meningeal tuberculosis in England. Most of these 
viruses were obtained. from Leeds and the surprising 
feature was that 10 out of 30 specimens of cerebro- 
spinal fluid yielded bovine type bacilli. In a later 
communication ? he dealt with 214 English and 37 
Scottish cases. The former yielded 52 (24:3 per 
cent.) bovine types, while the latter yielded 15 
(40°5 per cent.). The English cases were from widely 
different localities. From Leeds one noted 10 bovine 
infections among 49 city cases (20 per cent.) and 
8 bovine infections among 17 rural cases (47 per cent.). 
Throughout this report there was a higher incidence 
of bovine types in rural areas. 

The Scottish cases reported by Dr. Griffith in this 
review included 18 of the present series with 33 per 
cent. bovine types; 15 from Aberdeen with 47 per 
cent. bovine types ; and 4 from Ayr with 50 per cent. 
bovine types. 

Dr. Agnes Macgregor has since reported? that 
14 out of 50 cases of meningeal tuberculosis in 
Edinburgh (28 per cent.) could be ascribed to bovine 
bacilli ; only 8 of these 50 lived in rural areas and 
3 of these were infected with the bovine type. 
Dr. Blacklock 4 states that 12 out of 60 cases in 
Glasgow (20 per cent.) yielded bovine bacilli, and 
notes that the bovine percentage was higher in 
country (27) than in city (18) children. 

The series here described comprises cases of 
meningeal tuberculosis from Glenlomond Sanatorium 
admitted from year 1924 to date, and specimens of 
cerebro-spinal fluid sent us between 1932 and 1935 
from the wards of the Royal Infirmary, Dundee, 
bv Prof. A. Patrick, Dr. James Thomson, and 
Dr. Gordon Clark, to whom we are much indebted 
for information. Specimens of cerebro-spinal fluid 
from 59 cases have been examined. Meningeal 
tuberculosis is not an uncommon mode of death in 
cases of chronic pulmonary tuberculosis and 9 of the 
specimens examined were from such patients. These 
were all adults whose sputa yielded us eugonic growths 
of typical human types and similar types were also 
grown from the cerebro-spinal fluids. These 9 cases 
are not included so that we limit our review to cerebro- 
spinal fluids from 50 patients who came under 
observation on account of symptoms suggesting 
meningeal involvement. 

In our earlier cases no attempt was made to obtain 
growths direct from the cerebro-spinal fluid and the 
fluid was injected into a guinea-pig. In later years, 
as we became more certain of growth, direct inocula- 
tion of suitable media became the rule and was 
carried out as well as inoculation of a guinea-pig. 
In all, 27 were obtained by direct inoculation. while 
the others were obtained solely by inoculation of a 
guinea-pig. i 

DISTRIBUTION OF CASES 

Of the 50 cases 14 were from Glenlomond and 

36 from the Royal Infirmary, Dundee. Of the 


Glenlomond cases 7 and of the Dundee cases 11 
proved bovine in type. Glenlomond Sanatorium 
receives its patients from the counties of Fife and 
Kinross, but exclusive of the large burghs of Kirkcaldy 
and Dunfermline; so that apart from some smaller 
burghs the patients are drawn from purely rural 
areas. 

Of the Dundee patients 4 (in each of whom the 
virus was found to be bovine) came from rural areas— 
viz., 3 from rural Perthshire and 1 from a rural 
district of the county of Angus. No human type 
Dundee case came from a rural area, so that, all 
told, 18 cases came from rural areas and yielded 
11 bovine types, while 32 cases were urban and 
yielded 7 bovine types. 

Tuberculosis in the human subject due to bovine 
bacilli is much more a rural than an urban problem 
and this aspect will be more in evidence as facts are 
elicited in this paper. 


‘CULTURAL CHARACTERISTICS AND PATHOGENICITY 


Of 50 strains, 18 (36 per cent.) exhibited the cultural 
characteristics of the bovine type bacillus while 
32 were identical with the eugonic human type 
bacillus. 


Before acceptance of a dysgonic moist-looking growth 
as being a bovine type a pathogenicity test has always 
been carried out, and the test used by us is the intravenous 
inoculation of a rabbit of about 1500 g. weight with 0°01 mg. 
of the wet virus. A bovine strain will kill the rabbit. in 
approximately thirty days, the lesions being those of 
progressive generalised tuberculosis, while the human 
strain in the same dose will scarcely ever kill the rabbit 
and certainly not in less than 90 days, and as a rule 
produces only minimal non-progressive lesions. All the 
dysgonic types proved fully virulent to the rabbit and 
were true bovine types. Moreover, all these viruses were 
examined at Cambridge by Dr. A. Stanley Griffith and 
accepted as bovine types. 


Table I. shows the age-distribution according to type. 


TABLE I 
— Total. | Human. E vibe 
0- 5 ycars.. .. | 20 | 9 11 (55) 
5-15 4, ee n 18 14 4 (22°2) 
Over 15: ,, .. Js 12 9 3 (25) 
= . | 50 32 18 (36) 


These figures do not surprise us in’any way. We 
were quite prepared for a high percentage of bovine 
types in the age-group 0-5 years. All the children 
under two years of age who showed disease due to the 
bovine type bacillus had been fed on cow’s milk 
unboiled. 

Noteworthy too is the number of bovine types 
found in persons over 15 years. The oldest in the 
series was the case of a ploughman of 30 years of age. 


RURAL AND URBAN DISTRIBUTION 


When we come to separate our cases by a rural and 
urban distribution, we meet with some very significant 
facts as shown in Table IT. 

It will be seen that there is a big difference in the 
percentage of bovine infections in rural and urban 
areas. This is to be expected, for there is no 
pasteurisation of milk in rural areas and no dilution 
of infection by bulking. In Dundee about 60-70 per 
cent. of the city’s supply may be considered safe, 


394 THE LANCET] 


whereas it is doubtful if any rural supply can be 
considered safe apart from milk from a tubercle-free 
herd. The significant fact is that the incidence of 


TABLE II 
Urban. Rural. 


Human. | Bovine. | Human. | Bovine. 


pA OE | ere a | eS 


0— 5 years .. T 9 5 — 6 
5-15 œ T 11 2 3 2 
Overl15 ,, «- oe 5 — 4 3 
Porcantage bovine... — 21:9 — 60°1 


bovine types is three times greater in the rural areas 
than in the city. The only protection in rural areas 
is to boil the milk. 

EPIDEMIOLOGY 


The Tables show that the rural population supplies 
us with far the greater proportion of our cases due to 
the bovine bacillus. Even in the later age-periods 
we find cases of meningeal tuberculosis due to the 
bovine type from rural areas. Dr. Griffith reports 
the case of a man of 32 years of age from Lincolnshire 
whose cerebro-spinal fluid yielded a bovine virus 
and the oldest case in our series is that of a ploughman, 
30 years of age, from Perthshire; while we can also 
show the cases of a youth of 19 from Fifeshire and a 
girl of 17 from Perthshire, from each of whom bovine 
types were obtained. Ploughmen in Scotland usually 
receive milk from the farm. as part payment, and the 
question of compensation might reasonably arise 
if disease due to the bovine bacillus was found to be 
the cause of death. The difficulty would be to fix 
the actual source of the infection. Ploughmen do 
not remain long in one service. 

In the prevention of tuberculosis, one of us has 
previously stressed the fact that after notification 
of a case of meningeal tuberculosis the family must 
be carefully reviewed, especially to ascertain if 
there is a case of pulmonary tuberculosis or other 
visceral tuberculosis in the household. If no other 
case of tuberculous disease is found, full inquiry as 
to the source of the milk-supply must be made. 

With regard to the cases from Fife county, it was 
easy for us to get all the facts. In every instance 
where a human type virus was found in the cerebro- 
spinal fluid there was, or had been, a known case of 
pulmonary tuberculosis in the home. With regard 
to the bovine types from Fife county, the discovery 
of so many cases of pulmonary tuberculosis due to 
the bovine type virus makes us keep in mind that 
we must be careful to review the whole family even 
if we do know the virus from the cerebro-spinal 
fluid is bovine in type. In no case due to the bovine 
type from Tife, however, did we find anyone with 
visceral tuberculosis in the home, and so in these 
cases we were forced to regard the milk-supply as the 
likely source of infection. 

In recent years it has been our practice to notify 
Dr. G. Pratt Yule, medical officer of health of Fife, 
at once whenever we have found bovine type in a 
cerebro-spinal fluid. From the cases notified, Dr. 
Yule has been able to find an offending cow in two 
instances. We were much disappointed to be 
unable to find the source in the case of an eight 
months’ old child whose virus was bovine in type. 
Careful examination of the herd by the county 
veterinary officer failed to reveal disease in any cow 
and a biological test of the milk proved negative. 


PUBLIC HEALTH 


[FEB. 15, 1936 


Urban cases—When we come to consider the 
epidemiology of the cases from Dundee, we confine 
our inquiries to those cases in which a bovine virus 
was obtained. We are indebted to Dr. John Hunter, 
tuberculosis officer, Dundee, for his help in obtaining 
full information about these cases. 

In Dundee there are two large companies which 
pasteurise milk and over 50 per cent. of the city’s 
supply is pasteurised, while 10 per cent. will be from 
tubercle-free herds; so that probably between 60 
and 70 per cent. of the supply will be safe. There are 
many deliveries from the churn by cart and there 
are a few dairies in the city where cows are bought in 
and milked till dry and then sold. These cows never 
go out from the byre. 

In 11 instances the bovine type virus was found. 
The family history in one case revealed that the 
father suffered from pulmonary tuberculosis and 
tubercle bacilli of human type were obtained from 
his sputum ; he had also had extensive tuberculosis 
of the cervical lymph nodes ten years previously. 
This finding is in keeping with those cases described 
by Walker > when he reviewed the lack of evidence 


of human-to-human infection by the bovine type. 


In this case there was opportunity of infection by 
milk as the supply was not from a safe source. 

In one other case there was a history that the father 
had had a hemoptysis, but no sputum ever was 
obtained. 

In every case the milk-supply was from a doubtful 
source and there was a common dairy in three 
instances. This information has been passed to the 
medical officer of health and we learn that this dairy 
buys in milk for sale. It will be most difficult to 
overtake a complete examination of the cows in 
such a circumstance. 


IS THE PRESENT LEGISLATION SUFFICIENT FOR THE 
EXAMINATION OF COWS ? 


The 1914 Milk and Dairies Act is the Order under 
which a local authority can act. This is supplemented 
by the Tuberculosis Order, 1925. These appear 
to us to be utterly insufficient and the faults lie 
in two places. 

Firstly, the definition of a dairy is too restricted. 
The term includes any creamery, farm, &c., from 
which milk is sold or supplied for sale, but excludes 
premises where cows are kept solely for the use of the 
farmer and his servants, or where milk is sold to 
a very limited number of neighbours. Therefore - 
such premises need not be registered and there is 
no inspection. 

With the knowledge that deaths have occurred 
among farm servants, and that cervical lymph-node 
tuberculosis is not uncommon among farm servants’ 
families, being often due to the bovine type bacillus, 
it is obvious that all places where milk is obtained 
should be inspected. This is not meant to imply 
that the farmer is careless as to milk-supply to his 
staff. For example :— 


A farmer residing a few miles from Glenlomond 
Sanatorium purchased a cow as sound, the milk to go to 
his staff. The farm grieve and his wife did the milking 
and noted at once a slight induration in one quarter. 
The cow was again examined and passed as sound, but 
the grieve brought the strippings of the indurated quarter 
here for examination and numerous tubercle bacilli were 
found. ‘On report of this the farmer had the animal 
destroyed at once and examination revealed extensive 
tuberculous disease. 


The farmer who merely keeps cows to supply milk 
to his staff would, we feel sure, not knowingly retain 
an unsound cow, but there ought to be inspection. 


THE LANCET] PUBLIC 

The second serious defect in the Order lies in the 
qualification of disease in the cow. The cow-keeper 
must report to the local authority if a cow (1) has 
a chronic cough, (2) is emaciated, or (3) has disease 
or induration in an udder. But these, surely, are 
terminal features? A cow in any such state, if 
tuberculosis is the cause, will have done all the 
damage she can do, and we can hardly think that 
the dairy farmer only suspects when any of the above- 
mentioned states is present. And the amazing feature 
in the Order follows. If the dairy farmer reports 
such an animal to the local authority and on inspec- 
tion tuberculosis is found he is compensated.. It 
is very different with other tradesmen. A sale 
of adulterated foodstuffs is punishable but the farmer 
is compensated if he notifies an unsound beast. 

These Orders do not deal with the problem at all, 
but leave it possible to profit by the sale of unsound 
milk and subsequently by notification of the unsound 
cow. 

CONCLUSIONS 


Of 50 cases of meningeal tuberculosis 18 (36 per 
cent.) were attributable to bacilli of bovine type. 
Rural cases give 60 per cent. of bovine types while 
urban cases yield 22 per cent. Taking the figures 
for Fife alone, we find that 7 out of 14 (50 per cent.) 
are of bovine type—a figure which probably gives a 
better idea of the actual position. Tuberculosis due 
to the bovine type is an urgent rural problem, and 
the present legislation is inadequate. 


REFERENCES 


1. Griffiths, A. S.: TaS Path. and Bact., 1932, xxxv., 97. 

2. : THE LANCET, 1934, i., 1382. 

3. Macgregor, A. : “Trans. Tuberc. Se Scotland, 1933-34, p. 383 
or Edin. Med: Jour een 

4. Blacklock, J. W. S.: , 4 

5. Brit. Med. Ir, 1934, i., 371. 


d 


Walker, G. : 


Medical Inspection in American Schools 


Ir is a common experience to meet a friend just 
returned from a foreign country full of enthusiasm 
for its wonderful organisation, and soon after another 
who has nothing to tell but of its backwardness 
and deplorable conditions. Strangely contradictory 
accounts have been given of the state of school 
medical work in America and the discrepancies may 
be resolved by study of a searching review by Dr. 
J. F. Rogers, of Washington, in the Quarterly Bulletin 
of the League of Nations Health Organisation. The 
degree of etficiency ranges from organisation such as 
that in New York State to that in Illinois. In New 
York State there is a director with a central staff of 
eight : (1) a general supervisor of medical inspection ; 
a supervisor of (2) sight and hearing ; (3)oral hygiene ; 
(4) heart and lungs; (5) psychiatry ; (6), (7) two 
supervisors of school nursing ; and (8) a supervisor of 
health for teacher-education institutions. The out- 
side staff consists of 1300 school medical inspectors 
and 600 nurses. The inspectors have had special 
post-graduate training in the principles of health 
education and in its organisation in public schools. 
The nurses, after full training, have all taken an 
approved course in health education. There are 
besides many trained dental hygienists working under 
the dentists. In Illinois there is no legislation on the 
subject at all, and this is the case in 5 other States ; 
although in some of these there may be good systems 
of examination in certain schools. In 27 the law is 
mandatory, in 13 it is merely permissive. The 
inspections are carried out in 3 States by the county 
health officer, in 5 by a physician, in 9 by a physician 
or a nurse, in 6 by a physician or a teacher, in 5 by 
a physician, teacher, or nurse, in 3 by a nurse, in 


HEALTH 


[FEB. 15,1936 395 


7 by a teacher, and in 2 by a dentist only. Obviously 
a teacher cannot make a full medical examination 
but he may recognise defects such as those of sight 
and hearing, and in some places teachers are given 
specific instruction in the detection of gross defects. 

On the credit side of the account must be put the 
fact that in 20 States the examinations are annual— 
a frequency which is being advocated by some - 
reformers in this country. Against this must be set 
the fact that in only 14 States is there a full general 
medical examination. In general the object of the 
inspection is to remove obstacles to education rather 
than to promote better health and physique. The 
school medical officer who has graduated in public 
health is nearly non-existent. The administration is. 
more often conducted by the education department 
than by the health authority, and this bias is increas- 
ing ; there is something to be said for it if it is true 
that there is less of politics in the work of education 
than of public health and hence a more secure tenure 
of office and personnel. The examinations are looked 
upon as educational in another sense; they teach 
the children, and perhaps their parents, the value of 
periodic medical supervision and may lead to the 
habit of seeking it in later life. Instruction in hygiene 
does not appear to be widely organised. 

Special schools for the blind and partially blind, 
for the deaf and hard of hearing, for the crippled and 
the delicate, are highly developed in some States and 
non-existent in others. Some types of special schools 
—e.g., those for the partially deaf—can, we believe, 
be definitely traced to the example of our own 
country. Treatment facilities vary greatly. A common 
practice is just to inform a parent that the child 
‘seems to be suffering’ from some abnormal con- 
dition. Apart from dental clinics there are few 
treatment centres; and even within the boundaries 
of New York State the proportion of defects treated 
varies from 15 to 95 per cent. 


INFECTIOUS DISEASE 
IN ENGLAND AND WALES DURING THE WEEK ENDED 
FEB. IsT, 1936 


Noitfications.—The following cases of infectious 
disease were notified during the week: Small-pox, 
0; scarlet fever, 2509; diphtheria, 1304; enteric 
fever, 27; acute pneumonia (primary or influenzal), 
1605 ; puerperal fever, 52; puerperal pyrexia, 101 ; 
cerebro-spinal fever, 27; acute poliomyelitis, 6; 
encephalitis lethargica, 3; dysentery, 52; oph- 
thalmia neonatorum, 65. No case of cholera, ‘plague, 
or typhus fever was notified during the week, 


The number of cases in the Infectious Hospitals of the London 
County Council on Feb. 7th was 4233, which included: Scarlet 
fever, 1089; diphtheria, 1096; measles, 693; whooping- 
cough, 681; puerperal fever, 17 mothers (plus 13 babies) ; 
encephalitis letbargica, 281; poliomyelitis, 4. 
Margaret’s Hospital there were 24 babies (plus 6 mothers) 
with ophthalmia neonatorum. 

Deaths.—_In 121 great towns, including London, 
there was no death from small-pox, 2 (1) from enteric 
fever, 41 (5) from measles, 4 (0) from scarlet fever, 
25 (2) from whooping-cough, 46 (8) from diphtheria, 
58 (21) from diarrhoea and enteritis under two years, 
and 98 (19) from influenza. The figures in parentheses 
are those for London itself. 

The mortality from influenza is maintained, the total deaths 
for the last nine weeks (working backwards) being 98, 104, 89, 
110, 110, 80, 67, 62, 45. The deaths this week are scattered 
over 46 great towns, Birmingham reporting 9, Manchester 5, 
Bradford 4, Leeds 3, no other great town more than 2. Liver- 
pool had to report 11 deaths from measles, Salford 5, Sheffield 
and Warrington each 3. Liverpool also reported 5 deaths from 
whooping-cough, Birmingham 3. Deaths from diphtheria were 
reported from 29 great towns: 3 each from Hull, Liverpool, 
and Plymouth, 2 each from Bradford, Manchester, and Bir- 
mingbam. 

The number of stillbirths notified during the week 
was 251 (corresponding to a rate of 42 per 1000 total 
births), including 31 in London. 


396 THE LANCET] 


[FEB. 15, 1936 


OBITUARY 


SIR CHARLES BALLANCE 


Tie death occurred on Saturday last of the dis- 
tinguished surgeon and neurologist, Sir Charles 
Ballance; he was 79 years of age and had been 
recently in a delicate state of health. A notice of 
his life will appear later. The following tribute 
to him as man and worker has been received 
from Sir Charles Sherrington: “As one who 
knew Sir Charles Ballance and in earlier years 
saw him much I gladly accept the suggestion 
to pay his memory, at this time of our loss, 
some tribute in words even if brief. Between 
the years 1887 and 1895 at St. Thomas’s Hospital 
medical school, Ballance, and with him Walter 
Edmunds, was a colleague who, I might say literally, 
frequented the physiological laboratory. Among 
other research which the two did there were their 
experiments on the bursting strain of arteries. Also 
at the Brown Institution, which was under me in those 
days, they did work on the thyroid and the results 
of its extirpation in the monkey. 

“For Ballance in those years any hour up to 
10 o’clock in the evening might bring him. He used 
to smile and say, ‘ at home they have yet to under- 
stand that I like my coffee cold!’ The microscope 
would occupy us sometimes until after midnight. 
He was interested in an experimental study as to the 
source and behaviour of the cells which repair after 
inflammation. Ife would be so keen in following the 
movement of the cells that he would read ‘ motives’ 
into their behaviour, In Walter Edmunds he had an 
admirably objective collaborator. Their tracing of 
how the tied artery becomes structurally closed when 
and where ligated in continuity without rupture of 
its coats stands as a monument to their admirable 
collaboration. : 

“ A colleague with whom in those years, and after, 
he did much research was Samuel Shattock. At the 
period I am alluding to they were engaged in a quest 
for possible parasitic protozoa in cancer. They con- 
ducted the search with attempts at culture as well 
as by microscopic examination of the cancerous 
tissue. J was privileged to look on at times, and the 
pains taken, the long patience shown, the scrupulous 
loyalty to results dishearteningly negative were an 
example to remember. Ballance had an enthusiastic 
admiration for Shattock’s great knowledge of and 
experience in morbid macro- and micro-anatomy. 
Ile would compare, and prefer, him to Rudolf Virchow, 
and add, ‘ Shattock will never disappear into politics !’ 
a remark with which it was not diffieult for all who 
knew Shattock, and that he carried habitually with 
him a copy of St. Francis of Assisi, to concur. l 

“ After removing from London I had to my regret 
far less opportunity of seeing Ballance. When I did 
he always renewed just the same frank friendship. 
His enthusiasm for laboratory research in surgery 
did not diminish. He had undertaken his experi- 
ments on nerve-suture and nerve-grafting and the 
repair of nerves. The experimental work by David 
Ferrier always remained a source of inspiration to 
Ballance. He appraised Ferricr’s work on the removal 
of portions of the brain in apes as the actual pionecr- 
step leading to modern cerebral surgery. He followed 
with intense interest the recent developments by his 
own college, the Royal College of Surgeons of England, 
in providing facilities for experimental research in 
surgery—namely, the field laboratory at Down, in 
Kent, and the installation of experimental laboratories 
in the College itself. 


“If as he grew older he seemed a little liable to 
‘preach’ somewhat, this is explained by the fact 
that the theme of which he never tired was experi- 
mental research in surgery. Ballance was sincerity 
itself. A scrupulously conscientious man, on the 
invasion of Belgium by Germany in 1914 he took 
the German decoration, bestowed on him some years 
before, to the Thames Embankment and flung it into 
the river, an incident he would relate with a short 
laugh of satisfaction. In 1933 he was awarded the 
Lister Memorial medal and gave the Lister Memorial 
lecture. This latter give him opportunity to report 
upon and to demonstrate some of his latest work, 
done with junior colleagues, on nerve-grafting. The 
award and the occasion were a profound satisfaction 
to him. Those who were present are not likely to 
forget the impression he conveyed to all there of 
what he stood for.” 


WILLIAM HENRY BATTLE, F.R.C.S. Eng. 
CONSULTING SURGEON, ST. THOMAS’S HOSPITAL 
THE death occurred early on Sunday morning, 
Feb. 2nd, of William Henry Battle, consulting 
surgeon to St. Thomas’s Hospital, following an 
illness of several months’ duration. 


Born in Lincoln in 1855, the son of Mr. F. R. Battle, 
an alderman of that city. he was one of a family of 
nineteen children. He received his general education 
at Lincoln Grammar Schoo! and entered St. Thomas’s 
Hospital in 1873. He was a successful student, 


a prizeman and Solly medallist. and obtained the 
diplomas of M.R.C.S. Eng. and L.S.A. Lond. in 
1877. He served 
a fine apprentiee- 
ship to his later 
position on the staff 
of St. Thomas’s, 
being house phy- 
sician, house sur- 
geon, and resident 
accoucheur. TIn 
1880 he took the 
diploma of F.R.C.S. 
and became surgical 


registrar at the 
hospital, proceed- 
ing to the posi- 
tion of resident 
assistant surgeon. 


At the same time 
he began a long 
connexion with the 
Royal Free Ilos- 
pital by appoint- 
ment to the staf 
as assistant surgeon 
and demonstrator of practical surgery in the School 
of Medicine for Women. He continued his early 
obstetric work by acting as surgeon to the Dispensary 
for Women in Shadwell and was also appointed to 
the staff of the Kast London Hospital for Children. 

In 1892 Battle became assistant surgeon to 
St. Thomas’s Hospital, and in that year, in succession 
to Sir John Tweedy, he joined the staff of THE LANCET 
as general surgical adviser. Such was the arrange- 
ment of work within the office of THE LANCET in 
those days that this post implied the editing of a 
department entitled A Mirror of Hospital Practice, a 
section of the paper that was much developed by 
Tweedy. It entailed the personal visiting of the 


MR. BATTLE 
l Photograph by Beresford 


THE LANCET | 


operating theatres in London on certain days, as well 
as the securing of reports from the theatres of large 
hospitals without the metropolis. Already when 
Battle succeeded to the work its design, framed in 
an era when operations were few and when it was 
possible to relegate their performance to particular 
hours of the week, had become ill-defined, for the 
task of anything like inclusive reporting could not 
be attempted. Thus under Battle’s editorship the 
Mirror of Hospital Practice changed in character and 
became a method of personal approach by the paper 
to authors whose contributions would be obviously 
valuable to our readers. In this way Battle served 
the paper well, while it was his habit, following that of 
Tweedy, to precede the accounts of the operations 
reported with historical notes of analogous cases or 
of similar displays of technique, such as to-day are 
very usually furnished by the authors themselves 
in relation to their communications. The provision 
of these notes, which sometimes formed a ground- 
plan for longer articles, came the easier to Battle, in 
that he had been editor for two years of the surgical 
reports of St. Thomas’s Hospital and a frequent 
contributor to those reports. He seldom recorded 
in the Mirror of Hospital Practice any work of his 
own, but he published in our columns, in the 
Transactions of the Pathological Society and in those 
of the Clinical Society, numerous articles dealing 
with a large range of clinical subjects. 


In 1890 Battle was appointed a Hunterian professor 
at the College of Surgeons, and delivered a valuable 
series of lectures on injuries to the head. The 
composition of these lectures entailed upon him 
investigation of a large number of recorded cases, 
and the work, carried out with judgment and acumen, 
brought together in readable form a great deal of 
valuable information. In 1906, now full surgeon to 
St: Thomas’s Hospital and the Royal Free as well as 
joint lecturer in practical surgery at the former institu- 
tion, he gave a course of clinical lectures at St. 
Thomas’s, entitled the ‘‘ acute abdomen,” in which 
he pointed. out in a detailed manner the difficulties 
presented in diagnosis, and therefore in the first 
stages of treatment, presented by cases of appendi- 
citis, intestinal obstruction, intussusception, perfora- 
tions in the alimentary tract, and gynzxcological 
inflammation. His personal knowledge ranged almost 
from the time when operative interference in these 


spheres was contemplated only as a last resource, so. 


that he was able to tell the full story in a graphic 
manner, 


In addition to these lectures and reports he wrote, 
in collaboration with Mr. E. M. Corner, a practical 
treatise on the appendix and its surgical complica- 
tions. The work attained to a second edition and 
marked the great interest with which Battle had 
always followed the development of abdominal 
surgery. Its publication added to his high claims 
to prominence as a surgeon. “In my opinion,” 
writes Mr. Corner, “he was unequalled for dexterity 
and clever manipulation in abdominal conditions. 
His ingenuity and boldness were justified by good 
results. He could on necessity be extremely quick 
and when the unexpected happened he was never 
disturbed, for his skill and experience allowed him to 
adapt procedure in accordance with emergencies. 
As a teacher he was forcible, distinct, and quiet, 
and the practical value of his advice was aided by 
care in suiting his instruction to his audiences. As 
a colleague I can speak of him as always reasonable, 
consistent, and loyal. He earned the respect of all 
who worked with him.” 


OBITUARY 


(FEB. 15,1936 397 


Battle at the time of his death was consulting 
surgeon at the Royal Free Hospital, and Mr. Willmott 
Evans, who for many years was his colleague at that 
institution, describes the many opportunities he had 
of seeing Battle at work. He writes as follows: “ As 
a surgeon Battle was an expert operator, rapid where 
the facts showed the need for action, but in all 
doubtful cases very careful. He was a scrupulous 
diagnostician so that the information obtained at 
the operation usually coincided exactly with his first 
opinion, although he never had any hesitation in 
modifying his diagnosis as further information or 
circumstances warranted. His teaching at the 
medical school associated with the Royal Free 
Hospital was much valued, especially by the senior 
students who could appreciate the caution with which 
he balanced his data, although he showed his care 
in the instruction of more junior students by his 
readiness to clear up any point in his lectures or 
demonstrations which presented difficulty to them. 
He always took particular pains to point out 
to students which were the things that seemed 
to him of the most importance when coming 
to conclusions, so that he effectively made clear 
the basis on which his teaching was formed 
and the circumstances which should . dictate 
diagnosis.”’ | 

Battle’s interest in the diagnosis to be made and 
the procedure to be followed in abdominal surgery 
continued through his life. As far back as 1910 
he delivered the annual oration to the Medical Society 
of London upon intraperitoneal injuries, and in 
that discourse gave a lucid description of where 
particular attention should be paid in ascertaining 
the exact lesion present. And only three years ago, 
after considerable retirement from St. Thomas’s 
Hospital, he wrote in these columns a valuable 
letter upon the occurrence of appendicitis, con- 
sidering that obvious evidence existed for a 
thorough scrutiny into the increasing incidence of 
the disease. | 

Mr. Battle retired from the position of surgeon at 
St. Thomas’s Hospital in 1925 with the rank of 
consultant, leaving behind him the reputation of a 
devoted hospital servant as well as a great surgeon 
and teacher. 


Sir Cuthbert Wallace writes: ‘‘ Every surgeon 
has attributes by which he is remembered by 
those that he taught. In thinking of Battle the 
one thing that stands out in my memory was his 
devotion to his duty as shown by his regularity of 
attendance on his hospital days. Nothing interfered 
with his hospital work and a student was sure to 
find him in his ward at the appointed time, and 
was equally sure of having a profitable afternoon. 
His teaching was simple, clear, direct, and seemed to 
supply just what the student wanted. This resulted 
in his having a large following in the wards whenever 
he appeared. He had a wide knowledge of the 
literature of his subjects and no doubt his constant 
writing for the journals crystallised useful data in his 
mind and enabled him to distinguish facts from 
theories, much to the advantage of those he 
taught. As a surgeon he may be described as 
sure and safe rather than brilliant, and as an 
operator he was neat, quiet, and without fuss. 
Many men still practising must have grateful 
thoughts for Battle.” 


Mr. Battle married in 1892 Anna Marguerite 
Vulliamy by whom he had three sons and two 
daughters. One son was killed in the war, and of 


398 THE LANCET] 


the survivors one is squadron-leader in the R.A.F. 
and the other is Mr. Richard Battle, who follows in 
his father’s footsteps as surgical registrar at St. 
Thomas’s Hospital. 


FARQUHAR MACRAE, M.B. Glasg. 


WE regret to announce the death of Mr. Farquhar 
Macrae which occurred on Feb. 2nd at Newmill, 
St. Andrews, where he had retired in 1929 after a 
long period of surgical practice in Glasgow and the 
West of Scotland. 

Farquhar Macrae graduated M.B., C.M., with 
commendation at Glasgow University in 1895, after 
which he acted as house surgeon and house physician 
at the Glasgow Western Infirmary and Royal Hospital 
for Sick Children. At the termination of these 
appointments he studied under Prof. W. D. Halli- 
burton at King’s College, London, for some time, and 
thereafter became 
assistant to Sir 
Arthur Mayo Rob- 
son in Leeds. It 
was during this 
time that he 
gained that insight 
into gall-bladder 
surgery which 
stood him in great 
stead in later life. 
After a few years 
in Leeds, he 
returned to Glas- 
gow and was 
appointed surgeon 
to the out-patient 
department at the 
Western Infirmary, 
where he was asso- 
ciated with Sir 
Hector Cameron 
and Sir Kennedy 
Dalziel, both in 
hospital and 
private practice. Later he was appointed to the 
post of assistant surgeon to the Victoria Infirmary, 
surgeon to the City of Glasgow Fever Hospitals, and 
consultant surgeon to Ayr County Hospital. He 
returned to the Western Infirmary in 1922 as visiting 
surgeon and was appointed a lecturer in surgery to 
the university. On various occasions he acted as 
examiner in surgery both at Glasgow and Edinburgh 
Universities, and was a fellow of the Association of 
Surgeons of Great Britain and Ireland. 

On his retirement in 1929 he bought a house at 
St. Andrews, but shortly afterwards he was invited 
by the General Medical Council to undertake the 
duties of inspector of examinations. These occupied 
the best part of three years, and at their termination 
he forwarded to the G.M.C. a report which was at 
once recognised as being of the greatest importance. 
His excellent work here led in 1933 to his being 
asked by the India Office to undertake the post of 
secretary-inspector to the newly formed Indian 
Medical Council and he proceeded to India, remaining 
there for more than a year. He found the work 
one of great delicacy for an official not possessing 
special knowledge of India and Indian educational 
Standards, but he did valuable work in preparing the 
ground, 

Macrae never wrote much, but he was ever a keen 
student of the literature of his subject and was 
possessed of the rare faculty of being able to sift the 


MR. MACRAE 
[Photograph by Annan 


OBITUARY 


[FEB. 15, 1936 


grain from the chaff. Among his publications are 
the following : Editor, ‘‘ Diseases of the Gall-bladder 
and Bile-ducts,” second edition, 1900; joint author, 
Affections of the Gall-bladder and Bile-ducts, Encye. 
Med.; Diagnosis of Peritonitis occurring during 
Enteric Fever; Cholelithiasis, Diagnosis, and Treat- 
ment, Brit. Med. Jour., 1922 ; Diagnosis in Abdominal 
Diseases, Finlayson’s ‘* Manual of Clinical Medicine,” 
1927. 

He was a man much loved by all who knew him 
well. With tall stature and strong countenance, he 
inspired great confidence in his patients and friends, 
while his wide experience and sound knowledge were 
always available to those who sought his help. As 
a clinician he was outstanding, so that he attracted 
large numbers of students to his clinics. His teaching 
was inspiring, based on a wide knowledge of pathology 
and literature in general. He was sometimes of 
short temper and could then employ a cutting tongue, 
but his actions were never petty, and-he was a 
particularly sound judge of men, and was often 
consulted regarding appointments. 

Farquhar Macrae built up a large surgical practice 
and when he retired in 1929 his loss both as surgeon 
and man was felt to be great. He leaves a widow 
to whom we extend our deepest sympathy. 


A colleague of Farquhar Macrae writes : ‘‘ The death 
of Mr. Farquhar Macrae is a great loss to the medical 
profession and to his many friends. His career has 
been outlined above and his surgical influence on 
the Glasgow school appreciated, but it is the influence 
and personality of the man which I would emphasise. 
Macrae had not many degrees, nor did he publish 
frequently. He did not seek publicity, and believed 
in inherent ability and honesty of purpose. Out- 
standingly he was a man. A tall, handsome figure, 
somewhat severe in expression, he inspired great 
confidence in all who met him; and more than 
confidence, for sympathy where deserved was one of 
his great attributes. Children loved him, and with 
them he was at his best. His simplicity of heart, 
ready understanding, and directness of purpose 
without excuse or explanation endeared him to 
them, and children are seldom wrong. The per- 
sonality, the poise, the honesty of Macrae are seldom 
found in one human being, and with those he 
combined wealth of clinical acumen—that clinical 
sense which is of more value than much book 
learning ; yet he had an intimate knowledge of all 
recent advances and a keen critical faculty as to 
their value. 

‘* After his retiral in 1929 he acted as inspector of 
examinations for the G.M.C. and for the Dental 
Council. His reports on these matters were so 
excellent that he was appointed to an extremely 
responsible post as secretary to the Medical Council 
for India. The strain and difficulties of this and the 
climate of India had their effect on his health and 
he was unable to continue and returned to St. Andrews 
after fourteen months’ service to carry on his interest 
in the furtherance of medical problems and study, 
his work in India having laid a sound foundation 
for a successor. Unfortunately his illness proved 
more serious than was supposed and he had not 
many months left of active life. His funeral was 
attended by many friends, and his great relaxation 
of golf was made noticeable by the fact that a number 
of St. Andrews’ caddies attended the graveside. 
They, like his medical and lay friends, appreciated 
the greatness of the man, great of stature, great of 
mind; they understood his personality, his humour, 


THE LANCET] 


OBITUARY 


[FEB. 15, 1936 399 


and his lovableness. We who knew him mourn him 
deeply and doubt if his like will pass this way again 
in our time.” 


ARTHUR JOHN SCOTT PINCHIN, M.D., 
F.R.C.P. Lond. 


Dr. A. J. Scott Pinchin died at his home in 
Gledhow-gardens on Feb. 7th. He was in his 
sixtieth year and had been ill with pneumonia for 
only three days. Born at Sutton, Surrey, in 1877, 
the son of Alfred James Pinchin, oil broker, he was 
educated at Dulwich College and St. Thomas’s 
Hospital from which he graduated in 1906, taking 
the gold medal in medicine at the London M.D. 
examination three years later. After holding house 
appointments at St. Thomas's, first as house physician 
to T. D. Acland, then as resident anxsthetist and 
casualty officer, Dr. Pinchin settled for a year or 
two in general 
practice at Egham, 
Surrey, becoming 
an active member 
of the Windsor 
Medical Society and 
assistant school 
medical officer to 
the L.C.C. But he 
soon decided to 
devote himself to 
consulting work in 
diseases of the 
chest, and to this 
end he secured 
positions on the 
honorary staff of 
the Hampstead 
General Hospital, 
the West London 
Hospital, and the 
Victoria Park 
Chest Hospital, to 
two of which at the time of his death he was 
senior physician. He also took charge of the 
tuberculosis dispensary at Hampstead and was 
consulted by the New End Poor-law Hospital at 
Hampstead and the Maidenhead Hospital. 


All this work, combined with a considerable private 
practice, kept him more than fully occupied for 
25 years, only broken by a period during the war 
when he had charge of the officers’ hospital at 
Imtarfa, Malta. Dr. Pinchin was an exceptionally 
good diagnostician and a sound practical physician, 
skilful in the use of instruments and quick to see 
their possibilities in modern medicine. He took 
charge of the electrocardiograph department when 
it was started at Victoria Park ; after the war he was 
early in the field with the use of the thoracoscope, 
and with his junior colleague, Dr. H. V. Morlock, 
founded the bronchoscopic clinic at the same hospital. 
Despite indifferent health he was an indefatigable 
worker, devoted to the hospital side of his work, 
and popular with his house staff to whose assistance 
he was always ready to come in trouble. Almost 
his last act before he was taken ill was to attend a 
former resident in a rapidly fatal attack of pneumonia. 


DR. SCOTT PINCHIN 


“Scott Pinchin,” a colleague writes, ‘‘ was a very 
lovable person and I doubt if he had an enemy in 
the world. He was a man of deep religious con- 
Victions, quiet and self-effacing. A shy and rather 
nervous manner made him avoid formal lecturing 
and public speaking as far as possible. He will be 


remembered by his colleagues for sterling worth and 
a gift of friendship.” 


He wrote a good deal at various times, mostly in 
medical journals, covering at first a wide range of 
intrathoracic subjects but later concentrating chiefly 
on chronic pulmonary suppuration. His last con- ` 
tribution to our columns in June, 1935, concluded a 
series of papers, written over many years with Dr. 
Morlock, dealing with abscesses of the lung. ‘‘ From 
small collections of clinical impressions such as 
these,” he quoted modestly, ‘‘ it may become possible 
in time to obtain an individual] experience which will 
bring to bear at the right moment all the weapons 
available for use in this distressing condition.” But 
he was writing from an experience of 2000 broncho- 
scopies over a period of four years, which has added 
substantially to our knowledge and for which clinical 
medicine is in debt to his memory. 

Dr. Scott Pinchin married Miss Margaret Johnson, 
daughter of David Johnson, a well-known inventor, 
who survives him. There were no children of the © 
marriage. 


JOHN HENRY WILLIAMS, L.S.A., M.P. 


THE death is announced as occurring on Feb. 7th 
of Dr. John Henry Williams, Member of Parliament 
for the Llanelly division of Carmarthen. Dr. Williams, 
by birth a Liverpool man, received his medical 
education at the Cardiff Medical School and the 
London Hospital and was for a time medical 
officer in the Booth Line. When he eventually 
settled in Wales at 
Burry Port he 
became a promi- 
nent practitioner 
and energetic in 
public causes. He 
was chairman first 
of the Burry Port 
district council and 
later of the Carmar- 
thenshire county 
council and took a 
leading part in the 
promotion of the 
general health of the 
county and also in 
child welfare work. 
A Socialist in 
politics he had 
represented Llanelly 
in the House of Commons for more than 12 years, 
a proof of considerable determination on his side, 
for he was not successful until his fourth attempt in 
1922; but having obtained admission to the House 
he stood the brunt of future contests and at the 
general election of November last was returned 
unopposed. From this short record it will be clear 
that in Dr. Williams his community has lost a 
valuable servant, 


DR. WILLIAMS 


WILLIAM HENRY RUSSELL FORSBROOK, 
M.D. Lond. 


TuE death was announced in our columns last 
week of Dr. William Forsbrook, a well-known prac- 
titioner in. the Eaton-square district. A prominent 
student at the Westminster Medical School where he 
was Chadwick prizeman and Bird medallist, he took 
the diplomas of L.S.A. and M.R.C.S. Eng. and 
graduated with honours as M.B. Lond. in 1878, later 
proceeding to the M.D. degree. Before going into 


400 THE LANCET] 


private practice he held the resident posts at the 
Westminster Hospital and was also surgical registrar. 
He was a frequent adviser to medical men proposing 
to practise in South Africa. He died on Feb. 3rd 
aged 85. i 


THE LATE SIR JOHN MARNOCH 


Emeritus Professor J. A. MacWI Liam, F.R.S., 
sends the following personal appreciation of Sir John 
Marnoch of whom an obituary notice appeared last 
week :— 

“ Far and wide the news of Sir John Marnoch’s death 
will reach, and everywhere touch responsive chords of 
deep sympathy and awaken many memories. My 
own mind goes back to the time, more than forty 
years ago, when I was so fortunate as to have his 
able assistance in the work of the physiology depart- 
ment at Aberdeen after his brilliant student career. 
It is grievous to think now that his fine record has 
come to the end. Until he was suddenly stricken by 
illness some three years ago he looked very young 
for his age ; whether seen at his work or in his ideally 
happy hospitable home, his slender alert figure and 
his keen vitality and notable zest in life gave every 
promise of many active years still to come. The 


PARLIAMENTARY 


PARLIAMENTARY INTELLIGENCE 


(FEB. 15, 1936 


decline of his physical strength in recent time he 
accepted in the fine impersonal spirit characteristic 
of the man. Superb operator as he was, quiet, 
quick, and infinitely dexterous, what was still rarer 
was a supreme gift of wise and balanced judgment in 
dealing in comprehensive and far-sighted fashion 
with the various considerations of complex and 
difficult problems. His clarity of thought was 
remarkable. When an involved subject had been 
dealt with by Marnoch it came out shorn of all non- 
essentials, reduced to its simplest terms and expressed 
in a Minimum of precise and lucid sentences. 

‘“ Marnoch was a gifted musician, his strikingly 
beautiful hands equally at home on the violin and 
with the scalpel. As a golfer and a salmon fisher on 
the reaches of his beloved Spey he was keen and 
skilful—an artist in all that he touched, whether 
work or recreation. His great success never changed 
John Marnoch in the least; his simplicity, absolute 
sincerity, and innate modesty were conspicuous in 
him -while life lasted. Endlessly willing and most. 
generously helpful, with a gift of leal-hearted friend- 
ship, his memory will ever be cherished by all who 
knew him and had to do with him as colleagues, 
students, patients, or friends.” 


INTELLIGENCE 


NOTES ON CURRENT TOPICS 


Advertisement of Medicines and Surgical 
Appliances 

Ix the ballot of private Members of the House 
of Commons for the right to present Bills which will 
come up for second reading on Fridays between 
now and Easter which took place on Feb. 6th Mr. 
G. A. V. DUCKWORTH (Shrewsbury, Unionist) was 
one of the first eight names in the ballot. The 
Bill which he proposes to bring forward is entitled 
the Medicines and Surgical Apphances (Advertise- 
ment) Bil. The measure is the outcome of the work 
of a committee representative of the various interests 
connected with the trade in proprietary medicines, 
and aims at the removal of some of the worst abuses 
in the advertising of those articles. Among the 
deputation which presented the Bill to the Minister 
of Health were representatives of local authorities, 
the British Medical Association, the Society of 
Medical Officers of Health, the Parliamentary Medical 
Committee, the Parliamentary Committee on Food 
and Health, newspaper and advertising associations, 
the Pharmaceutical Society of Great Britain, and 
bodies representing the drug trade, manufacturers 
of surgical instruments, and the Proprietary Associa- 
tion of Great Britain. The prohibitions in the Bill 
extend only to certain types of advertising. No 
one is prohibited by the Bill from treating any ail- 
ment or from supplying any medicine or appliance. 
Certain ailments and conditions are specified, and 
restrictions are imposed upon certain methods of 
‘holding out ”? medicines, appliances, or treatment 
as beneficial to those suffering from them. The 
Minister of Health may remove any of the specified 
ailments or conditions from the operation of the 
Act, but he may not add new ones. 


THE OFFENCE OF ‘f HOLDING OUT ”’ 


According to an explanatory memorandum drawn 
up by the promoters of the Bill it is proposed to make 
it illegal in connexion with the supply or offer of a 
medicine or appliance or treatment to bold it out as 
effective for the cure or for the prevention or for 
exercising any salutary influence on any of the follow- 
ing ailments :— 

(a) Bright’s disease, cancer, consumption, diabetes, 
epilepsy, fits, locomotor ataxy, lupus, or paralysis. 


It would also be illegal in connexion with the supply 
or offer of a medicine or appliance or treatment to 
hold it out as effective for any of the following 
purposes :— 

(b) The cure of amenorrhcea, hernia, blindness, any 
structural or organic ailment of the auditory system, 
habits associated with sexual excess or indulgence, and 
any ailment associated with those habits; (c) procuring 
miscarriage of women; (d) the promotion of sexual 
virility in men or of sexual desire in women. 


It would be illegal for the proprietor or distributor 
of a medicine or appliance and for a person adminis- 
tering treatment to publish a document which to 
his knowledge contains an intimation that any person 
is prepared to treat by correspondence any of the 
ailments or conditions mentioned under (a), (b), (c), 
and (d). The ailments referred to are those for 
which the Select Committee on Patent Medicines in 
1914 recommended that advertisements for cure 
should be prohibited. In the Bill, the prohibition is 
extended to advertisements claiming effectiveness 
for prevention and for exercising a salutary influence 
on the course of those mentioned under (a). 


EXCEPTIONS TO THIS OFFENCE 


A “holding out ”? which would otherwise be illegal 
would be permitted in the following circumstances :— 

(a) By a duly qualified medical practitioner or a regis- 
tered dentist in the exercise of his profession; (b) if it 
is directed to doctors, dentists, nurses, pharmacists, 
hospitals, and persons carrying on a business including 
tho practice of medicine or dentistry, or the supply of 
medicines or appliances; (c) in technical publications ; 
(d) in connexion with patent applications ; (e) to a patient 
for whom the medicine, apphance, or treatment has been 
prescribed by a doctor or dentist. 


Certain advertisements for articles of diet which 
would otherwise be illegal are proposed to be permitted. 
But the claim made must be no more than that, as 
an article of diet and not otherwise, the article is 
effective for the preventing or exercising a salutary 
influence on (but not curing) any of the ailments 
mentioned under (a). 

A person who publishes or delivers any document 


which the Act makes illegal commits an offence unless 


he can show that he delivered it in a package con- 
taining a medicine or appliance in the form in which 
it was supplied to him, 


THE LANCET] 


DIAGNOSIS OR TREATMENT BY CORRESPONDENCE 


Invitations to correspond with a view to diagnosis 
or treatment may not be issued by the proprietor or 
distributor of a medicine or appliance or a person 
who administers treatment. It is illegal for such a 
person to publish any document which to his know- 
ledge intimates that any person is prepared to diag- 
nose by correspondence or to receive a statement 
of symptoms of ill-health with a view to advising 
for treatment by correspondence. 

It is, however, permissible to advertise that a 
person will receive from someone who states that he 
knows himself to be suffering from a particular ail- 
ment particulars with a view to the supply of some 
article for its treatment. No such advertisement 
may refer to any of the ailments included under (a) 
or to amenorrheea or to blindness. It is to be noted—- 

(1) That the offence is the publication of a document ; 
(2) that the intimation must be for treatment by corre- 
spondence ; (3) that the ailments and conditions to which 
the prohibition applies are limited. 


No prosecution can be instituted without the consent 
of the Attorney-General. 


SAVING CLAUSES 


There is a saving clause for proprietors, publishers, - 


printers, and distributorsof newspapersand periodicals; 
for printers and distributors of circulars and other 
documents; for advertising agents; and for the 
employees of any of them. None of them is liable to 
be convicted of an offence under the Act if in the 
ordinary course of his particular business he has 
taken part in the publication of an advertisement 
which is illegal under the Act. 

There is a further saving clause for a person pro- 
fessing a religious belief in the effectiveness of some 
means other than medicines or appliances for 
curing or preventing or exercising a salutary influence 
upon any of the ailments included under (a) or for 
curing any of the habits included under (b) in para. 2 
of this memorandum. He may hold out the means 
as being effective for that purpose or he may publish 
an intimation that someone is prepared to employ 
that means for that purpose by correspondence. 
But to avail himself of this defence he must show 
to the satisfaction of the court that he is acting in 
accordance with the principles and practice of a 
religious body comprising a substantial number of 
persons resident in the United Kingdom who profess 
that belief, and also that he is authorised in accord- 
ance with the constitution of that body to act in 
that way. This exemption is to cover such treat- 
ment as ‘“‘faith-healing’”’ or prayer. To prevent 
the rogue taking shelter under it, it is limited to 
members of organised religious bodies, as, for example, 
Christian Scientists and Spiritualists. 


In the House of Commons on Friday, Feb. 7th, 
Mr. DUCKWORTH presented the Medicines and 
Surgical Appliances (Advertisement) Bill which was 
set down for second reading on March 27th. 

In the House of Lords on Thursday, Feb. 6th, the 
Royal National Pension Fund for Nurses Bill was 
presented and read a first time. 

On Monday, Feb. 10th, in the House of Commons, 
Mr. TINKER presented the Public Health (Coal Mines 
Refuse) Bill, the object of which is to amend the 
Public Health Act, 1875, with respect to coal mine 
refuse liable to spontaneous combustion. 

In the House of Lords on Tuesday, Feb. 11th, the 
report of Amendments to the Voluntary Hospitals 
(Paying Patients) Bill was agreed to on the motion of 
Lord Luke. 


HOUSE OF COMMONS 
WEDNESDAY, FEB. STH 
Departmental Inquiry into Workmen’s 
Compensation 


Mr. Tom SMITH asked the Home Secretary what pro- 
gress was being made by the departmental committce 
inquiring into certain matters connected with the Work- 


PARLIAMENTARY INTELLIGENCE 


[FEB. 15,1936 401 


men’s Compensation Act.—Mr. GEOFFREY Lioyp, Under. 
Secretary of State for the Home Department, replied : 
I understand that the committee have had several meet- 
ings and taken a substantial amount of evidence. A good 
deal more, however, remains to be heard, and it is not 
possible at present to forecast when the inquiry is likely 
to be completed.—Mr. BurRKE: Will the hon. gentleman 
take into consideration the very great difficulty that 
workmen suffering from silicosis have in making a claim 
under the Compensation Act ?—Mr. Luoyp: That is a 
matter for the committee. 


THURSDAY, FEB. 6TH 
Protection of Life from Fire 


Mr. GRAHAM WHITE asked the Minister of Health (1) if 
his attention had been drawn to the loss of life due to 
recent outbreaks of fire in Edinburgh and Tyldesley ; 
and whether, in view of the fact that in these and other 
cases escape from burning buildings had been prevented 
by the destruction of staircases, he would in future, 
where possible, prescribe and elsewhere recommend that 
staircases should be constructed from fireproof material ; 
and (2) if it was his intention to introduce legislation for 
the better inspection of buildings, with a view to reducing 
the risk of life and damage from fire to a minimum.— 
Sir K. Woop replied: My attention has been called to 
the outbreaks of fire referred to. I have no power to 
prescribe the method of constructing staircases, but local 
authorities can deal with the matter by by-laws and 
have various powers of inspecting buildings. I will con- 
sider whether it is desirable to issue any recommendation 
to local authorities. 


Grants for Water-supply 

Mr. WELLS asked the Minister of Health (1) the number 
of applications received in respect of water-supplies and 
the total amount of grants up to the end of January 
last, and also the number of grants that had been given 
for areas where the rates, previous to a proposed scheme, 
had been under 10s. in the £; and (2) the total number 
of cases in which applications for grants in respect of 
water-supplies had been refused.—Sir K. Woop replied : 
Up to the end of January last applications had been 
received in respect of 876 schemes relating to 2227 parishes. 
Grants totalling £831,000 had been provisionally allocated 
in respect of 550 schemes for 1707 parishes, including 
182 schemes where, previous to the proposed scheme, 
the rates were less than 10s. in the £. Grants had been 
refused in respect of 190 schemes on the ground that they 
were not needed to enable the schemes to be carried 
out. 

Nutrition Surveys 

Mr. JoEL asked the President of the Board of Education 
whether, in view of his departmental circular on free 
meals and free milk for underfed school-children, he 
could state whether any education authorities were 
acting on his advice to hold periodically nutrition surveys 
at which all children not receiving free meals would be 
passed under review; and whether he could give the 
names of such authorities.—Mr. OLIVER STANLEY replied : 
I understand that certain local education authorities 
have acted, or propose to act, on the Board’s suggestions 
that periodical nutrition surveys should be held at which 
children not receiving meals would be passed under 
review. I am afraid however that I have no information 
about the number of these authorities, but I understand 
that the areas in which complete or partial surveys have 
been or will be held include Swansea, Gateshead, Norwich, 
Liverpool, and Workington. 


Spa Treatment for Health Insurance Patients 

Mr. MANDER asked the Minister of Health if he would 
consider the desirability of arranging that spa treatment 
should be an additional benefit under national health 
insurance.—Sir K. Woop replied: The present lst 
of additional benefits affords to approved societies 
a wide variety of forms of remedial treatment, and in 
fact the surplus funds of societies available as a result 
of the last valuation have already been allocated on this 
basis. The addition of spa treatment was considered but 
was not selected. If before the date of the next valuation 
I have evidence that there is a fairly widespread desire 


402 ‘THE LANCET] 


on the part of societies for the suggested addition, I will 
give the matter further consideration. Mr. MANDER : 
Has not the right hon. gentleman recently had a good 
many representations from societies on this subject ? 
Sir K. Woop: Yes, Sir, that is so. 


Typhoid Fever in Derbyshire 

Mr. HoLLAND asked the Minister of Health if he was 
aware that an outbreak of typhoid fever was affecting 
a number of persons residing in the village of Langwith, 
Derbyshire, in the area controlled by the Blackwell rural 
district council; and what steps had been taken to deal 
with the matter.—Sir K. Woop replied: The answer to 
the first part of the question is in the affirmative. As 
regards the second part, on the recommendation of my 
department the previous source of the water-supply to 
this village has now been abandoned in favour of one 
which, it is believed, is free from pollution, and I hope 
that there will be no recurrence of the outbreak. 

Mr. HoLLAND asked the Minister of Health if his atten- 
tion had been drawn to the frequent floodings from a 
canal on one side and a polluted river on the other of 
houses situate in Meadow Rams, Pinxton, Derbyshire, 
endangering the health of the inhabitants and giving 
riso to great inconvenience; and was he satisfied that 
proper progress was being made by the Blackwell rural 
district council in dealing with the matter.—Sir K. Woop 
replied: My attention has not previously been drawn to 
this matter. I will make inquiries. 


Mental Treatment 


Mrs. TATE asked the Minister of Health what was the 
increase, if any, in proportion to the population, in the 
number of persons receiving mental treatment in private 
homes and State and voluntary hospitals, in the years 
1900, 1920, 1930, and 1935 respectively ; and whether 
there was in every case sufficient accommodation for 
those requiring treatment.—Sir K. Woop replied: The 
number of persons per 10,000 of population receiving 
mental treatment in the places indicated was 25'4 in 1900 ; 
26°3 in 1920 ; 31°3 in 1930 ; and 32°8 in 1935. The answer 
to the second part of the question is in the affirmative, 
except that in 1930 and 1935 the number of beds available 
in some public mental hospitals was not sufficient to 
enable the prescribed standards of bed space to be fully 
observed. Local authorities in the areas concerned are 
now actively engaged in providing additional accom- 
modation where needed. 


Workmen’s Compensation: Medical and Legal 
Expenses 

Mr. T. SmirH asked the Home Secretary whether he 
would arrange that in future annual statistics on work- 
men’s compensation, legal and medical expenses should 
be shown as separate items.—Mr. G. Luoyp replied: 
The returns under the Workmen’s Compensation Act on 
which the annual Home Office statistics are based cover 
only the compensation paid, and I am afraid that there 
would be great difficulties in the way of obtaining the 
amount of the legal and medical expenses incurred by 
the various parties concerned. So far as regards insur- 
ance companies I understand that for the group belong- 
ing to the Accidents Offices Association, which includes 
most of the larger companies, legal expenses are estimated 
at 2} per cent. and medical expenses at 1? per cent. of 
the premium income. 


MONDAY, FEB. 10TH 
Bombing of Red Cross Units in Abyssinia 


Mr. WATKINS asked the Secretary of State for Foreign 
Affairs whether he had any information on how many 
occasions since the outbreak of hostilities Italian aircraft 
had bombed Red Cross units in Abyssinia; and whether 
any British Red Cross units or British subjects serving 
with Red Cross units had been attacked in this way.— 
Mr. Epen replied: According to such information as is 
available, I understand that the American hospital at 
Dessie was bombed on Dec. 6th last. On Dec. 30th the 
Swedish ambulance operating with the Ethiopian forces 
on the southern front was virtually destroyed by aircraft 
near Dolo, and on Jan. 4th Ethiopian Red Cross Ambu- 
lance No. 1, whose staff includes two British subjects, 
was bombed and machine-gunned near Dagabur. The 


PARLIAMENTARY INTELLIGENCE 


[FEB. 15, 1936 


one wholly British ambulance now serving in Ethiopia 
has not suffered as the result of Italian air action. 


Dialling of Emergency Telephone Calls 

Mr. Day asked the Postmaster-General whether, in 
view of the delay caused at times when dialling O on the 
automatic telephone exchange in the case of an emergency, 
he would consider with his engineers whether another 
dialling signal could be substituted on all automatic 
exchanges direct to fire, police, and ambulance stations; 
and if he could say how long it would take to make this 
alteration in the present telephone equipment, and what 
would be the estimated cost.—Major Tryon replied: 
I recently appointed a committee to consider the best 
means of securing the rapid setting up of emergency 
telephone calls; and I am afraid it would be difficult to 
frame estimates such as the hon. Member asks for before 
receiving their recommendations. 


Milk Designations Draft Order 


Mr. THomas WILLIAMS asked the Minister of Health 
how many protests had been received by his department 
concerning the revised draft order, special designations 
for milk ; whether he was aware of the general opposition 
of all producers of Certified milk and all those agencies 
who were trying to improve the standard and quality 
of milk; and if he would consult with interested bodies 
before the revised draft order came into force.—Mr. 
SHAKESPEARE, Parliamentary Secretary to the Ministry 
of Health, replied: My right hon. friend has received 
very few representations with regard to the revised draft 
Milk (Special Designations) Order which was published 
on Jan. 24th. The answer to the second part of the 
question is in the negative. It is open to any interested 
parties to make representations to my right hon. friend 
upon the draft within 40 days of its publication and any 
such representations will receive full consideration. 


Duties of Nurses in Mental Hospitals 

Sir Francis FREMANTLE asked the Minister of Health 
what wore the orders or regulations governing off-duty 
hours and facilities for nurses in mental hospitals; and 
whether he would inquire into their adequacy, considering 
the special need in such occupation of daily and weekly 
change of environment.—Sir K. Woop replied: The 
hours of duty and conditions of service for nurses in mental 
hospitals are determined by the visiting committees of 
those institutions. The majority have adopted the scheme 
recommended by the joint conciliation committee repre- 
senting employers and nurses. An increasing number of 
local authorities are providing change of environment 
and recreational facilities by establishing nurses’ homes 
for mental hospital staffs. I am not aware of circum- 
stances indicating the necessity for an inquiry, but if my 
hon. friend has particular cases in mind, perhaps he will 
communicate with me. 


Resident Chaplains in Mental Institutions 

Sir Francis FREMANTLE asked the Minister of Health 
whether, in view'of the value of intelligent and sympathetic 
ministers of religion in the treatment of mental disease 
and deficiency, he would take steps to promote the appoint- 
ment in mental institutions of resident chaplains suited 
and qualified for the work.—Sir K. Woop replied: The 
appointment of whole-time or resident chaplains is within 
the discretion of tho authorities owning mental institu- 
tions. The importance of such appointments in large 
mental hospitals was emphasised in the report of the 
Board of Control issued last year, and the matter will be 
brought to the notice of individual authorities as oppor- 
tunity occurs. I am not, however, empowered to give 
any direction in the matter. 


Milk Act, 1934, to Remain in Force 


Sir Epwarp Rucctes-BrisE asked the Minister of 
Agriculture what action the Government proposed to 
take when the main provisions of the Milk Act, 1934, 
expired at the end of March.—Mr. EL.iot replied: For 
several reasons, including the currency of various trade 
agreements and the fact that the report of the Reorganisa- 
tion Commission for Milk for Great Britain is not likely 
to be published for some time to come, it is not possible 
at present to bring before Parliament long-term legislation 
for the milk industry. In order to allow adequate time. 


THE LANCET] 


MEDICAL NEWS 


[FEB. 15, 1936 403 


for the consideration by all parties of the important 
questions at issue, the Government have decided to ask 
Parliament to continue until the end of September, 1937, 
the main provisions of the Milk Act, 1934. A Bill to give 
effect to this decision will be introduced forthwith. l 


TUESDAY, FEB. llTH 
Loss of Dangerous Drugs and Poisons 


Sir Josera LAMB asked the Home Secretary whether 
his attention had been called to the increasing number 
of cases where dangerous drugs and poisons had been 
lost in transit or stolen from unattended vehicles and to 
the danger caused thereby to the general public; and 
what action, if any, he proposed to take in the matter. 
—Sir J. Srmon replied: There is, I think, no reason to 
suppose that there has been any increase in the number 
of such cases, though they have had more publicity of 
late by reason in particular of the fact that broadcasting 
is now employed when a loss or theft of this kind is 


reported to the police and it is thought necessary that . 


the public should be warned by this means. The remedy 
seems to lie in the exercise of more care and good sense 
by those concerned, and I hope that the wider publicity 
will help to achieve that result. 

Sir JosepH Lams asked whether, if that did not bring 
about the desired result, the Home Secretary would 
bring in more stringent regulations to prevent these 
happenings. 

Sir Jonn Srmon said the hon. Member would see that 
there would be danger, if they were not careful, of 
restraining persons from reporting such losses for fear of 
the consequences to themselves. It was much better 
that they should report the loss quickly, then the police 
could be helpful. 

Medical Attendance of Arrested Persons 


Mr. JAGGER asked the Home Secretary what were the 
regulations governing medical attendance on persons 


detained under arrest at police stations pending appearance 
before the magistrates; and if he would say whether 
such arrested persons had the right to see a doctor on 
request.—Mr. GEOFFREY LLOYD, Under-Secretary, Home 
Office, replied: All police forces have instructions to take 
special care in regard to the treatment of prisoners 
suffering from illness, to call a doctor to examine any 
prisoner who complains of illness or shows symptoms of 
being in a feeble state of health, and to have him removed 
to hospital if the doctor thinks it necessary. If such a 
person wished to call in a doctor selected by himself, 
steps would be taken to meet his wishes if possible, but 
the police would not wait for a request or complaint from 
him if they considered that he needed medical attention. 


Variola Minor 


Mr. BRoMFIELD asked the Minister of Health whether 
he would consider the advisability of making a special 
investigation of the circumstances attending the outbreak . 
of variola minor which prevailed in certain limited areas 
of this country during the years 1922-34, with a view 
to ascertaining what were the causes of its greater incidence 
in mining areas and whether the disease affected mainly 
those areas where infant vaccination had declined most. 
—Sir K. Woop replied: During the years referred to in 
the question small-pox occurred in no less than 49 of the 
61 counties in England and Wales. The circumstances 
in which the disease occurred were described in the 
annual reports of the chief medical officer of my depart- 
ment, and also in a review published in 1931 entitled 
“A Review of Certain Present Aspects of Small-pox 
Prevention in relation particularly to the Vaccination 
Act, 1867 to 1907.” The published reports contain full 
statistics as to the numbers of vaccinated and unvac- 
cinated children, respectively, who contracted the disease, 
and they afford ample evidence of the value of vaccination 
as a preventive of the disease. In these circumstances 
I do not think that any special investigation is necessary. 


MEDICAL NEWS 


University of Cambridge 

The degree of bachelor of medicine has been conferred 
on W. A. Law and the degree of bachelor of surgery on 
K. G. F. Mackenzie. 
University of London 

Four lectures on the endocrine organs in relation to 
metabolism will be given by Dr. C. Reid on Mondays, 
March 2nd, 9th, 16th, and 23rd, at University College, 
Gower-street, W.C., at 5 p.m. The lectures are open to all. 


University of Glasgow 


On Wednesdays, Fridays, and Mondays from April 15th,,. 


in the ophthalmic department of the University, Prof. 
Arthur Brückner, of Basle, is giving six lectures on physio- 
logical optics and their relation to clinical ophthalmology 
and special clinical ophthalmological problems. 


Royal College of Physicians of Edinburgh 

A quarterly meeting of the college was held on Feb. 4th 
with Dr. W. T. Ritchie, the president, in the chair, when 
Dr. John Philip Cameron (Edinburgh) was introduced 
and took his seat as a fellow, and Dr. Prag Nath Kapur 
(Delhi) and Dr. Venkatasubha Mahadevan (Madras) were 
elected to the fellowship. 

Dr. J. G. Greenfield was appointed the Morison lecturer 
for 1936, Sir Thomas Lewis the George Alexander Gibson 
lecturer for 1936, and Dr. J. D. Gilruth the Dr. Alexander 
Black lecturer for 1936. 


Royal Faculty of Physicians and Surgeons of 
Glasgow 
At a meeting of the faculty held on Feb. 3rd, with 
Prof. Archibald Young, the president, in the chair, Dr. 
Sailes Chandra Guha, of Rangoon, was admitted to the 
fellowship. 


Royal Microscopical Society 
At a meeting of this society at B.M.A. House, Tavistock- 
square, London, W.C., at 5.30 P.M. on Wednesday, 


Feb. 19th, Dr. G. M. Findlay will read a paper on a new 
virus disease of mice. 


Grants for Scientific Investigations 

Particulars of government grants for scientific investi- 
gations may be obtained from the clerk to the government 
grant committee of the Royal Society, Burlington House, 
London, W.1, and applications should be sent to him not 
later than March 3lst. ' 


Lectures in Hospital Administration 


A three months’ course of lectures and demonstrations 
on clinical practice and hospital administration will be 
given by Dr. J. V. Armstrong at the Brook Hospital, 
Shooters Hill, Woolwich, S.E., on Mondays, Wednesdays, 
and alternate Saturdays, beginning on Wednesday, April Ist. 
Further particulars may be had from the medical officer 
of health of the London County Council, Public Health 
Department (Special Hospitals), County Hall, S.E.1. 


The Cost of Superstition 


The serpent, emblem of the healing art, twined round a 
staff on the tower of East Grinstead’s new hospital is 
probably to be removed, because it is thought to have 
brought bad luck to the hospital. The institution was 
opened less than a month ago and, according to a 
correspondent in the Times, two patients have already 
died in hospital, the matron has been ill, and it is now 
recalled that the rain fell in torrents on the day of the 
opening. It will cost £60 to remove the serpent. 


Tuberculosis Conference 

The twenty-second annual conference of the National 
Association for the Prevention of Tuberculosis will be 
held at the County Hall, London, from July 16th to 18th, 
under the presidency of Sir Robert Philip, chairman of 
the council of the association. Subjects for discussion 
will include: examination of contacts; protection of 
the adolescent and young adult from tuberculosis ; tubercle- 
free herds; and the need for closer coöperation between 
the tuberculosis service and the maternity and child 
welfare service, and possibly the educational authorities. 
The secretary may be addressed at Tavistock House 
North, Tavistock-square, London, W.C.1. 


404 THE LANCET] 


Sir Aldo Castellani has been appointed medical 
adviser to the King of Greece. He is at present on a tour 
of inspection of the Italian forces in Abyssinia. 


Oldham Municipal Hospital 


It is proposed to spend £30,000 on enlarging this 
hospital, as about 40 more beds are required in the 
general section. 


New Health Clinic for Wellington 


A new public health clinic has been opened by Lady 
Forester at Wellington. Part. of the clinic will be used 
for tuberculosis cases and provision has been made for 
orthopedic after-care treatment. 


Guild of Hospital Librarians 


The second annual meeting of this association will be 
held from May 8th to llth in La Salle Debussy, 8, Rue 
Daru, Paris, under the chairmanship of Dr. René Sand. 
Further information may be had from Mrs. M. E. Roberts, 
hon. secretary of the guild, 48, Queen’s- gardens, London, 
W.2. 


Poisons for Rodents 


The University of London Animal Welfare Society is 
holding a discussion on this subject at the College of the 
Pharmaceutical Society, 17, Bloomsbury-square, London, 
W.C., at 5.30 P.M., on Thursday, Feb. 27th. The object 
of the discussion is to explore the feasibility of selecting 
and devising poisons with a view to humane considera- 
tions. Mr. J. G. Wright, F.R.C.V.S., will deal with the 
pathological effects of poisons, Mr. J. D. Hamer, F.I.C.. 
will describe chemical rat-control in ships and docks, and 
Mr. T. Howard will speak on poisoned baits. The general 
discussion will be opened by Mr. G. D. Lander, D.Sc., 
and Prof. J. H. Burn, M.D., will be in the chair. Medical 
practitioners who wish to attend should inform the hon. 
secretary of the society, 42, Torrington-square, W.C. 


Medical Congresses at Wiesbaden 


The 27th meeting of the Deutsche Réntgen-Gesell- 
schaft is to be held at Wiesbaden on March 26th, 27th, 
and 28th, under the presidency of Prof. Hans Dietlen. 
The first two days of the meeting will be devoted to 
diagnostic radiology and short-wave therapy, while on 
the last day physical and technical problems will be 
discussed. The 48th meeting of the Deutsche Gesell- 
schaft für Innere Medizin is being held at Wiesbaden 
from March 23rd to 26th under the presidency of Prof. 
Schwenkenbecher, and on the 26th a joint meeting of 
the two societies will take place. Dr. Karl Frik, Brücken- 
allee 22, Berlin, N.W. 87, is the secretary of the radio- 
logical congress. 


Maternal Mortality and Abortion 


On Feb. llth Sir Kingsley Wood, the Minister of 
Health, received a deputation from the National Council 
of Women of Great Britain. Its object was to submit to 
the Minister a resolution urging (1) that the Government 
should appoint a representative committee to inquire 
into the incidence of abortion and as to the law and its 
administration dealing with criminal abortion and 
attempted abortion, and to consider what measures, 
if any, are advisable to improve the existing position ; 
and (2) that future official returns should show the deaths 
attributable to abortion separately from the general 
figures for maternal mortality. The Minister said in his 
reply that the high rate of maternal mortality in certain 
districts had, for some time, been under investigation by 
medical officers of the Ministry, and before considering 
any further inquiry he would prefer to await their report, 
which he hoped to receive before the end of the year. 
He nevertheless promised that the deputation’s statements 
would be examined to see if any action could usefully 
be taken in advance of the report. The problem was 
largely a social one, and he was determined to press on 
with the measures for slum clearance and abatement of 
overcrowding on which a good start had already been 
made. He would also continue to press local authorities 
to improve their maternity and child welfare services, and 
particularly to provide adequate antenatal care for 
pregnant women. A Bill to improve the midwifery 
service was about to be introduced. 


MEDICAL NEWS.——-MEDICAL DIARY 


[FEB. 15, 1936 


Dr. George Leslie Milburn has been appointed 
an official member of the Legislative Council of the Presi- 
dency of St. Christopher and Nevis. 


Society of Radiotherapists 

This newly formed society will hold its first clinical 
meeting at the rooms of the Medical Society of London 
(11, Chandos-street, W.) on Friday, Feb. 21st, at 4.30 P.m. 
Mr. Geofirey Keynes and Dr. W. M. Levitt will open a 
discussion on the technique of radiotherapy in carcinoma 
of the breast which has not been previously treated. The 
hon. secretary of the society is Dr. B. W. Windeyer, 
Middlesex Hospital, London, W.1. 


Tribute to Medical Officer 


At a recent meeting of the town council Dr. James 
Gairdner, who for 56 years has been medical officer for 
Crieff, received the congratulations of the burgh on 
attaining his 90th birthday. Dr. Gairdner has always 
taken a special interest in industrial diseases, and as long 
ago as 1895 described in his annual report valuable 
investigations into the composition of metallic fumes 
and the effects of manganese poisoning. 


Medical Diary 


Information to be included in this column should reach us 
in proper form on Tuesday, and cannot appear if it reaches 
us later than the first post on Wednesday morning. 


SOCIETIES 
ROYAL SOCIETY raat E, 1, Wimpole-street, W. 


TUESDAY, Feb. 
Otto Leyton: The Morbid 


Medicine. 5 P.M. Dr. 
Conditions which Cause Progressive Hyperglycemic 
Glycosuria and the Circumstances which Modify its 
Course. Dr. J. Grabam Willmore, Dr. H. P. Hims- 
worth, and Dr. T. C. Hunt will also speak. 

General Meeting of Fellows. 5.30 P.M. 

Ballot for election to the Fellowship. 

Pathology. 8.15 P.M. (London School of Hygiene, 
Keppel-street, W.C.) Sir Rickard Christophers : 
1. Specimens ‘illustrating B. knowlesi (the Parasite of 
Monkey Malaria). Dr. I. N. Asheshov: 2. Technical 
Methods Used in Investigation of the Bacteriophage. 
J. C. Cruickshank : 3. Bact. typhiflavum. H. Schwa- 
bacher: 4. Desensitisation of Tuberculin-sensitive 
Gaines pies. E. A. Straker: 5. Solubility of Pneu- 
mococci in Sodium Hydrate. G. S. Wilson: 6, Modi- 
fied Methylene Blue Test for the Grading of Milk. 
7. Rapid Method for the Quantitive Enumeration of 
Bact. coli and Bact. wrogenes in Water. 

THURSDAY. 


RE ROU 5 P.M. (Cases at 4 P.M.) Dr H. W. 
Barber: Keratosis Pilaris Atrophicans (previously 
shown). Dr. F. F. Hellier (for Dr. H. W. Barber): 


2. Urticaria Pigmentosa. Dr. 
Schamberg’s Disease. Dr. W.J 
Erythematosus Treated by 
Bamber: 5. Fibroma with 


G. B. Dowling: 3. 
.O’Donovan: 4. Lupus 
alin Dr. G. W. 
a Typical Epithelial 


Proliferation. Dr. Elizabeth Hunt: 6. Sebocysto- 
matosis. , 
Neurology. 8.30 P.M. (Cases at 8 P.M.) Dr. T. Tennent : 


The Diagnosis and Treatment of Congenital General 
Paralysis. Dr. J. Brander, Dr. W. D. Nicol, and Dr. 
R. M. Stewart will also speak. 

FRIDAY. 

Obstetrics and Gyneecology, 8 P.M. Dame Louise Mellroy : 
Atresia of the Vagina Operation followed by 
Pregnancy and Cwsarcan Section. Mr. A. A. Davis: 
Intrinsic Dysmenorrhea, Mr. Malcolm Donaldson, 
Mr. V. B. Green-Armytage, Mr. Chassar Moir, Mr. 
B. P. Wiesner, Ph.D., and Prof. James Young will 
also speak. 

Radiology. 8.15 P.M. Prof. H. Chaoul (Berlin): Some 
Recent Developments in X-ray Therapy. Prof. J. M. 
eee Morison and Dr. J. F. Bromley will also 
speak. 

MEDICAL SOCIETY OF LONDON, 11. Chandos-street, W. 
Monpay, Feb. 17th.—9 P.M., Dr. P. H. Manson-Bahr: 
The Differential Diagnosis of Diseases of the Colon 
(Dvysentery and Colitis) and their Complications (first 
Lettsomian lecture). 
CHELSEA CLINICAL SOCIETY. 
TUESDAY, Feb. 18th.—8.30 P.M. (Hotel Rembrandt. 
Thurloe-place, S.W.), Mr. Desmond MacManus and 
Mr. Cecil Rowntree: Ccnsultations. 


SOCIETY OF MEDICAL OFFICERS OF HEALTH, 1, Thorn- 
haugh-street, W.C. 
21st.—5 P.M., Dr. W.M. Ash: Prevention of 
River Pollution 


FRIDAY, Feb. 

Maternity and Child Welfare Group.—8s8.30 P.M., Dr. 
Andrew Topping : Certain Factors Influencing Maternal 
Mortality and the Part Played in Combating them. 

Tuberculosis and Dental Officers’ Groups.—8 P.M., Discus- 
sion on Dental Treatment of Tuberculous Patients. 


THE LANCET] 


APPOINTMENTS.—BIRTHS, MARRIAGES, AND DEATHS 


(FEB. 15,1936 405 


ROYAL SOCIETY OF TROPICAL MEDICINE AND 
HYGIENE, Manson House, 26, Portland-place, W. 

THURSDAY, Feb. 20th.—8. 15 P.M., Dr. R. Lewthwaite: 

Recent Work on the Typhus-like. Fevers of Malaya. 
TUBERCULOSIS ASSOCIATION. 

FRIDAY, Feb. 21st.—5.15 P.M. (Manson House, 26, Port- 
land-place, W.), Dr. H. H. Scott and Dr. C. C. 
Toussaint : Primary Tuberculosis in Children and its 
Relationship to Meningitis. 8.30 P.M., Sir Henry 
Gauvain and G. R. Girdlestone : The Treatment 
of Tuberculous Lesions of Bones and Joints. 

SOUTH-WEST LONDON POST-GRADUATE ASSOCIATION. 

WEDNESDAY, Feb. 19th.—4 P.M. (St. James’ Hospital, 

diate baited S.W.), Dr. George Graham: Treatment 
a 
SOCIETY OF RADIOTHERAPISTS. 

FRIDAY, Feb. 21st.—4.30 P.M. (11, Chandos-street, W.), 
Mr. Geoffrey Keynes and Dr. W Levitt: The 
Technique of Radiotherapy i in Carcinoma of the Breast 
which has not been previously Treated. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 


ey hides We OF SURGEONS OF ENGLAND, Lincoln’s 
nn Fie 

MONDAY, Feb. 17th, WEDNESDAY and FRIDAY.—5 P.M., 
Dr. Jobn Beattie : Temperature Regulation (Arris 
and Gale lectures). i 

UNIVERSITY OF LONDON. 

FRIDAY, Feb. 21st.—11 A.M. (London School of Hygiene, 

Keppel-st -street, W.C.), Dr. W. Savage: Food 
HAMPSTEAD GENERAL AND NORTH-WEST LONDON 
HOSPITAL. 

WEDNESDAY, Feb. 19th.—4 P.M., Mr. A. Clifford Morson : 
Fads and Fancies in the ’ Treatment of Prostatic 
Obstruction. 

‘NATIONAL HOSPITAL FOR DISEASES OF THE HEART, 
Westmoreland-street, W. 

TUESDAY, Feb. 18th. —5. 30 P.M., Dr. T. F. Cotton : Mitral 

Disease and its Treatment. 


Ho AL FOR SICK CHILDREN, Great Ormond-street, 


WEDNESDAY, Feb. 19th.—2 P.M., Mr. James 
Tonsils, "Adenoids, and Accessory Air Sinuses. 
Dr. A. Signy : Bacteriology of Tonsillitis. 

Out- paleng clinics daily at 10 A.M. and ward visits at 


NATIONAL HOSPITAL, Queen-square, W.C. 
Monpay, Feb. 17th.—3.30 P.M., Dr. Kinnier Wilson: 
Some Heredo Familial Diseases (I.), Extra Pyra- 
midal (II.). 
TUESDAY.—3.30 P.M., Dr. Critchley : 
Disease (IV.). 


Crooks: 
3 P.M., 


Cerebral Vascular 


WEDNESDAY.—3.30 P.M., Dr. Kinnier Wilson: Clinica] 
Demonstration. 

THURSDAY.—3.30 P.M., Mr. Leslie Paton: Optic Atropby. 

FRIDAY.— 3.30 P.M., Dr. Purdon Martin: Poliomyelitis. 


Out-patient Clinic daily at 2 P.M. 
WEST LONDON HOSPITAL POST-GRADUATE COLLEGE, 
Hammersmith, W. 

MONDAY, Feb. 17th.—10 A. M., Medical wards and skin 
clinic. 11 A. M., Surgical wards. 1.30 P.M., Gynæco- 
logical wards. 9 P.M., Surgical wards, gynecological 
and eye clinics. 4.15 P.M., Mr. Green-Armytage : 
Sterility. 

TUESDAY.—10 A.M., Medical wards. 


11 A.M., Surgical 


wards. 2 P.M., Throat clinic. 
WEDNESDAY.—10 A. M. , Children’s ward and clinic. 11 A.M., 
- Medical wards. 2° P.M., Eye clinic. 4.15 P.M., Lecture 


on anesthesia. 

THURSDAY.—10 A.M., Neurological 
clinics. Noon, Fracture clinic. 
genito-urinary clinics. 

FRIDAY.—10 A.M., Skin clinic. Noon, Lecture on treat- 
ment. 2 P.M., Throat clinic. 

SATURDAY.—10 A.M., Surgical and children’s 
medical wards. 

Operations, medical and surgical clinics daily at 2 P.M. 

The lectures at 4.15 P.M. are open to all medical practi- 
tioners without fee. 

JOHN CLINIC, Ranelagh-road, S.W. 

FRIDAY, Feb. 21st.—4.30 P.M., Mr. Martin Oldershaw : 
Some Chronic Causes of ‘‘ Rheumatism ” in Women. 

LONDON SCHOOL OF DERMATOLOGY, 5, Lisle-street, W.C. 
TUESDAY, Feb. 18th.—5 P.M., Dr. S. E. Dore: Pruritus, 

Prurigo, and Lichenification. 
WEDNESDAY.—5 P.M., Dr. I. Muende: Histopathology. 

FELLOWSHIP OF MEDICINE AND POST-GRADUATE 

MEDICAL ASSOCIATION, 1, Wimpole-street, W. 

Monpbay, Feb. 17th, to SUNDAY, Feb. 23rd.—CHELSEA 
HOSPITAL FOR WOMEN, Arthur-street, S.W.  All-day 
course in gyniecology.—NATIONAL TEMPERANCE Hos- 
PITAL, Hampstead-road, N.W. Tues., 8.30 P.M., Mr. 
R. Y. Paton: Deformities. Thurs., 8.30 P.M., Mr. 
David Patey: Liver, Spleen, and Pancreas.—SsrT. 
JOHN’s HOSPITAL, 5, Lisle-street, W.C. Afternoon 
course in dermatology.—PRINCESS ELIZABETH OF 
YORK HOSPITAL, Shadwell, E. Sat. and Sun., course 
in children’s diseases. 

Courses are open only to members and associates of the 
fellowship. 

LEEDS GENERAL INFIRMARY. 

TUESDAY, Feb. 18th.—3.30 P.M., Mr. Pain: Common Foot 
Complaints in General Practice. 

LEEDS PUBLIC DISPENSARY. 

WEDNESDAY, Feb. 19th.—4i PM., 
Influenza. 


and gynecological 
2 P.M., Eye and 


clinics, 


ST. 


Dr. S. J. Hartfall: 


UNIVERSITY OF DURHAM. 
SUNDAY, Feb. 23rd.—10.30 A.M. (Newcastle General 
Hospital), Mr. A. Logan: Surgical Cases. 


GLASGOW POST-GRADUATE MEDICAL ASSOCIATION, 
WEDNESDAY, Feb. 19th.—4.15 P.M. (Royal Infirmary), 
Ae TE ae Smith: Some Infective Diseases of 

e n. 


Appointments 


London County Council Hospital Staff.—The following appoint- 
ments, promotions, and transfers are announced. A.M.O. 
(I.) and (II.) =Assistant Medical Officer, Grades I. and II. 


See J. P., M.D., M.R.C.P. Irel., A.M.O. (II.), Bethnal 
reen ; a; 
H., M.B. Lond., A.M.O. (II.), Constance-road 


etua. 
Youne, R. M., M.D. Edin., A.M.O. (II.), Constance-road 
ore Fulham ; 


Institution ; ; 
RAMSAY, A. M., M.B. Aberd., A.M.O. 
JONES-DAVIES, T. E., M.R.C. S. Eng., A.M.O. (II.), Highgate ; : 
i B., M.D. Lond., D.T.M. & H., A.M.O. (II.), 
Highgate 
MCGREGOR, C. Ba , M.B. Glasg., D.P.H., High Wood Hospital 


for Children 
MATHESON, I. W., F.R.C.S. Eng., A.M. n: (II.), Mile End ; 
DICKIE, A. E., M. 'B. Glasg., A. M.O. : 
SIMON, E. L., M. B. Lond., "A. M.O. 
Fox, R. W. S., M.B. Melb., A.M.O. (IÍ. ), St. Charles’ ; 
A. K., ’ M.B. Glasg:, A.M.O. (II.), St. George-in-the- 


East ; 
ROWLANDS, E. A., M.B. Melb., F.R.C.S. Eng., A.M.O. (I.), 
(II.), St. Olave’s ; 


St. Mary, Islington ; ; 

MERSON, G. P., M.B. Aberd., A.M.O. 

LAWSON, W. S. G., M.B. Lond., are (II.), St. Pancras ; 

TULLIDGE, G. M., M.B. Lond., D.T.M. & H., House Physician, 
High Wood. Hospital for Children ; : 

Evans, W. G., M.B., D.P.H., House Physician, North- 
Western ; ; 

ORPWOOD, R. "M. M. C., M.R.C.S. Eng., D.P.H., House Physi- 
cian, "Queen Mary’ s Hospital for Children ; 4 

PEARSON, H. E. S., M.B., M.R.C.P. Lond., A.M.O. (I.), 


St. Mary, Islington ; ; 
M.R.C.P. Lond., A.M.O. (I1.), 


GREEN, R. D., M.B., 
D., M.B. Belf., A.M.O. (I.), Mile End. 


St. Pancras ; 
FLATLEY, G. 

verity es Surgeons under the Factory and Workshop Acts: 
Dr. W. F. Mason (Bradford (Cleckheaton) District, 
Yorks (West Riding)); Dr. R. McC. PATERSON (Shepshed 
District, Leicestershire); Dr. R. L. UNSWORTH, (West- 
houghton District, Lancashire) ; and Dr. GAVIN BRONS 
(Mochrum District, Wigtown). 


Births, Marriages, and Deaths 


BIRTHS 


BaRKER.—On Feb. Ist, at a nursing-home, the wife of Dr. 
A. N. Barker, Maidstone-road, N., of a son. 

HoLMwoop.—On Feb. 7th, at Aldermaston, Berks, the wife of 
L. S. Holmwood, M.R.C.S. Eng., of a son. 

LEANING.—On Feb. 2nd, in Edinburgh, the wife of Capt. 
R. R. Leaning, R.A.M.C., of a daughter. 

LEvi.—On Feb. 5th, at Woodchurch-road, N.W., the wife of 
David Levi, M.S. Lond., F.R.C.S. Eng., of Harley-street, 
W., of a daughter. 

ORR. —On Jan. 25th, at Neyyoor, Travancore, India, the wife 
of Ian M. Orr, M. D. Glasg., F.R.C.S. Edin., of a son. 

SHaw.—On Feb. 7th, at Welbeck- street, to ’ Mary Michael 
Shaw, M.B., B.S., wife of C.C. Shaw, B. ‘Arch, »A.R.1I.B.A.— 
a son. 

SUTHERLAND.—On Jan. 3lst, at Bath, the wife of Dr. Alister 
Sutherland, of a daughter. 


MARRIAGES 


GRIFFITHS—WRIGLEY.—On Feb. Ist, at the Congregational 
Church, Buxton, Griffith John Griffiths, B.Sc., . Lond., 
of Colwyn Bay, to Nancy Bryceson W rigley, elder daughter 
of Mr. W. F. Wrigley of Buxton 

STEVENSON ĠLUcK.—On Feb. g “at London, John Black 
Stevenson, M.C., M.B. Glasg., of Sanderstead, Surrey, to 
Marie Gluck, daughter of the late I. Gluck, Esq., of London. 


DEATHS 


BALLANCE.—On Feb. Sth, at St. John’s Wood Court, N.W., Sir 
Charles A. Ballance, K.C.M.G., M.S. Lond., F. R. C.S. Eng. 

BosSwELL.—On Feb. 6tb, at York- -avenuc, East Sheen, S.W. 
Alexander Boswell, M.D. Aberd., aged 82. 

LEEcH.—On Feb. 7tb, 1936, Priestley Leech, M.D. Lond., 
F.R.C.S. Eng., the dearly loved husband of Emmie Milson 
Leech, in his 74th year. Was laid to rest in St. Paul's 
Churchyard, King Cross, Halifax, Feb. 10th, 1936. 

MAITLAND.—On Feb. 6th, at Dudley, Vivian Gray Maitland, 
M.R.C.S. Eng., D.P.H. Dub., in his 58th year. 

MILNER.—On Feb. 4th, in London, Major “Arthur Edward 
Milner, M.R.C.S S. Eng., late R.A.M.C., in his 68th year. 

PINCHIN.—On Feb. 7th, at Gledhow-gardens, S.W., Arthur 
Jobn Scott Pinchin, M. D., F.R.C.P. Lond., aged 59. 

WILLIAMS.—On Feb. 7th, at Burry Port, Carmarthenshire, 
John Henry Williams, L.S.A. Lond., M.P., Carmarthen- 
shire, Llanelly Division. 


N.B.—A fee of Ts. 6d. is charged for the insertion of Notices of 
Neb as J f Births, Marriages, and Deaths. 


406 THE LANCET] 


[FEB. 15, 1936 


NOTES, COMMENTS, AND ABSTRACTS 


FURNITURE FOR CONVALESCENCE 


CONVALESCENT homes too often carry the hospital 
tradition into what should be a holiday atmosphere. 
At the new convalescent home for children, built 
under the Zachary Merton trust for the Royal 
Manchester Children’s Hospital, the furniture has 
been specially designed by Heal’s to please the 
imagination of the child returning to health. The 
beds are of iron, and run on strong wooden castors, 
but there their likeness to hospital beds ends, for the 
smooth half-moon of iron at the head and foot of 
each bed is coloured green with cellulose paint, and 
bears a fine large picture of a country flower—a 
different flower for each bed, painted by hand, not 


a single design transferred interminably. The cots 


are green, too, each again with its special flower, 
and both sides of the cot can be lowered smoothly 
with no crashing of hinges or damage to nurses’ 
insteps. The beds are sprung with strong chain 
springs, impervious to bouncing, and in addition to 
a good hair mattress each child has a feather pillow 
and a pillow of feather and down. Over the beds 
are spread wool rugs designed in shades of green, 
and at every bedside is a cupboard of weathered 
oak with a towel rail and a green top of cork and 
rubber composition on which the evening milk can 
be spilt and not one tear need be shed about it. The 
dining tables and play tables of strong and simple 
pattern have the same perdurable surface, but in a 
colour in harmony with the weathered oak of which 
all the furniture is constructed. The sturdy chairs are 
in two sizes, for longer and shorter patients. In the 
day-rooms the large toy cupboards have half-moons 
of wood for handles and roomy shelves. The book- 
cases are low and stout so that they can be climbed 
upon without damage to themselves and fallen off 
without damage to the climber. Sun couches with 
adjustable backs, wheel-chairs, and glass cupboards 
and trolleys for surgical equipment are the only 
things which recall the hospital a little ; but even the 
ironwork of the cupboard is painted green. The 
comfort of the nurses has been equally considered. 
Their box-spring beds have a little bookshelf in the 
oak headpiece and a concealed light under its upper 
border. Such furniture as this has a look of summer 
even on a February day, and fully carries out the 
determination of Messrs. Heal and Son to avoid the 
hospital atmosphere. It is on view at their show- 
rooms in Tottenham Court-road, London, until 
Feb. 21st. ; | 
CHEST RADIOGRAPHY 


A YEAR ago Messrs. Watson and Sons, Ltd., invited 
inspection of a new condenser set for radiography 
of the chest. One of these sets, installed on approval 
in a London hospital, has taken about 12,000 radio- 
grams with little trouble and much efficiency. The 
principle of the condenser discharge is not new 
but has been revived in this set owing to the large 
current that can now be passed through a Rotalix tube 
for a thirtieth of a second without damage to the 
focus. The set is shock proof, the mechanical parts 
and tube being totally enclosed in a metal cabinet. 
It takes up 6 ft. 5in. by 2 ft. ll in. by 9 ft. 2 in. high. 
The advantages of this type of construction are 
briefly : (1) itis simple in operation ; (2) variation in 
film density is controlled solely by variation of kilo 
voltage ; (3) no time switch is required ; (4) patients, 
no matter of what size, can be radiographed in the 
same exposure time of 1/30 sec.; (5) the level of the 
tube from the floor is fixed,.the patient being centred 
by raising or lowering a platform electrically. 

The quality of the radiographic detail is of a high 
order, showing a ‘“‘ soft ”?” picture with a wealth of 
detail. Nine variations of penetration are provided, 
a “tail” being provided which gives a slightly 
increased exposure time per stud. In practice it is 
found that studs Nos. 1 and 2 are of no value. No.3 
has been used for children, 4, 5, and 6 for normal 


adults according to their thickness, studs 7, 8, and 
9 only being required for stout patients. Anterior 
views are taken at a distance of 5ft., since at this 
distance the machine gives the requisite blackening 
in a patient of average build. The hope of obtaining 
views of comparable density in radiograms of the 
same subject taken at intervals was not realised, 
although it would be unfair to attribute such difference 
as arises to the set itself when other factors are present 
such as alteration in weight of the patient, change in 
dark-room technique, or screen speed. 

Certain disadvantages have been noticed in practice : 
(1) The limited number of available variations of 
penetration, the lower studs being too low for present- 
day screen speed ; the gaps between successive studs 
represent a change of 5k.v. per stud. (2) The 5 ft. 
distance at which the radiograms are taken is a 
non-standard distance; a disadvantage in cardiac 
work. (3) The exposure factors are only sufficient 
to produce a lateral radiogram of the chest at a 
distance of 3ft. in a patient of small build. (4) 
Patients cannot be X rayed in the erect position 
unless able to stand; many would be steadier and 


more comfortable in the sitting position. (5) The 
set cannot be used for stereoscopic work. 
The manufacturers deserve credit for having 


produced so serviceable a plant, and no doubt in 
future models they will meet some at least of these 
difficulties. Many patients are able to sit up to be 
radiographed at a time when they are unable to stand. 
With more variations of penetration and smaller gaps 
between them it should become practicable to adjust 
penetration more exactly to the patient’s thickness. 
It seems likely that the problem of obtaining 
penetrating views and lateral radiograms will be 
solved more easily when faster films or intensifying 
screens are available. 


SMALL BOOKS ON GREAT MATTERS 


THREE more of Cassell’s ‘‘ Health Handbooks,” 
under the general editorship of Dr. A. D. Baker, 
have recently been published at ls. each. The first, 
by Dr. G. J. V. Crosby, is concerned with ‘‘ Insomnia 
and Disordered Sleep,” the causes of which are 
classified as physical, psychical and mixed. Certain 
obvious extraneous causes such as noise or cold feet 
account for still another group. Among the physical 
causes the author rightly places high blood pressure; 
he calls this a disease of modern civilisation and 
large communities, whereas it is common enough 
among unhurried persons in rural areas. He also 
revives the bogy of auto-intoxication from a loaded 
bowel, an injudicious resurrection with which to 
confront an already purgative-ridden generation. 
Somewhat sweepingly he asserts that intoxication 
by the poisons of typhoid, acute fevers, syphilis, 
lead, and tobacco, if untreated, lead to hardening 
of the arteries. Though sound on the sleep require- 
ments of children he perhaps exaggerates the 
significance of ‘‘the mysterious and frightening 
manifestations of puberty ”? which are surely nowadays 
for the most part properly dealt with. There is 
a short chapter on somnambulism and nightmares 
and appended to each chapter is a summary of 


conclusions. 


In these days of infant welfare clinics the feeding 
and management of babies have been so thoroughly 
worked out that they are no longer very disputatious 
matters. ‘‘ IHlealthy Babies,” by the Hon. Mrs. Noel 
Olivier Richards, M.D., is a simple, authoritative, 
and practical little book with which it is difficult 
to find fault. Not everyone will endorse the view 
that weaning may be postponed till the twelfth 
month or even later. Prolonged suckling is 
undoubtedly a strain on some otherwise healthy 
women. The author advocates that when the 
baby is put to sleep out of doors it should lie in a 
secluded place free from interruption “ by visitors 


THE LANOET] 


and out of reach of dustbins, brooms, drains, or 
kitchens or the dust from the road.” ‘Cats might 
have been added to.the list. Dr. Richards takes 
the sensible view that masturbation in the young 
child should be ignored and that the tendency to 
examine and explore should not be discouraged. 
Perhaps, however, she over-emphasises the need 
to protect the small child from physical dangers. 
Any parent who has watched his or her offspring 
clambering upstairs or climbing into a high-chair 
will have been struck with the degree of native 
caution it displays if left to itself. 


The third volume, entitled ‘‘ Birth Control,” 
is contributed by Dr. Helena Wright, and might well 
have been confined to practical matters, whereas it con- 
tains much propaganda in it. Some of the statements 
made seem over-dogmatic ; for instance, that ‘‘ there 
is no way of conducting a reasonable happy married 
life without a method of controlling the number of 
children,” and again ‘“the cap and chemical take 
about two minutes to place in position . .. and no 
harm results to the woman concerned if this technique 
is used every night for an indefinite numbers of years.”’ 
On both of these points, picked at random from the 
book, it would seem impossible to make such a 
definite pronouncement at the present time. In 
her discussion of the problems of limiting the size 
of families Dr. Wright makes no mention or allowance 
for the rapid decline in natural fertility which is 
apparently occurring in the Western races. Although 
there will not be universal agreement among doctors 
that the best techniques have been here described, 
the book has undoubted merit. It is written in 
concise and simple style and its arguments and 
the descriptions of such methods of birth control 
as are advocated by the author are easy to follow. 


A NEW FORM OF MERCURY ARC 


THE mercury arc as we know it to-day has altered 
little since the early discoveries of Arons, Cooper 
Hewitt, Kuch, and others. The ‘atmospheric ”’ 
type of burner made it unnecessary to tilt the tube, 
to strike the arc by applying external heat, but the 
mercury lamp still remained as a discharge between 
two massive pools of mercury. A new type of 
arc has recently been placed on the market by 
Messrs. Hanovia Ltd., which employs a new system 
of starting, though the final quality of output remains 
unchanged. This burner is based on the recent work 
of Spanner, and consists of a simple quartz tube 
containing a very little mercury, a certain amount of 
the rare gas argon, and is fitted with special electrodes 
of ‘‘ activated ° metal. When switched on, a spark 
discharge is established which rapidly heats up the 
electrodes until they are emitting electrons in the 
same way as the filament of a thermionic valve 
generates electrons. As the temperature rises the 
mercury is volatilised and the spark discharge passes 
into the normal mercury arc. 

The new burner does not require tipping to start 
it and will burn in any position. It has other 
advantages over the standard type. Owing to the 
absence of the heavy reservoirs of mercury the tube 
is far less fragile and can be sent by post if well 
packed. The time taken for the establishment of 
full output is considerably less than with the standard 
type, probably because of the smaller quantity of 
heat needed. The new arc can run equally well on 
alternating and direct current, and since the alternat- 
ing supply is becoming universal this is of great 
importance. The old form of three-electrode tube 
for A.C. never proved as satisfactory as the D.C. 
type. 

As regards output a 15 per cent. increase is claimed 
on a reduced current. The quartz of the tube suffers 
the same progressive deterioration as has been 
observed in all other mercury arcs, but a new 
compensating rheostat has been incorporated by which 
the current can be pushed up after the burner has 
been in use for a certain number of hours. 


NOTES, COMMENTS, AND ABSTRACTS 


[FEB. 15,1936 407 


It will be found that these advantages are reflected 
in the price, but the manufacturers are offering 
special terms for replacement of old burners. 


THE GLAXO LABORATORIES 


THE transfer, from cramped and adapted town 
premises to a spacious semi-rural site, of a manu- 
facturing concern based on scientific control is a vast 
undertaking. The Glaxo company is to be con- 
gratulated on the successful way in which they 
have done this. A site of 15 acres at Greenford— 
that classic spot where Perkin discovered the first 
aniline dye—has given opportunity for considered 
and ordered design, an opportunity which has not 
been lost. 

A long well-lighted very modern building with 
only one floor above ground level is arranged so that 
raw materials brought in at one bay, adapted for 
easy unloading of lorries, pass through the various 
processes in their way across the factory part of the 
building to a dispatch bay, without confusion or 
unnecessary handling: In some cases raw material 
is brought to the upper floor so that it may be 
ground, sieved, mixed with other products or other- 
wise treated ; so the final preparation then gravitates 
to the lower level where it is divided into appropriate 
measured or weighed units and put in suitable con- 
tainers for sale and use. All this necessary prepara- 
tion is done with the minimum of effort and with 
proper regard to cleanliness, but without the eyewash 
of redundant precautions designed to make an impres- 


sion on visitors. 


The substances prepared at Greenford include 
vitamins A, B,, B,, C, and D, parathyroid extract, 
the cestrogenic hormone, ergot alkaloids, pituitary 
extract, and antiviruses and similar bodies; many of 
them are sent out in admixture with suitable food 
products or mineral constituents which may be 
deficient in the human body and form useful adjuncts 
to the organic preparations. Milk and malt products 
and cod-liver oil of guaranteed potency are also 
handled at Greenford. Most of the products men- 
tioned can only be offered with confidence to medical 
men and their patients if their activity and com- 
position can be guaranteed as suitable and reasonably 
constant in batches made or sold at different times. 
The greater part of the upper floor of the Greenford 
laboratories is therefore devoted to control and 
research. 

The chemical laboratory consists of one large 


- room where research and analytical control goes on 


side by side. This arrangement which, although not 
usual, is followed in some other large laboratories, 
such as those at County Hall, has the advantage of 
enabling the scientific staff to survey the whole of 
the work and ensures the pooling of knowledge, 
experience, and initiative, besides easing the. disloca- 
tion caused by sickness or holidays. Chemical 
control is supplemented by physical examination 
where this is of service, as, for example, in the spectro- 
metric assay of vitamin A. 

Chemical or physical examination suffices for some 
purposes and in others enables batches of material 
to be packed ready for issue, but where the question 
of activity is important, as in the case of vitamins, 
actual issue is delayed until experiments on animals 
have shown that the preparation is up to standard. 
For this purpose a large animal department is kept 
up, in which thousands of white rats of the well- 
known Wistar strain are bred and stored, both for 
sale to research workers and for experiments in the 
laboratory itself. Besides the laboratories mentioned 
others are devoted to bacteriology and the prepara- 
tion of vaccines, 

The occupation of the new laboratories was carried 
out very carefully; an illustrated pamphlet was 
distributed among the workers before the move was 
effected, and everyone could see from it where he 
would be working and how to get there, besides 
finding his way to any part of the building which might 
concern him, When a visit was paid to Greenford, a 


408 THE LANCET] 


few weeks after the move, everyone seemed as 
“ native and to the manner born’’; the obvious 
newness. of the building and some plant erection 
which was going on were the only signs that the 
place had not been running smoothly for years. 


SPECIMENS IN THE POST 


FEW parcels can be more unpleasant, if not 
dangerous, in the post than material badly packed 
and sent for pathological examination. To prevent 
the risk of infecting Post Office servants and of con- 
taminating the mails, the Postmaster-General has 
drawn attention—he says he has reason for 
doing so—to the conditions for sending speci- 
mens. The material must be in a hermetically 
sealed or securely closed container, placed in a strong 
case with enough absorbent packing to prevent 
movement and any possible leakage. It must be 
clearly labelled ‘‘ Pathological specimen. Fragile, 
with care,” and sent only by letter post. If a packet 
fails to conform to these regulations it is at once 
destroyed with all its wrappings and enclosures, and 
the sender is liable to prosecution. 


A DISCLAIMER 


Drs. David and Robert Thomson write to disclaim 
responsibility for the publicity given to an article 
which they and Mr. E. T. Thompson recently wrote on 
giving vaccine by mouth. “The lay press’s interest 
in colds and influenza,” they say, ‘“‘ is so great that it 
is almost dangerous now for a doctor to publish an 
article on the subject except in some obscuie medical 
journal.” 


V acancies 


For further information refer to the advertisement columns 
All Saints’ Hospital, Austral-street, West- -square, S.E. —Rces. H.S. 
At rate of £100. 

Archway Hospital, Archway-road, oa M.O. £250. 
Pa Caernarvonshire and Anglesey Infirmary.—Sen. and 
. H.S.’s. At rate of £150 and £100 respectively. 

Bath aad Wessex Children’s Orthopedic Hospital, Combe Pale — 
H.S. At rate of £120. 

Birmingham, Queen’s Hospital.—Sen. Res. Anesthetist. At 
rate of £70-£100. 

Birmingham, Romsley Hill Sanatorium.—Res. Asst. M.O. At 
rate of £240. 

Birmingham, St. Chad's Hospital.—Jun. Res. M.O. At rate 
of £150. 

Blackburn, Bia Park Hospital and Institution.—Res. Jun. 
Asst. M.O. At rate of £150. 

Surg. O. £250. 

Brad ord, Municipal General ‘Hospital, St. Luke’s.—H.P.’s and 

H.S.’s. Each at rate of £150. 

Brighton, Royal Sussex County Hospital.—Second Asst. Patho- 
logist. £450. 

British Postgraduate Medical School, Ducane-road, W'.—Two 
First Assts. for Dept. of Surgery. Each £250-£500. 

Cambridge, Addenbrooke’s Hospital. —H.S. At rate of £130. 

Cancer Hospital, Futham-road, S.W.—Res. M.O. for Radium 
Dept. At rate of £100. 

Carlisle, Cumberland Infirmary.—Second H.S. At rate of £155, 

Central London Ophthalmic Hospital, Judd-street, W.C.—Sen. 
and Jun. H.S. £120 and £100 respectively. 

Chelsea Hospital for Women, Arthur-street, S.W.—Registrar 
(Gynecological) and Radium Officer. £75. 

City of London Hospital for Diseases of the Heart and Lungs, 
Victoria Park, l’.—Asst. Laryngologist. 


Constance-road Institution. East Dulwich, S.E.—Asst. M.O. bade 

Coventry and Warwickshire Hospital, Res. Cas. O. £12 

FEastbourne, Princess AliceMemorial Hospital —Hon. Ànwsthetist, 

Egyptian Government.—Director of Lunacy Division in P.H., 
Dept. L.E. 1020 to L.E. 1200. 

Evelina Hospital for Sick Children, Southwark, S.E.—H.P. At 
rate of £120. 

Forest Gate Hospital, Forest-lane, E.—First Asst. Res. M.O. 
£525. Also Second Asst. Res. M.O. £350. 

Gloucestershire Royal Infirmary, d&:c.—H.S. to Ear, Nose, and 
Throat Dept. At rate of £150. 

Halifax Royal Infirmary.—Third H.S. At rate of £150. 

Hampstead General and N.W. Donio Hospital, Haverstock Hill, 
N.W.—Cas. Surg. O. for Out-patient Dept. At rate of £100. 

Hertford, Ware Park Sanatorium. —Asst. M.O. £300. 

Hospital of St. John and St. Elizabeth, 60, Grove End-road, N.W. 
Surg. Reg. £100. Also Clin. Asst. to Ear, Nose, and 
Throat Dept. 

Hull Royal Infirmary.—First H.S. £150. 

I ord, Bee Ham Mental Hospital, Goodmayes.—Jun. Asst. M.O. 

Ipswich, Fast Suffolk and Ipswich Hospital.—H.S. £144. 

Ipswich Mental Hospital.—H.P. #150. 

Kingston upon Hull City and County.—Asst. M.O.H. £600. 


VACANCIES 


Warwickshire County Council.—<Asst. 


[FEB. 15, 1936 


Leicester County Sanatorium and Isolation Hospital, Markfield.— 
Jun. Res. M.O. At rate of £300. 

Lewisham Hospital, High-street, S.E.— Asst. M.O. £350. Also 
Asst. M.O. £250 

Lincoln County Hospital. —Jun. H.S. At rate of £150. 

sae Piast aoee General Hospital.—H.P. and H.S. Each at rate 
o ` 

London Fever Hospital, Liverpool-road, N.—Anesthetist. 

M an nade Booth Hall "Hospital. —Jun. Asst. M.O. Atrate of 

00 

Aranesa Duchess of York Hospital.—Sen. Res. M.O. At rate 
o 

Manchester “Royal Children’s Hospital, Gartside-street.—Two 
Asst. M.O.’s for Out-patients’ Dept. Each at rate of £150. 


Manor House Hospital, Golders Green, N.W.—Jun. M.O. £200. 
Metropolitan Hospital, E.—Hon. Surgeon. Also Surg. Reg. 
Middlesex County Council.—Tuber. M.O. £750. Tuberculosis 


Sanatorium, South Mimms. Deputy Med. Supt., &c. £450. 

M aor Hospital, IV .—Anwæsthetist. Also Asst. Anestbetist. 
£101 

Miller General Hospital, Greenwich-road, S.E.—Cas. O., Out- 

patient Officer. Each at rate of £150. Also H.P. & H.S. 
Each at rate of £100 

Mount Vernon Hospital, Northwood.—H.S. At rate of £150. 

National Hospital, Queen-square, W.C.—Res. M. O. £200. 

N greon Tospital, Merton, S.W .—Two Res. H.S.’s. Each at rate 
of £100. 

New End Hospital, Hampstead, N.W.—Asst. M.O. £250. 

Nottingham General Hospital.—m—H.S. for Fracture and Ortho- 
peedic Depts. £300. Also H.S. to Ear, Nose, and Throat 
Dept. At rate of £150. 

Plymouth, Prince of Watles’s Hospital, Greenbank-road.—H.S8. 
and H.P. Each at rate of £120. 

Preston, Biddulph Grange Orthopedic Hospital.—Jun. H.S. At 
rate of £200. 

Prince of Wales's General Hospital, N.—Res. Jun. H.P.’s and 
H.s.’s. Each at rate of £90. Also Hon. Med. and Surg. 
Regs. Each £100. 

Princess Beatrice Hospital, Richmond-road, Earl’s Court, S.W .— 
H.S. and H.P. Each at rate of £110. 

Queen’s Hospital for Children, Hackney-road, E.—H.P. and 
Cas. O. Each at rate of £100. 

Rochdale Infirmary and Dispensary.—Second H.S. £150. 

koyal London Ophthalmic Hospital, City-road, E.C. — Sen. Res. O. 
£150, 

Royal Naval Medical Service.—Eight vacancies. 

St. Andrew’s Hospital, Devons-road, E.—Asst. M.O. £250. 

St. Barlholomew’s Hospital Medical College. —Sen. Demonstrator 
in Dept. of Pathology. £400, 

St. George's Hospital, S.W .—Asst. Bacteriologist. £500. 

St. Leonard's Hospital, Hoxton-street, N.—Asst. M.O. £250. 

St. Luke’s Hospital, Sydney-street, S. W .—Asst. M.O. £250. 

Salford Roual Hospital.—Hon. Asst. Gynecologist. 

Salisbury General Infirmary.—H.S. At rate of £125. 

Soar. Isolation Hospital and Sanatorium.—Jun. Res. 
M.O. £200, 

South Eastern Hospital for Children, Sydenham, S.E.—Jun. Res. 
M.O. At rate of £10 

South London Hospital for Women, Clapham Common, S. W.— 
H.P. At rate of £100. 

SORE on Trent, North Staffordshire Infirmary.—Radium Officer. 

500. 

Swansea County Borough.—Asst. M.O. £500., 

Tancred’s Studentships.—Three. Each £100. 

University College Hospital, Gower-street, W.C.—Bilton Pollard 
Fellowship. £650. 

Warrington County Mental Hospital, Winwick.—Asst. M.O. £500. 

County M.O.H. £500. 

Westminster Hospital, Broad Sanctuary, S.W.—Obstet. Tutor 


and Reg. £100. 

West Riding of Yorkshire, Middleton-in-Wharfedale Sanatorium.— 
Res. Asst. M.O. £350. 

Whitechapel Venereal Diseases Clinic, Turner-street, E.— 
Director. £1250. 


The Chief Inspector of Factories announces vacancies for 
Certifying Factory Surgeons at Rhondda (Porth) (Glamor- 
gan), Cowbridge (Glamorgan), and Larkhall (Lanark). 


RoyvAL HALIFAX INFIRMARY.— Increased funds 
are needed at this hospital if the standard of 
efficiency is to be maintained. During the year 22,372 
patients were treated, an increase of 1603 on the 
previous year, and the average cost of each in- 
patient was £6 8s. 4d. Workpeoples’ contributions for 
the first time exceeded £10,000, and the paying patients’ 
ward produced £4750. 


INDEX TO “THE LANCET,” Vou. II., 1935 


Tne Index and Title-page to Vol. II., 1935, 
which was completed with the issue of Dec. 28th, 
is now ready. A copy will be sent gratis to sub- 
scribers on receipt of a post card addressed to the 
Manager of Tur Lancet, 7, Adam-street, Adelphi, 
W.C.2. Subscribers who have not already indicated 
their desire to receive Indexes regularly as published 
should do so now. 


THE LANCET] 


[FEB. 22, 1936: 


ADDRESSES AND ORIGINAL ARTICLES 


JOHN HUNTER TO JOHN HILTON * 


By C. H. Facer, M.S. Lond., F.R.C.S. Eng., 
F.R.A.C.S. (Hon.) 


CONSULTING SURGEON TO GUY’S HOSPITAL, LONDON 


“It would be well, I think, if the surgeon would fix 
upon his memory as the first professional thought which 
should accompany him in the course of his daily occupa- 
tion this physiological truth—that Nature has a constant 
tendency to repair the injuries to which her structures 
may have been subjected, whether those injuries be the 

‘result of fatigue or exhaustion, of inflammation or 
accident.” —JoHN Himton—‘ Rest and Pain.” 


IN any attempt to assess a teacher’s claim 
to greatness we must consider the influence he 
exerts upon his pupils. 

In his Hunterian ora- 
tion of 1921, Sir Charters 
Symonds! traced the 
influence of Hunter upon 
the surgery of the suc- 
ceeding generation in the 
person of Sir Astley 
Cooper; it will be my 
endeavour to link up the 
teaching of John Hunter 
with that of John Hilton 
—with one of a genera- 
tion later than that of 
Astley Cooper. The Hun- 
terian lesson did not 
come direct to John 
Hilton—Hunter had been 
in his grave more than 
thirty years when Hilton 
went to Guy’s. But Cline 
of St. Thomas’s was one 
of his most ardent dis- 
ciples and Astley Cooper 
of Guy’s was himself a 
pupil of Hunter, and 
further, worked under 
Cline from whom, as Sir 
Charters Symonds has 
told us, he derived the 
spirit which Hunter 
inculcated. 

It is no disadvantage 
to my purpose that Astley 
Cooper and John Hilton | 
were in many respects | 
dissimilar. Astley Cooper 
was a man of fine pre- 
sence, courtly manners, 
and an operator of enter- 
prise and dexterity. When we attempt to conjure up 
his personality we cannot escape from the influence of 
Lawrence’s portrait which hangs: in our council 
chamber and in which the silk knee-breeches and 
swallow-tailed coat proclaim the aristocrat of mind 
as well as of bodily form. Hilton was broad, short, 
and brusque in manner. In appearance he suggested 
a successful man of business in the city rather than a 
scientific surgeon: he wore the heavily braided 


* Part of the Hunterian oration for 1936 delivered before 
the president and council of the Royal College of Surgeons of 
England on Feb. 14th. 

2 THE LANCET, 1921, i., 359. 

5869 


broadcloth of early Victorian days, with a flowered 
waistcoat and widely open collar. Hilton had no 
chance to become an assured operator, but as a 
scientific investigator and thinker he was much more 
closely in accord with Hunter’s traditions than his 
illustrious predecessor. I venture to think that 
Hilton more fully understood their significance, and 
pursued his inquiries in a scientific spirit which 
Astley Cooper had not at his command. 

John Hilton, the eldest son of John and Hannah 
Hilton, was born in 1805 at Sible Hedingham in the 
county of Essex, and was educated at the grammar 
school (now known as King Edward VI.’s School), 
Chelmsford, and at Boulogne. During his boyhood 
his parents were in poor circumstances; in later 
years his father’s interest in the straw-plaiting 
industry prospered, but at the time John Hilton 
went to Guy’s in 1824 
he could not afford to 
purchase an apprentice- 
ship to a member of the 
staff, so that, when 
twenty years later he 
was elected assistant sur- 
geon, he was the first 
member of the surgical 
staff of any London hos- 
pital whose appointment 
had not been ‘ bought 
and paid for.” 

During his studentship 
Guy’s medical school 
separated from that of 
St. Thomas’s and Hilton, 
appointed in 1828, was 
the second demonstrator 
of anatomy in the new 
medical school: he 
taught in the dissecting- 
room for sixteen years 
and gained the nickname 
of “ Anatomical John.” 

Hilton was a member 
of the surgical staff of 
Guy’s from 1844-70. In 
1843 he was one of the 
300 original fellows of 
this College to be elected 
under the terms of our 
third Royal Charter; he 
was vice-president from 
1865-67, and was elected 
president in 1867, serving 
for one year only as 
was customary in those 
days. He died of cancer 
of the stomach at 
Hedingham House, Clapham Common, on Sept. 14th, 
1878. 

In his obituary notice of Hilton, Mr. Jacobson has 
little to tell us of his youth and upbringing.? Mr. 
Jacobson’s essay is, in my judgment, the equal of his 
better known essay on Arthur Durham ?; this latter 
was obviously a labour of love and showed Jacobson 
at his very best. His ease of diction, the purity and 
simplicity of his prose, and his unerring aptitude of 
quotation gained for the writer a place which no 


2? Jacobson, W. H. A.: Guy’s Hosp. Rep., 1892, xlix., 37. 
? Jacobson, W. H. A.: Ibid., 1895, lii., 43. 
H 


410 


THE LANCET] 


MR. C. H. FAGGE: JOHN HUNTER TO JOHN HILTON 


(FEB, 22, 1936 


other of my teachers at Guy’s at the end of the last 
century could contest. 


In the former essay Jacobson argues that success 
in life without the help of a good education, money, 
or influential friends stamps a man as above the 
common, and quotes Hilton as an example. What 
little he tells us of Hilton’s student days includes the 
story of a dinner which after the separation of Guy’s 
from St. Thomas’s in 1826 was held annually and 
which was the origin of the United Hospitals Club, 
a dining-club which still flourishes after celebrating 
its centenary in 1928. To this dinner in one of his 
later student years Hilton was bidden. The habits 
of those days were unchecked by the conventions of 
to-day, and as chair after chair became vacant, 
either by the guest leaving, or finding repose under, 
the table, Hilton moved up until he reached a seat 
of honour at one side of the chairman, Benjamin 
Travers. 

Contemporary events must have had a great 
influence upon the mind and career of John Hilton. 
His childhood was, without doubt, darkened by the 
spectre of the ‘Corsican Ogre’? who dominated 
Europe until the year 1815 saw his overthrow. 
Those whose youth has been spent in the shadow of 
the Great War and the hardships of the succeeding 
years will have sympathy for Hilton whose own 
boyhood, rather more than a century earlier, must 
have been deprived of the few luxuries which might 
have been possible had not England been in the 
trough of a world-wide trade depression. 

Another event which must have had a most 
important effect upon his career was the Anatomy 
Act of 1832. A previous Bill to amend the law 
relating to the supply of bodies for dissection had 
been opposed in 1829 by a petition from the president 
and council of this College, who considered it 
‘injurious to the interests and advancement of the 
profession of Surgery and to the Rights of your 
Petitioners.” Largely owing to the activity of Sir 
Astley Cooper the amended Bill, which became law 
in 1832, was altered to comply with the views of the 
College. William Hunter had been the first British 
anatomist to provide opportunities for individual 
dissection by students, when he founded his school 
in 1746,‘ this innovation, it has been said, was the 
greatest debt—and that of many—which surgery 
owes to William Hunter. But in spite of this, 
anatomical knowledge made little progress largely 
owing to the precarious supply of material. 

In the same year as Hilton was appointed demon- 
strator of anatomy, the action of Bransby Cooper v. 
Wakley took place. Hilton’s part in this can only 
have been a passive one yet, this group of Guy’s 
surgeons shows that even at that date he had acquired 
some repute as an anatomist. 

It is difficult to believe that only a hundred years 
separate us from the time when such errors in taste 
as are here depicted and what would now be regarded 
as contempt. of court were permissible, yet there is 
no reason to suppose that our manners and con- 
ventions will appear any more acceptable to the 
educated classes of a century hence than are those 
of a hundred years ago to us. When we consider 
the increased rapidity of travel, and the easy inter- 
change of thought and experience which the scientific 
discoveries of the past century have rendered possible, 
it is interesting to reflect that at Waterloo in 1815 
the rival armies moved at no greater speed than 


‘William Hunter took over Sharpe’s School and Iectureship 
in 1746, and ostablished his own school in Great Windmill- 
street in 1770. 


could prehistoric warriors who had subjected the 
wild horse to domestic use; there had till that date 
been no speeding-up in communications between 
different parts of the world. 


In 1825 George Stephenson’s steam-engine was 
first used for passenger and goods traffic on the 
Stockton-Darlington line. We have perhaps as yet 
scarcely realised the influence of the ever-increasing 
rapidity of communication of modern times upon the 
fortunes of the British Empire, and it is doubtful 
whether those who were witnesses of early steam 
locomotion could visualise the effect it would produce 
upon nations and upon the progress of knowledge 
throughout the world. 


John Hilton as an Anatomist 


One of Hilton’s chief claims to the approbation of 
posterity is the dissections which he made in order 
that Joseph Towne should copy them in wax. Towne’s 
wax models, which include the most beautiful and 
best known anatomical models in the world, also 
depict many varieties of skin disease and certain 
morbid processes. They are nearly one thousand in 
number and most of them adorn the museum of Guy’s 
Hospital; it is remarkable that the colour and 
consistency of the wax still remain unchanged after 
a lapse of over one hundred years. 

Joseph Towne,® the son of a dissenting minister 
at Royston, came to London by coach to obtain the 
opinion of an anatomical authority upon the accuracy 
of a wax model of a human skeleton which he had 
fashioned secretly at night. Itis stated that he had 
never seen a complete human skeleton. Knowing 
no one in London he knocked by chance at the house 
of a doctor in Hackney who gave him an introduction 
to Sir Astley Cooper; in the year 1826, at the age 
of 17, he became modeller to Guy’s, two years before 
Hilton began to teach anatomy. His appointment, 
so far as I can discover, was made by Benjamin 
Harrison, on his own responsibility, for the minutes 
of the governors’ committee contain no record of 
Towne’s election. Benjamin Harrison—whose des- 
potism gained for him the name of ‘‘ King ” Harrison 
—was the Guy’s treasurer whose strong hand and 
sound judgment of men guided so wisely in its early 
years the fledgling ® which had just left the parent 
nest. Towne was a great artist, even though he was 
entirely self-taught. His model in wax of a skeleton 
gained the first silver medal of the Society of Arts, 
and is now in the Guy’s Hospital museum. He was 
awarded the gold medal of the Society of Arts in 
1827 for a model in coloured wax of the human 
brain, one of a series which is “read up” by all 
Guy’s students. Towne served Guy’s for over 
50 years—in fact, probably till the date of his death 
in 1879. He worked alone in a locked room and the 
secret of his methods died with him. 

Hilton was a pioneer in the accurate and detailed 
description of topographical anatomy, of which he 
was one of the first to show the value to any young 
man who aimed at distinction as a surgeon. It is 
well for this College to bear this in mind as there 
are those who, never having had any degree of 
insight into this subject, question its practical appli- 

cation to surgery. In Ifilton’s day the modern text- 
book of descriptive anatomy did not exist; such 
books as there were for the medical student in 1824 7 
contained a smattering of superficial anatomy, 


è? Bryant, T.: Guy’s Hosp. Rep., 1883, xli., 1. 
€ Guy’s separated tout St. Thomas’s in 1826 in part; the 
final separation took place in 1849. 
7 Bell, John: The Anatomy of the Human Body, 1803. 


THE LANCET] 


strongly interlarded with physiology of an elementary 
type, and any observations on comparative anatomy 
as seemed to be even remotely relevant to the 
structure which was being described. 

In the year 1839 Hilton was made a Fellow of the 
Royal Society, chiefly for his work on the superior 
laryngeal nerve of 
man; from his 
dissections of this 
and other nerves 
in man he evolved 
Hilton’s law— 
which states that 
a nerve supplying 
the muscles which 
control the move- 
ment of a part also 
supplies the skin or 
other sensory sur- 
face which overlies 
that part. In later 
work he elaborated 
this theory in a 
most important 
relation when he 
showed that the 
nerves, supplying 
the muscles con- 
trolling a joint and 
sensation to the 
skin over the joint 
| also supply the 

¥ structure of the 
el joint itself. He 
i fe s writes: “ The same 


~ trunks of nerves, 
= fu! = 


whose branches 
supply the groups 
Wax model of skeleton made by 
Joseph Towne, 


of muscles moving 
a joint, furnish 
also a distribution 
of nerves to. the skin over the insertions of 
the same muscles; and the interior of the joint 
receives its nerves from the same source.” 

Hilton does not appear to have thought of pursuing 
this idea or to have been alive to the obvious deduc- 
tions arising out of this discovery—for it is not until 
1876 that Ferrier’s work on monkeys established the 
presence of cortical centres. This led ultimately 
to the conception that the association of motor and 
sensory tracts could be carried much further back 
to the cerebral cortex where it has been shown that 
the centres for associated functions are in close 
anatomical relationship. 

Hilton’s work ‘‘On the Cranium” is less well 
known than his other anatomical writings, but in 
some ways it is even more worthy of notice. Part 
of this book, which is founded on his anatomy lectures 
delivered at Guy’s, appeared in the Guy’s Hospital 
Reports just before their temporary demise in 1853.8 
This interruption was the reason for their separate 
publication. 

Its opening paragraphs disclose the foundation of 
his anatomical beliefs—the dependence of structure 
upon function or, as Hilton himself puts it, ‘‘ Nature’s 
universal precision in adapting means to ends.” 
The capacity of the author to extract points of 
interest, even from dry bones, is apparent in every 
line—thus the frontal sinuses act as a natural pro- 
tection to the brain in adults which is absent in 
children. The superciliary ridges, with the eyebrows, 


* A new series began in 1855. 


MR. C. H. FAGGE: JOHN HUNTER TO JOHN HILTON 


[FEB. 22, 1936 411 


serve the purpose of diverting the ‘‘sweat of the 
brow’ of the working man from passing over the 
eyeball when it would obstruct his vision. Frequent 
attention is drawn to physical signs of surgical 
importance—e.g., the meaning of a depressed or 
raised anterior fontanelle in a baby. To our genera- 
tion Hilton’s unceasing endeavour to explain the 
form and position of every structure by its alleged 
function is somewhat tiresome, but allowance must 
be made for his teleological views. 

He disposes of phrenology by pointing out the 
dissimilarity between the exterior of the skull and 
the surface of the brain, and makes observations 
upon the function of the cerebro-spinal fluid, though 
it will be noticed that he had no conception of its 
purpose save as a purely mechanical buffer for the 
brain or as a substance which could replace, or be 
replaced by, an equivalent volume of blood. To 
establish this belief he performed a series of experi- 
ments on the cadaver and showed that when he 
forced blood into the cranial cavity there was ‘‘ an 
aflux of cerebro-spinal fluid into the spinal canal.” 


He is in doubt whether the clear fluid which 
escapes from the ear of a boy with a fractured base 
is cerebro-spinal fluid, so he compresses the jugular 
veins to promote intracranial congestion, and is 
convinced that the increased flow of fluid from the 
ve is conclusive evidence that it is cerebro-spinal 

uid. 


He is much interested in the various ridges of 
compact bone which pass in all directions along and 
across the base of the skull; he attributes to them — 
the function of transmitting vibrations from falls 
on the vertex or those carried upwards from the 
spine, and devises an experiment which confirms 
his view that the petrous portion of the temporal 
bone plays a very important part in collecting these 
vibrations and diverting them from any deleterious 
influence which they might exert upon the brain. 
Hilton’s teaching inculcates the value of observation, 
for on a visit to Gloucester Cathedral he finds “‘ simi- 
larity in a portion of its structure to the position of 
the vomer in the nasal cavities.” 

From 1845 to 1853 Hilton lectured every week- 
day at 2 P.M.; in the same year as he began to 
lecture on anatomy Dr. Gull was appointed the 
first lecturer on physiology in the Guy’s medical 
school. Hilton’s interest in topographical anatomy 
is evidenced by his teaching in the dissecting-room, 


-and by the actual dissections which he prepared 


for Towne, but in addition the scientific aspect of 
anatomy attracted him. So his lectures, like those of 
all his contemporary anatomists, lean markedly 
towards teleology, which, strengthened by the recent 
publication of the Bridgewater treatises, reigned 
supreme in the London schools of his day. 


John Hilton as a Surgeon 


The sudden death of Aston Key, senior surgeon to 
Guy’s Hospital, of cholera, in 1849, made John Hilton 
a full surgeon at the age of 44—in current parlance 
‘gave him his beds,” for in those days the assistant 
surgeons at Guy’s had charge of out-patients only. 


At that time Lister had not yet given his message 
of hope to suffering humanity. Primary union rarely 
occurred—a ligature was left long with its ends 
hanging out of the wound; dry lint and strapping 
were the first dressing. Moreover, anesthesia was 
in its infancy, for the use of chloroform as an anæs- 
thetic by inhalation had been advocated by James 
Simpson only two years previously. 


412 THE LANCET! 


Hilton held the post of surgeon to Guy’s until 
1870, there being no age limit at that date.® He 
gained the reputation ot being a cautious scientific 
surgeon—not prone to any operation which did not 
promise well for his patient. It is unlikely that he 
acquired any degree of dexterity or brilliance, for, 
as has been noted, he had no operative experience 
as a young man—the smaller hospitals which now 
abound in and around our large cities and which 
provide welcome nurseries for the young surgeon of 
to-day being at that date unheard of. Nevertheless, 
his attitude towards surgery is demonstrated by his 
ability to introduce a new method for opening a 
deeply seated abscess; in his own words, “‘ cut with 
a lancet through the skin and cellular tissue and 
fascia . . . then push a grooved director . . . into 
the swelling.” ‘‘A blunt instrument such as a pair 
of dressing forceps is then run along the groove in 
the director into the swelling, when by separating 
the handles you may ‘so tear open the abscess.’ ” 

He is of opinion that such a “‘lacerated track ”’ 
will not close prematurely. This is still known as 
Hilton’s method. 

In Jacobson’s opinion? his imperishable claim to 
be remembered as a great scientific surgeon rests 
on the sound blending of anatomy and physiology 
in his teaching. For it was as a clinical teacher that 
John Hilton made his surgical reputation ; he brought 
to this task the same spirit of inquiry as had charac- 
terised his earlier scientific work. ‘‘ However chronic 
and uninteresting, however trite and trifling seemed 
the case, he had the power of getting information 
out of it.” He was constantly inquiring the reason 
for symptoms and signs, and allotting to each a 
significance which did not appear obvious to others, 
yet, when mentioned by the master, seemed to be 
peculiarly apt. 


« Rest and Pain ” 


In the years 1860 to 1862 Hilton was professor 
of anatomy and surgery to the Royal College of 
Surgeons; in this capacity, known after 1868 as 
Arris and Gale lecturer, he delivered annually six 
lectures, which, in book form, became his classic 1° 
— familiarly known as “ Rest and Pain.” 

Hilton’s classification of Rest as Mechanical and 
Physiological, clearly defines two distinct and separate 
conditions not necessarily of similar aim or of equal 
value. Physiological rest does not imply immobility ; 
for instance, the heart or stomach obviously cannot 
be brought to rest, yet rest for both these organs 
may be attained by the acquisition of a state of eased 
function favourable to recuperation and repair. He 
points out that repair can only occur satisfactorily 
when the part affected is in complete repose and that 
pain is the common danger signal that rest is 
necessary. 

In these days of scientific instruments of precision, 
the practitioner of medicine is apt to fail to attach 
due importance to those features of a sick patient 
which are open to his own observation. Yet Iilton’s 
dictum that every pain has its distinct and pregnant 
significance if we will but carefully search for it, 
still remains “the whole truth,” and every medical 
man, however small his experience, must realise that 
pain is, above all other symptoms, the one for the 


*Tho minutes of the general court of governors of Guy's 
Hospital show that the regulation making 60 the age limit of 
the members of the staff was passed in 1853. This would, of 
course, not apply to those members of the staff elected before 
that date. f 

10 Hilton. John: On the Influence of Mechanical and Physio- 


logical Rest, 1863. 


MR. C. H. FAGGE : JOHN HUNTER TO JOHN HILTON 


[FEB. 22, 1936 


relief of which a doctor is consulted. Therefore, it 
is scarcely possible to overrate the clinical value of 
pain. Keith?! writes: ‘‘If Hilton’s first service to 
surgery was to give ‘rest’ a foremost place in the 
means of treatment, his second was to give ‘pain’ 
its rightful place in the means of diagnosis.” 


Hilton’s teaching showed the way in which the 
clinical value of pain may be assessed—i.e., by careful 
and precise observation. He draws a tragic picture 
of our first parent ejected from the Garden of Eden, 
confronted by “his first wound, his first experience 
of pain,” with the recent denunciation ‘‘ Thou shalt 
surely die ” still ringing in his ears. He shows that 
all life needs periods of rest, and quoting John Hunter 
as an authority on this matter in relation to plants, 
asks, ‘‘ What would have been the condition of man 
on earth had it pleased the Creator to withhold from 
him this power of repairing his injured tissues ? >? 


He emphasises the value of sleep as a therapeutic 
agent, especially for children. One of Hilton’s most 
valuable clinical observations was in relation to the 
fixation in flexion of an inflamed joint. To quote 
his own words: ‘‘ When the interior of the joint is 
in a state of inflammation or of irritation, the influence 
of this condition is carried to the spinal marrow, and 
thence reflected to the various muscles of the joint, 
through the medium of the associated motor nerves, 
the muscles being supplied by the same nerves that 
supply the interior of the joint.” A fixed joint is 
thus produced and this fixation is only relaxed under 
anesthesia. He writes further: ‘“‘the flexors by 
virtue of their superior strength, compel the limb 
to obey them, and so force the joint into its flexed 
condition ’’—the joint thus becomes rigid and 
flexed. 

Here Hilton made a pathological observation of 
considerable physiological importance; his was a 
forecast or original thought upon a subject which 
was as yet imperfectly or only partly understood. 
It is true that in 1833 Marshall Hall}? had described 
‘‘excito-motor’”’ (reflex) actions, but his hypothesis 
embraced only the muscular response to the excita- 
tion of a sensory surface. To Hilton must be attri- 
buted the originality of the conception that abnormal 
stimuli from a joint—the seat of injury or disease— 
can influence the position of the limb through the 
action of muscles which owe their innervation to 
the same nerve trunks as those which supply the 
joint. 

Again, in the same paragraph he notes that the 
skin over an inflamed joint is very sensitive: thus 
he describes the condition which we now know as 
cutaneous hyperwsthesia and considers it to be a 
result of the distribution of the same nerves to the 
joint and to the skin over it. He shows that the 
distribution of the auriculo-temporal nerve leads to 
the association of earache and toothache with uni- 
lateral furring of the tongue—a “functional and 
structural deterioration depending upon nerve 
influence.” 

As was only to be expected Hilton’s explanations 
or conclusions in relation to the causation of many 
affections have not stood the test of time. It is 
more amazing that much of what he wrote still 
seems true, and that his foresight in regard to function 
was so accurate. His trend is always to supply a 
mechanical reason for a physiological or pathological 
process. This is only natural in the latter case as he 


7 oe A.: Memoirs of the Maimed. London, 1919, 
vol. X., p. 29. 

12 Hall, M.: On the Reflex Function of the Medulla Oblongata 
and Medulla Spinalis, 1833. 


THE LANCET] 


did not foresee the rôle of bacteria in the causation 
of disease; for instance, he answers the question, 
“Why does a surgeon open an abscess” by the 
statement ‘‘To give its internal surfaces rest,” and 
insists that such an opening must be situated “‘ at its 
lowest part.” 

He was much interested in the case of John Carter, 
a man of 21, who had fallen from a tree when in the 
pursuit of young rooks. He had sustained a “‘ crush 
fracture ” of the bodies of the fifth, sixth, and seventh 
cervical vertebrz and a complete transverse lesion 

of the spinal cord at the 

f same level, with the result 

| that he had total loss of 
power and sensation in 
his legs, trunk, and: arms. 

He lived for fourteen 

years after the accident 
''and earned his livelihood 

by drawing with a pencil 
or pen held between his 
teeth. A reviewer in the 

British Medical Journal 

of 1863 wrote of “ Rest 

and Pain”: “that Mr. 

Hilton’s lectures are per- 

haps the most consider- 

able contribution to sur- 
gical literature furnished 
by any of the professors 
of surgery who have 
occupied the Chair of the 

College of Surgeons since 

Sir James Paget’s cele- 

brated lectures on ‘ In- 

flammation’ in 1850.” 

It is open to question 

whether Hilton’s lectures 
have not had the more lasting influence on surgical pro- 
gress. Inregard to style, Hilton has no superior among 
medical writers : his characteristics are the simplicity, 
purity, and vividness of his English. 

Sir Arthur Keith’s opinion of the work of Hilton is 
shown in his book ‘‘ Menders of the Maimed,’’ of 
which the first chapter is devoted to John Hunter 
and the second to John Hilton. He shows how the 
practice of Hilton’s principle of rest has helped 
humanity. Surgeons are slow to learn lessons. In 
the late war one of the commonest causes of death 
after gunshot fracture of the thigh bone was shock. 
It was not at first realised that this was due to 
defective immobilisation during transport, yet this 
factor disappeared or at least dwindled into insigni- 
ficance so soon as the Thomas’s knee splint—itself 
an apparatus well known for many years—was 
restored to favour. Here was merely an illustration 
of the old lesson which Hilton taught. 

His deductions from his physiological experiments 
on pain led him to advocate certain lines of treatment. 
Such a sequence of thought should be the scientific 
basis of all therapeutic measures. 


A vertical section of John 
Carter’s spine. 


John Hilton and Modern Surgery 


John Hilton’s thesis that the surgeon should rely 
on nature’s ability to secure healing of many lesions 
provided that the injured part has been put under 
the favourable conditions of absolute physiological 
rest is necessarily followed by the corollary that the 
surgeon should be satisfied with the minimum of active 
interference: 

Hilton did not and could not be expected to foresee 
the impetus to surgery which Lister’s work has 


MR. C. H. FAGGH: JOHN HUNTER TO JOHN HILTON 


[yEB. 22, 1936 413 


afforded—shortly to be multiplied a thousandfold 
by the advent of aseptic surgery which was a logical 
outcome of Listerism. 

Modern surgery has not abandoned the principle 
of physiological rest—rather has it recognised its 
value and has increased the number and complexity 
of the procedures by which that state may be attained. 
It would be instructive to discover how far those 
who were responsible for the introduction of the. 
various short-circuiting operations—such as gastro- 
jejunostomy, that for the production of a pneumo- 
thorax, or the fixation of a limb in plaster for the 
resting of paralysed muscles—appreciate that they 
were merely following the principle laid down by 
Hilton when he insisted on the therapeutic value of 
physiological rest. 

Reference has already been made to the value of 
anatomy in surgery, and while operative dexterity 
depends upon anatomical exactitude in most opera- 
tions rendered possible by recent advances, it must be 
admitted that the dissecting-room is no longer as it 
was in Hilton’s day the sole or in fact the most 
important path to surgery. A comprehensive know- 
ledge of physiology, not only in theory, but also by 
experimental methods, has become essential to the 
surgery of progress. It is perhaps strange that 
Hilton should have gained the reputation of being 
the best anatomist in London, whereas if John Hunter 
must be regarded as the first British physiological 
surgeon, Hilton has supreme claims to be ranked as 
his immediate successor. 


John Hilton as Hunterian Orator 


In the year 1867 John Hilton delivered the Hun- 
terian oration ; he was at that time the senior vice- 
president of this College. 

In his oration Hilton postulates tliat Hunter’s 
trustees—Matthew Baillie and Everard Home—in 
establishing the oration, had a much higher 
object in view than the mere laudation of Hunter 

“their main object,’’ he writes, ‘was 
to perpetuate in our profession the mind that was 
in Hunter... to inspire Hunter’s successors with 
the same ardour of professional pursuit.” He goes 
on to inquire what ‘“‘ manner of mind’’ Hunter was 
possessed of, and is of opinion that its essential and 
outstanding attributes were its industry, inquisitive- 
ness, and common sense. 

Hilton emphasises an aspect of Hunter’s position 
which does not appear to have been given its due 
weight, and that is ‘‘ the solitariness of his pursuits— 
the want of a single mind to sympathise with his 
large and exalted view of the grandeur of animate 
nature—which must have had a chilling influence 
on his enthusiastic temperament. We shall fail to 
appreciate the full measure of Hunter’s mental 
stature if we do not recognise the difficulties under 
which he toiled.” 


Hilton’s Hunterian oration deals chiefly with 
sympathy—which would, in modern scientific lan- 
guage be termed referred pain—and gives as an 
example the pain at the end of the urethra occa- 
sioned by a stone in the bladder; he contrasts the 
theories of Darwin and Hunter in explanation of 
such phenomena and attempts to prove that they 
harmonise with his own work on the physiology of 
pain. He points out that Hunter had observed that 
in affections of the hip or the loins, “‘ the sympathising 
pain is felt in the knee before it is felt in the original 
seat; he shows that accurate knowledge of the dis- 
tribution of the obturator, anterior crural and sciatic 


414 THE LANCET] DR. CHASSAR MOIR: EXPULSIVE FORCE OF UTERUS DURING LABOUR 


nerves to the hip and knee joints sufficiently explains 
what Hunter was driven to veil under the covering 
of sympathy.” He passes on to make several original 
observations upon the reflex sympathies of which the 
5th cranial nerve provides the afferent and efferent 
paths, and remarks in explanation of Hunter’s 
observation that in diseases of the liver pain is 
referred to the right shoulder—‘‘the shoulder 
sympathises with the liver but the liver never 
sympathises with the shoulder.” He explains this 
sympathy on the assumption that the right 
phrenic arising from the 3rd and 4th cervical 
nerves (which also supply the skin over the point 
of the shoulder) gives off a branch into the porta 
of the liver. 

Hilton further reminds us that nature has a remark- 
able power of recuperation; if we do not prevent 
her she can bring about the patient’s recovery; at 
times it may be that she needs our aid, and when 
this is so he endeavours to point out the lines upon 
which this assistance should be based. This is, after 
all, only what Hunter taught. Keith! writes: 
“Were I to cite the most important contribution 
Hunter ever made to surgery, it would be his clear 
recognition of the fact that restoration is effected 
by powers inherent in the living tissues of the patient ; 
the surgeon can only help recovery by tending these 
powers.” 

Hilton had advanced in outlook and breadth of 
knowledge in the years between his “Rest and 
Pain”? and his Hunterian oration, yet apparently 
he does not dream of bacterial activity in 
disease when he accepts the Hunterian idea of sym- 
pathy as a large factor in the causation of tetanic 
spasms, although he admits that the pathology of 
this disease ‘‘is still indefinite.” 

When Hilton thought and wrote about matters 
of supreme importance he showed a disbelief in 
Darwinian evolution. His views may be gathered 
from a sentence in his oration 13 before the members 
of the Hunterian Society. ‘‘ When we approach the 
consideration of life itself or the spirit we are restrained 
by our finite reason. All is darkness to the human 
understanding.” ‘‘... These are mysteries... 
as inscrutable alike to the sage and to the savage... 
they are left in doubt purposely to make us set a 
right value upon all human science.” 

Here is the faith of this successor to Hunter, whose 
work for surgery and influence upon surgical thought 
have seemed worthy of our remembrance upon a 
day dedicated to the homage of his master. 


13 Lond. Med. Gaz., 1844, xxxiii., 673. 


HOSPITAL CO6RDINATION IN LANCASHIRE.—The 
Lancashire public assistance committee has appointed 
a special subcommittee to consider whether the control 
of public assistance hospitals should pass from tho 
committee and be given to the county council public 
health and housing committee. 


Dr. F. de B. Pim, whose death was announced 
at the end of January, retired from practice in the Barrow- 
ford and Nelson districts some two years ago. He was 
prominently associated with the St. John Ambulance 
movement and was a Knight of Grace of the Order of 
St. John. For over 50 years he worked for the Ambulance 
Association becoming the foremost figure in the district, 
and to commemorate his 50 years’ service a presentation 
of money and plate was made to him, One cup he gave 
to be held as a challenge cup between ambulance centres 
of Lancashire, and another for competition among police 
ambulance centres, 


[FEB. 22, 1936 


EXPULSIVE FORCE OF THE UTERUS 
DURING LABOUR * | 


By Cuassar Mor, M.D., F.R.C.S. Edin., F.C.0.G. 


READER IN OBSTETRICS AND GYNAZOOLOGY, UNIVERSITY 
OF LONDON 


“ My father, who dipped into all kinds of books ... had found 
out, that the lax and pliable state of a child’s head in parturition, 
the bones of the cranium having no sutures at that time, was 
such,—that by force of the woman’s efforts, which, in strong 
labour-pains, was equal, upon an average, to the weight of 
470 pounds avoirdupois acting perpendicularly upon it ;—it 
so happened, that in 49 instances out of 50, the said head was 
compressed and moulded into the shape of an oblong conical 
piece of dough, such as a pastry-cook generally rolls up in order 
to make a pie of.—Good God ! cried my father, what havoc and 
destruction must this make in the infinitely fine and tender 
texture of the cerebellum !... But how great was his apprehen- 
sion, when he farther understood, that this force acting upon 
the very vertex of the head, not only injured the brain itself, 
or cerebrum,—but that it necessarily squeezed and propelled 
the cerebrum towards the cerebellum, which was the immediate 
seat of the understanding !—Angels and ministers of grace 
defend us! cried my father,—can any soul withstand this 
shock ?—No wonder the intellectual web is so rent and tattered 
as we see it; and that so many of our best heads are no better 
than a puzzled skein of silk,—all perplexity,—all confusion 
within-side.’’ —(‘‘ Tristram Shandy,” Book II.). 


Tuus wrote Laurence Sterne nearly two hundred 
years ago, and in this revelation of obstetrical 
mysteries he presumably reflected the beliefs which 
were at one time held regarding the expulsive power 
of the uterus during parturition. The proposition 
that the foetal head is subjected to a force equivalent 
to 470 lb.—the weight of three ordinary men—was 
indeed calculated to awaken a lively interest. We 
can well understand the doubts and fears which 
assailed Tristram’s father, and can sympathise with 
him when he enlisted Dr. Slop’s aid and planned 
by exercise of obstetric art to circumvent these 
destructive forces, and to bring a less vulnerable 
part of his future offspring’s anatomy to bear as 
Nature’s battering-ram. 


With the lapse of time more rational views came 
to be held regarding the expulsive powers of the 
uterus, and there is no doubt that the magnitude 
of the forces at work was enormously over-estimated. 
Many endeavours have been made to measure the 
precise force exerted by the parturient uterus. 
Matthews Duncan?! tested the bursting strain of 
fotal membranes and from it deduced the expulsive 
power of the uterus. In more recent times various - 
workers have measured the tone of the uterine wall 
by an external apparatus and from this have calcu- 
lated the intra-uterine tension. Most direct and con- 
vincing of all the methods is the introduction of a 
hydrostatic bag into the uterine cavity itself and 
the measurement of the changes of pressure which 
are transmitted to this bag. As far back as 1872 
Schatz? obtained a mechanical recording of the 
uterine contractions of labour by this means, and 
his records give an indication of the true intra- 
uterine tension. Some years ago Bourne and Burn, 
by a similar method, carried out a systematic investi- 
gation of uterine activity during labour, and studied 
the response of the uterus to drugs and anesthetics. 
It will be recalled that they used a small uterine 
bag which could be inserted between the foetal 
membranes and the uterine wall high above the 
presenting part. This bag was connected by water- 
filled tubing to a mercury manometer which traced 
the variations of intra-uterine pressure on a slowly 


* From the department of obstetrics and gynecology of the 
British Postgraduate Medical School, incorporating work 
previously done in the obstetric unit of University College 
Hospital, London. 


THE LANCET] 


DR. CHASSAR MOIR: EXPULSIVE FORCE OF UTERUS DURING LABOUR [FEB. 22, 1936 415 


revolving drum. The records obtained by this method 
showed clearly the characteristics of the first and 
second stage labour pains and their approximate 
force. 


Findings Obtained by the Intra-uterine Bag 
Method 


I have repeated much of Bourne and Burn’s work 
on the uterine forces during labour, and can corro- 
borate their findings.* During the contractions of 
the first stage of labour the intra-uterine tension is 
increased by a pressure equivalent to 35-60 mm. of 
mercury; 45 mm. mercury may be regarded as an 
average figure (Fig. 1). During the second stage of 
labour the contractions continue as before, and 
their magnitude, as a rule, is not greatly altered. 
In exceptional cases as, for example, after injection 
of pituitary extract, the tension may increase by 
as much as 90 mm. of mercury. A prominent new 
feature can be seen in the tracings obtained during 
the second stage: large, sudden increases of intra- 
uterine tension occur with the acme of each uterine 
contraction, and are the result of the bearing-down 
efforts of the patient. This ‘“‘secondary expulsive 
power” is extremely important because, although 
intermittent and of short duration, it has the effect 
of doubling the previous intra-uterine tension. To 
be more exact, the additional pressure produced is 
the equivalent of 40-50 mm. of mercury (Fig. 2). 

It is a curious fact that similar experiments made 
before the onset of labour pains will show the presence 
of uterine contractions equal, or almost equal, in 
magnitude to those of parturition. While these 
painless contractions of late pregnancy appear to 
differ from those of true labour only in their less 
frequent occurrence, it may well be that subtle 
differences of quality are also present, such as altered 
neuromuscular mechanism or retraction of the 
fundus uteri, which the method of recording does 
not reveal. 


80 
60 
40 
20 


Zero +. 
RUE am aT en eee TH Oe ae nn On Oy Gry eS Oe meal 
Time in Minutes 


FIG. 1.—Tracing made with intra-uterine bag showing first 
stage labour contractions. Pressures in mm. Hg. 


of the uterus occurring in the weak scar of a previous 
Casarean-section wound is an accident which happens, 
as a rule, not in the late stage of labour, but in the 
early first stage, or even during the last few weeks 
of pregnancy before recognisable labour pains start. 
This fact is readily explained by the findings just 
mentioned. 

One small refinement in the method of recording 
must be mentioned. In the experiments described 
the deflated bag is inserted into the uterus, and the 
fluid pressure in the recording system is then raised 
to a level sufficient to cause the bag to be comfortably 
filled to its normal capacity of 10 c.cm. of fluid (I have 
always used a pressure of 25 mm. of mercury for 
this purpose), Recording can now begin and, as 
already indicated, the force of the uterine contrac- 


It is interesting to recall that rupture. 


tions above the resting tension can be measured 
with reasonable accuracy. Thus far, however, no 
allowance has been made for this resting tension of | 
the uterus. For various reasons it cannot be measured 
directly. During the rest intervals the level of the 
tracings—i.e., the fluid pressure in the recording 
system—js maintained (1) by the support given to 
the fluid by the stretched rubber walls of the bag 
itself; (2) by the intra-uterine tension acting on the 


80 

60 

40 | | 
20 


i een anne ene ene er 


Time in Minutes 


FIG. 2.—Tracing made with intra-uterine bag showing second 
stage contractions. The dark upstrokes showing the uterine 
contractions are due to the bearing-down efforts of the patient. 
(Note: the zero level of pressure was not determined in this 
case, and the pressures are in consequence measured from the 
resting tension of the uterus.) 


bag. Only the last mentioned is of interest, and it 
can be measured by subtracting the first; this is 
done by withdrawing the bag still fully distended 
from the uterus and marking on the recording chart 
the level to which the pressure then falls. This zero 
mark is shown in Fig. 1, and from it the measurements 
of tension are taken. 

It can now be said that the pressures recorded 
are, on the average, as follows :— 


Resting tension ie. .., we ii 15 mm. mercury., 
First stage contractions plus resting tension 60 mm. > 
Second stage contractions plus resting 

tension plus secondary expulsive force .. 105 mm. i 


These measurements may be accepted as giving a 
generally satisfactory answer to the problem of 
intra-uterine pressure during labour. Certain objec- 
tions, however, have been raised to the method. In 
particular, it has been said that the presence of a 
foreign body in the uterus acts as an irritant, and so 
produces an abnormal uterine activity. For these 
and other reasons an alternative method of measuring 
uterine powers is desirable. 


A New Method of Measuring Intra-uterine 
Tension l 


The possibility of using a method which would 
dispense with the need for an intra-uterine bag 
occurred to me when watching a patient during the 
third stage of labour. As usual in such circum- 
stances, each uterine contraction caused the clamped 
stump of the umbilical cord to become tense with 
blood forced into it from the squeezed placenta. 
Here, surely, was Nature’s own intra-uterine bag 
with tubing presented ready for connexion to a 
recording manometer. Experiments soon showed 
that while records of uterine contractions could 
be obtained by these means, the observations were 
often marred by the partial or complete expulsion 
of the placenta from the fundus uteri. It was, 
however, an easy step to apply the new method to 


` 


416 


THE LANCET] DR. CHASSAR MOIR: EXPULSIVE 


a twin pregnancy and to use the placental end of 
the cut cord of the first delivered fostus to record 
the pressures acting on the second foetus in utero. 
The method is as follows :— 


After delivery of the first foetus the cord is clamped and 
cut as usual. The umbilical vein of the placental portion 
of the cord is then opened and a few c.cm. of blood allowed 
to escape. A small quantity of sterile sodium citrate 
solution is then injected into the vein in order to prevent 
clotting. The volume of the injected fluid should be 
rather less than the amount of blood which previously 
escaped. A glass cannula is now tied into the umbilical 
vein and connected by thick rubber tubing containing 
citrate solution to a mercury manometer which stands 
at the side of the bed level with the patient’s uterus. The 
mercury column of the manometer carries a small float 
which presses on a slowly revolving drum in the usual 


100 Membranes 
Ruptured 
80 { 
60 
: M, 
20 
Zero -L4 


Time in Minutes 


FIG. 3.—Record made by umbilical-cord method, showing 
pressures acting on the second fœtus of a twin pregnancy. 


manner, and which thus records in graphic form the 
variations of intra-uterine pressure. 

After setting up the apparatus a mark is made on the 
chart to indicate the resting position of the mercury 
column or zero pressure. 
tubing is then released, and at once the mercury column 
rises to a level which represents the resting uterine tension. 
With each uterine contraction the mercury column 
rises and records a wave which is precisely similar in type 
to those recorded by the intra-uterine bag (Fig. 3). 


The tracing which is reproduced shows the highest 
pressures which have been registered by this method. 
The resting pressure is equivalent to 25 mm. of 
mercury, and the uterine contractions increase this 
by 75 mm. of mercury, thus causing, in all, a pressure 
of 100 mm. of mercury to be recorded. It will be 
seen that the tracing is typical of first stage contrac- 
tions, and, inasmuch as the second foetus was still 
above the pelvic brim, this was indeed the stage of 
labour to which the patient had reverted at the 
time the recording was made. It is not usually 
possible to record second stage contractions because 
the foetal head is then in the pelvic cavity, and the 
umbilical cord consequently compressed. This hap- 
pened with the rupture of the membranes in the 
example shown. 


Certain minor criticisms may be made of this method 
of determining pressures. (1) The pressure in the umbilical 
vein is, in part, the result of the tension of the fetal 
vessels themselves. This causes the measurement of the 
resting uterine pressure to be exaggerated. The error is, 
however, probably small, and can be lessened by allowing 
the blood which escapes from the cord to be a few c.cm. 
in excess of the injected citrate solution. It is obvious 
that the method will give accurate measurements only 
when the circulations in the two placentas do not com- 
municate—i.e., a binovular pregnancy. This can be 
ascertained after completion of labour. (2) The pressures 


The clamp on the rubber .; 


FORCE OF UTERUS DURING LABOUR [FEB. 22, 1936 
recorded are those produced by a partly retracted uterus 
acting on the second fœtus, and are not necessarily the 
same as those which obtain when the uterus is fully 
distended, for the following reasons: (a) the reduced 
size of the uterus makes its spherical curvature greater, 
and this, if other things remain equal, would result in a 
higher internal pressure; (b) added to this, the walls 
of the uterus are now thicker, and can presumably exert 
a greater contractile force per unit area than they could in 
the thinned-out condition. It is a common clinical observa- 
tion that, whereas the uterus often shows a state of 
comparative inertia during the birth of the first of twins, 
it will, when it resumes activity after retraction, show a 
more vigorous behaviour during the delivery of the 
second foetus and cause its expulsion in a very short time. 
The possibilities just mentioned under headings (a) and (b) 
give a reasonable explanation of this, and they also 
explain why, in the example shown, the pressures recorded 
were distinctly higher than those obtained by the intra- 
uterine bag method used in cases of single pregnancy. 


The two methods of recording pressures thus 
provide data for an interesting comparison and, if 
we bear in mind the different circumstances in which 
the records are obtained, the results are substantially 
in agreement. It is particularly important to note 
that the main objection which has been made against 
the intra-uterine bag method—namely, that it pro- 
vokes an abnormal activity of the uterine muscle— 
is proved to be without foundation, for similar, or 
even greater, contractions are found to occur when 
the uterus is not disturbed by a foreign body inserted 
into its cavity. 


The Uterine Thrust on the Fetus 


It is now possible to make an estimate of the 
propulsive force transmitted to the foetus by the intra- 
uterine pressure. 

The part of the foetal head which is thrust against 
the pelvic tissues during the second stage of labour, 
and dilates or canalises these structures, is limited 
first by the sub-occipito-bregmatic plane, and later 
by the sub-occipito-frontal plane. For the present 
purpose it will be suflicient to regard this area as 
being circular in outline and having a diameter of 
4 in. (10 cm.). A simple calculation may then be 
made. 


Diamcter of fœtal head exposed 
to pressure s ox ie 


I 


10 cm. 


Area of foetal head exposed to 


pressure (H). x 3-14 (area 


or 78:5 sq. cm. 
Each sq. cm. supports a pressure equivalent to 60 mm. mercury 


7R*) 


(average). 
1 c.cm. mercury weighs 13°6 g. 
.°.6 c.cm. 4 sé 136 x6 = 816 ¢g. 
Weight supported by head 81:6 x 785g. 


6406 g., or 14 1b. (approx.). 


If to this figure is added the extra pressure caused 
by the bearing-down efforts of the mother (equivalent 
on the average to 45 mm. mercury), a similar reckon- 
ing will show that the total pressure acting on the 
fetal head is the equivalent of approximately 
245 lb. Similarly, if the pressures registered in 
exceptional cases are taken into account, as, for 
example, those seen after injection of pituitary 
extract, the total thrust exerted on the fetal head is 
found to equal the weight of 32 Ib. 


Comparison with Other Methods 


It is interesting to compare these figures with 
the estimation of uterine force obtained by other 
means. Matthews Duncan, to whom reference has 


THE LANCET] 


already been made, determined the pressure required 
to rupture fotal membranes in 100 cases. From 
this he deduced that the uterine contractions trans- 
mitted, on the average, a propulsive force to the 
foetal head of not less than 16 lb. The highest figure 
he obtained in this series was 37-58 lb.f 

There is still another means‘of estimating the 
power exerted by the parturient uterus. This is the 
simple procedure of measuring the pull required to 
effect delivery of the fatal head by the obstetric 
forceps. The method is more direct, but for obvious 
reasons less accurate than those already described. 
Matthews Duncan 5 states that a pull not exceeding 
80 Ib. may be required. Wylie ô in a recent publica- 
tion gives tables of figures showing the traction 
required under different conditions. He states that 
35 Ib. is an average figure (for primigravidæ), but that 
his most difficult case required a pull equivalent to 
the weight of 74:8 lb. It must be added that Wylie 
measured the traction on the obstetric forceps at a 
time when the uterus was also contracting, and, 
although the uterine powers were probably con- 
siderably modified by anesthesia, this complicating 
factor makes it impossible to use his figures as more 
than a rough estimate for comparison with those 
already discussed. It will be seen, however, if we 
accept Wylie’s figures, that the force exerted during 
an instrumental extraction is, on the average, at 
least one and a half times that which is estimated 
to be transmitted to the fœtus by the expulsive 
powers of normal labour. During a _ difficult 
extraction the force employed may be more than 
twice that which is estimated to be transmitted’ to 
the fetal head by the maximum uterine and 
abdominal pressures of spontaneous delivery. 


THE TOTAL THRUST TRANSMITTED TO THE FETUS : SUMMARY 
OF ESTIMATIONS BY DIFFERENT METHODS 


By Intra-uterine Bag Method i 


(a) Resting tension plus uterine contractions (average).. 14 


(b) Resting tension plus uterine contractions plus 
secondary expulsive powers (average) 24} 


(c) As in (b) but after pituitary extract injection eae: y. 
By Fatal Cord Method 
Resting tension plus uterine contractions 


By Bursting Strain of Fatal Membranes t 


Average Measurement a on es we -. 16 
Greatest measurement 37°58 


234 


By Traction on Obstetric Forceps 
Average traction (for primigravide) i s sa “35 
Greatest traction P ae ‘es eu 74:8 


Conclusions 


1. Various methods are described by which the 
intra-uterine pressure during labour may be measured. 

2. A new method of measuring intra-uterine tension 
and of recording uterine activity without use of intra- 
uterine apparatus is presented. 

3. The intra-uterine resting tension is equivalent 
to a pressure of about 15 mm. mercury. 

4, First and second stage uterine contractions 
cause a pressure equivalent, on the average, to 
60 mm. mercury. 

5. Contractions of nearly equal magnitude can 
be recorded before the onset of true labour pains. 

6. During the second stage of labour the bearing- 
down efforts of the patient bring an extra pressure 
of about 45 mm. mercury to bear on the fotus. 


t Matthews Duncan assumed that the area of head in contact 
with the pelvic tissues measured 44in. in diameter; on the 
same basis my own figure would read 18 1b., 32 1b., and 41 Ib. 
instead of 14 lb., 24% lb., and 32 Ib. 


. terms as these: 


DR. F. G. HOBSON: WHAT IS SCARLET FEVER FOR THE CLINICIAN ? [reB. 22,1936 417 


7. From these pressures the total thrust trans- 
mitted to the fetus during parturition can be 
estimated. 


REFERENCES 
1. Dunca, J. M.: Researches in Obstetrics, Edinburgh, 1868, 
P. e 
2. Schatz, S.: Arch. für Gyn., has iii., 58. 
3. Bourne, A., and Burn, J. H.: Jour. Obst. and Gyn. of Brit. 
P., 927, xxxiv., 249. 
4. Moir, a A Trans. Edin. Obst. Soc., Edin. Med. Jour., 1934, 
5. Duncan, J. M. : Loc. cit., p. 323. 
6. Wylie, B.: Amer. Jour. dbst. and Gyn., 1935, xxix., 425. 


WHAT IS SCARLET FEVER FOR THE 
CLINICIAN? 
By F. G. Hosson, D.S.O., D.M. Oxon., 
F.R.C.P. Lond. 


PHYSICIAN TO RADCLIFFE INFIRMARY AND COUNTY 
HOSPITAL, OXFORD 


IN 1899 “The Infectious Diseases (Notification) 
Act” became law throughout England and Wales, 
and included in the schedule of compulsorily notifiable 
diseases is the disease ‘“‘ Scarlet Fever.” The penalty 
for failure to notify a ‘case of this disease is 40s. 

Upon the clinician in charge of a case rests the 
responsibility for diagnosis and notification, and it is 
pertinent therefore to review a situation in which 
he is placed not once but many times each year. 

Reference to any text-book of medicine will show 
that the disease ‘‘Scarlet Fever” is defined in such 
“ An acute infectious disease due to 
a streptococcus characterised by inflammation of 
the fauces and a punctate erythematous rash fol- 
lowed by desquamation, and associated with a special 
liability to nephritis and otitis media.” However 
much an individual clinician may recast or amplify 
these terms, it is impossible to omit “‘the punctate 
erythematous rash ” which is the “scarlet ”?” feature 
of the fever, and of diagnostic and therefore of noti- 
fiable significance. Every clinician after a few years 
of practical experience must ask himself certain 
questions ’:— 

1. If the above definition in truth describes accurately 
the picture presented by a relatively small group of patients 
suffering from streptococcal infections, has it any merit 
other than its ‘‘ classical attribute ” ? 

2. If the notification of ‘‘ Scarlet Fever ”’ is confined to 
cases of the “ classical ” type, would it not be as rational 
to confine the notification of meningococcal fever to those 
cases which are “‘ spotted ” ? 

3. If the purpose of notification is to identify and 
segregate those liable to disseminate an epidemic disease, 
is the incidental and relatively unimportant development 
of a punctate erythema to be the only criterion ? 

4. Is it of any value to retain the name “Scarlet Fever ” 
in the schedule of notifiable diseases, from the clinical 
or epidemiological point of view ? 

This is the problem, and before considering the 
clinical evidence it will be valuable rapidly to review 
the historical, bacteriological, and clinical aspects. 


HISTORY AND EPIDEMIOLOGY 


Rolleston, among many others, has remarked that 
“ Scarlet Fever was very mild a century ago, fifty 
years ago it was extremely malignant, and now again 
it is a mild infection, although its prevalence cannot 
be-shown to have diminished. 1 Jf this is true and 
“« Scarlet Fever” was and is a specific disease, the 
alteration in its clinical character is due to an altera- 


tion in the virulence or prevalence of the specific 


causal organism or the constitution and composition 
of the population affected. 
H2 


418 THE LANCET] DR. F. G. HOBSON: 
` Bacteriology lends no support to the view that the 
specific causal organism has altered its character ; 

-indeed there is no specific organism, although there 
are erythrogenic streptococci of many types. 

Epidemiological research has shown that the spread 
of disease is a function of the environment, and 
changes in social, sanitary, economic, industrial, and 
domestic conditions may have.an important effect 
on the population, influencing the prevalence and 
spread of infection. 

Absolute and statistical proof or - disproof of the 
statement that “ Scarlet Fever’ has changed its 
clinical characteristics is impossible because of the 
indefinite name, and the entire absence of bacterio- 
logical data over the period covered. 

The strongest inference that can justly be drawn 
from the records is that the erythematous feature has 
varied in epidemics of different malignancy. 

The ‘‘scarlet’’ feature was giving trouble some 
forty years ago when “Scarlet Fever ’’ was generally 
a severe disease, as is shown by the question raised 
by Dr. Clement Dukes, ‘‘ Is there a Fourth Disease ” ? 
The Fourth Disease (Duke’s disease) was in time 
succeeded by a fifth disease, Erythema Infectiosum, and 
eventually by a sixth disease, Exanthema Subitum.? 


BACTERIOLOGY 


In 1923 the Dicks isolated a strain of Streptococcus 
hemolyticus which produced typical cases of ‘‘ Scarlet 
Fever’’ in the susceptible, and demonstrated that 
after an attack a Dick-positive patient became Dick 
negative. The hope that the mysteries of the 
origin, infectivity, and clinical features of the 
disease had been removed proved false when further 
work revealed 27-30 strains of this streptococcus, 
hemolytic but not necessarily associated with an 
erythema. There appear to be instances of the 
association of non-hemolylic streptococci with a 
typical erythema and the clinical features and 
sequel of ‘‘ Scarlet Fever.” 

The Schulz-Charlton reaction, at first regarded as 
“ specific,” is now known to be specific only in the 
identification of an erythema as due to a.strain of 
streptococcus identical with the strain employed in 
the production of the antitoxic serum used in the 
test. This reaction regarded by some clinicians as 
of value in both prognosis and therapy finds this 
application only in approximately 50 per cent. of 
cases diagnosed as “‘ Scarlet Fever ” of the “‘ classical ”’ 
type. 

The most that bacteriology can offer may be 
summarised as follows :— 


1. Many strains of streptococci produce an exotoxin 
çontaining, among other noxious properties, an erythro- 
_ genic factor, this factor being most characteristic of the 
highly toxigenic hemolytic strains, which are associated 
with the more virulent infections of the throat, skin, 
connective tissues, and uterus. 

2. The development of an erythema deponds not solely 
upon the erythrogenic factor but also upon the 
susceptibility of the infected individual to it. 


Bacteriology has rendered a signal service to clinical 
medicine by proving that all cases of “ Searlet Fever” 
(in the classical sense) are due to a streptococcus, 
most frequently of the hemolytic type. 

Bacteriology confirms clinical experience in demon- 
strating that the ‘‘Scarlet’’ feature is no more than 
a partially specialised reaction, depending for its 
development upon two factors, the bacterial strain 
and the susceptibility of the patient. 

“Scarlet Fever,” though essentially bacterial in 
origin, flouts all the postulates of Koch and is barely 


WHAT IS SCARLET FEVER FOR THE CLINICIAN ? 


[FEB. 22, 1936 


able to support the dignity of a syndrome, yet it 
is a notifiable disease in an age in which the iden- 
tification and classification of diseases is a striking 
feature of the progress of medical thought. 


CLINICAL MEDICINE 


It is the clinician who has to face this grave and 
difficult problem with its many absurdities, when 
he has to treat not only his patients but also their 
neighbours as contacts. 

In the interests of medical practice and public 
policy a reconsideration of the whole position is long 
over-due. 

In one sense the position is clear: when the 
clinician notifies an identified erythema, and segre- 
gates the patient under suitable conditions, his legal 
responsibility is discharged, the public conscience is 
satisfied, quarantine is. observed by all contacts, 
and the erythematous patient is tended with al 
the care and devotion that the disasters of previous 
experience have shown to be necessary. The public 
is prepared for complications by the reputation of 
the disease. But what of the patient who develops 
no erythema? Many clinicians experienced in the 
subject have noted that in epidemics of streptococcal 
infection— 


1. A hemolytic streptococcus has been demonstrated 
in many cases which could not be called ‘‘ Scarlet Fever.” 

2. The liability to serious complications appears to be 
slightly greater without an erythema. If there is a rash 
a negative Schultz-Charlton reaction is an unfavourable 
sign. 

3. In household infections of streptococcal sore-throat, 
an erythema develops in only a few cases. 

4. The infectivity is identical with or without an erythema.* 


In other words the erythema is a favourable sign, 
and yet notification and strict isolation is reserved | 
for those cases alone. ‘‘ It is well known that, in so 
far as controlling an epidemic is concerned, the rigid 
hospitalisation of every case of ‘ Scarlet Fever’ has 
completely failed.” 

The position which the later clinical evidence will 
illustrate is that streptococci pathogenic to man, 
with a strong invasive tendency, give rise to a wide 
complex of pathological states, which have a close 
consequential relationship one with another. 

There may be a toxemia, from the absorption of 
exotoxin from the organisms in a primary focus, 
or there may be dissemination of the actual organisms 
from such a focus with secondary lodgment in 
distant organs, by a transitory bacterizmia, or lastly 
the organisms may enter and multiply in the blood 
stream giving rise to septicemia. 

From a primary focus there may develop one or 
all of these sequel, the path of dissemination being 
by the lymph stream, or by the blood stream, or by 
both. Each of these states may develop with or 
without an Erythema even when due to a streptococcus 
of the Hemolytic type. There are cases in which 
an Erythema develops apparently in association with 
a Non-hemolytic Streptococcus, and the clinician is 
tempted to wonder whether there is not a bacterial 
no-man’s land in which there are to be found strains 
of streptococci possessing the Erythrogenic but not 
necessarily the Hæmolytic factor. 

If it can be shown that streptococci of various 
types can, with or without an Erythema, produce patho- 
logical lesions strictly comparable from the clinical 
and epidemiological standpoints the case for the 
abolition of “Scarlet Fever” from the clinician’s 
vocabulary is proved. 


THE LANCET] 


GB Scarlet Fever, classical. erythema . 
[A + » atypical erythema . 
O » s» erythema absent . 


Temperature, cough, sorethroat . 
only» 


g» 19 


hospital, 
and are not in themselves 
From medical literature the 
evidence could be amplified a hundredfold. 


The cases are drawn from personal, 
or private practice, 
dramatic or unusual. 


TERMS USED IN CLINICAL REPORTS 


1. The erythema or rash—the “ classical ” fine punctate 
erythema, which is supposedly characteristic of ‘‘ Scarlet 
Fever,” is implied where this term is used without 
qualification. 

2. Desquamation and the appearance of the tongue 
are (usually) noted. 

3. In most instances differentiation of the streptococcus 
involved has been carried no further than the distinction 
‘between ‘‘ hemolytic ’’ and “ non-hemolytic.”’ 


CASES OF TONSILLITIS OR PHARYNGITIS WITH AND 
WITHOUT ERYTHEMA 


1. Mrs. J-J, Miss M. J-J, and Miss E. J-J stayed with 
friends suffering from *“‘ sore-throats.”’ Sept. llth, 1934.— 
Miss M. J-J developed an attack of acute tonsillitis with 
no rash; no sequele. The family returned home 
on the 16th. 19th.—Mrs. J-J (scarlet fever as a child) 
developed a very severe and acute tonsillitis ; no rash and 
no sequelex. 26th.—Miss E. J-J developed an acute 
tonsillitis and on the 27th a rash, later a typical strawberry 
tongue and desquamation ; no further sequel. . 

Comments.—Swabs from all throats had hemolytic 
streptococci. Miss M. J-J (the original case) still showed 
hemolytic streptococci on Oct. 15th. By law, only 
Miss E. J-J was notified. Similar family groups are met 
with again and again. 


2. A small epidemic in a school of 95 boys (Table I.). 


TABLE I 


Admissions to sanatorium. 


March oth, Pui; an 6 boys with acute pharyngitis and 


1933 acutely inflamed glands of neck. 
March 14th 1 boy with the same clinical features. 
March 28th, 31st 5 boys as és s 
Aprilth .. 2 boys ar + = 


Comments.—Each of the 14 boys had a tonsillectomy 
before entering the school; no one with intact tonsils was 
involved. The clinical picture presented by each was 
identical, the onset being acute with high fever and severe 
toxemia. Five boys were discharged 10-12 days after 
admission ; nine boys were ill for 21-35 days. Hæmo- 
lytic streptococci were demonstrated in the swabs taken 
from one member of each group. 

Boy No. 1 was a case of acute and severe illness with 
high remittent fever for five weeks, a rigor with a 
temperature of 104° in the fourth week (presumably a 


DR. F. G. HOBSON: WHAT IS SCARLET FEVER FOR THE CLINICIAN ? 


[FEB. 22,1936 419 


School Epidemic 1955 


Cases developing at home. 
a E | è u 
a i 


25 


transitory bacteriæmic shower) and acutely inflamed 
lymphatic glands. The glands eventually subsided without 
suppuration. 

Boy No. 12, admitted with acute pharyngitis and 
lymphadenitis, on the second day developed an acute 
otitis media (left) with instantaneous perforation; on 
the fourth day a general rash with subsequent desquama- 
tion. Operation later for left mastoiditis. 

By law, only No. 12 was notified. 


3. A small epidemic in a school of 75 boys (Table II.). 


TABLE Ii 
Admissions to 
sanatorium. Throat swab. 
- June 
1. Ev. Ist. Acute tons.; vomit -. Not done. 
2. D 3rd. Ditto; erythema on Hem. strept. 
second day. 

3. B. 8th. Acute tons. Non-heem. strept. 
4. C. 14th. Acute gran. pharyngitis ; Hem. strept. 
no rash; no sequel. 

5. H 29th. Acute tons. ; vomit 
6. V 30th. Ditto. : 
July Non-hæm. 
7 R lst. Ditto; erythema on strept. 
‘ second day. 
8 Ed. 9th. Acute tons. 


Tons.=tonsillitis. Hem. strept. = hæmolytic streptococcus. 


Other admissions to sanatorium in the above period 
consisted of minor sepsis and trauma. 

The swabs were all taken personally on the first day 
of admission to the sanatorium (temp. 102-103°) and were 
examined for K.L.B., hemolytic, and non-hemolytic 
streptococci. 

Boy No. 2 produced a typical erythema, tongue and 
subsequent desquamation without sequel, the infection 
being due to a hemolytic streptococcus. 

Boy No. 7 produced a typical erythema well developed 
over the back, lower abdomen, groins, and thighs— 
“ bathing drawers”? type—but lasting only 24 hours, 
the infection being due to a non-hemolytic streptococcus. 
In all cases the attacks were mild and recovery rapid. 
No. 2 and No. 7 showed no feature other than the erythema 
to distinguish them from the remainder. The urine 
in no case showed any albuminuria during the third 
week, after the initial tonsillitis. 


4. An epidemic in a school of 371 boys.—The 
material for this report has been kindly submitted 
to the writer by a colleague who, with the M.O.H., 
supervised the epidemic. The school is_ residential, 
and there are 338 boarders and 33 day boys. The boarders 
live in “houses ” and have a common dining-room and 
the boys also mix in the house dormitories and day- 
rooms. The history of the epidemic is shown in the chart.. 


420 THE LANCET] 


In the first half of February there was an outbreak of 
“ influenza ” with sore-throats, temperatures, coughs, and 
profuse nasal catarrh. 

Difficulty was experienced in controlling the epidemic 
for the following reasons :— 

(a) The cases were not confined to any particular house, 
dormitory, classroom, or dayroom, and as the boys mixed 
in all four places, practically the whole school had been 
exposed to infection. Isolation and detection of contacts 
was impossible. 

(b) The original cases were missed because of an epidemic 
of sore-throats, cough, and coryza, possibly influenzal, 
and the rashes might have been the result of influenza. 

The Dick test was unreliable in this epidemic of type V. 
(Franklin) hemolytic streptococci; and too much reliance 
was placed on a negative result in the presence of an 
atypical symptom. ` 

(c) The catarrhal symptoms in the “influenzal’”’ epi- 
demic would tend to increase the danger from normal 
carriers. 

The Schultz-Charlton reaction was reliable in the 
presence of a good rash, but the reaction was sometimes 
delayed for 48 hours. 

The endemic cases of scarlet fever in the town at this 
time were due to type I. hemolytic streptococci (Table IIT.). 

The typing of the streptococci was carried out by 
Dr. F. Griffith of the Ministry of Health. 


TABLE III 
Cases Analysed According to Type of Erythema 


Erythema. 
Remarks. | 
te Atypical | «. 
Class- Sur- 
8- land tran- » | Absent. 
ical. cent. gical. 
55 cases .. bes 34 | 14 1 6 
Streptococcus type V. .. 19 5 — 4 
’» type XI. = — = 1 
Untyped ee 15 | 9 1 1 
Complications: a Se | 18 | 3 | 1 3 
Analysis of Complications 
Total =25 (approximately 1 in 2) 
Rhinitis 5 — — — 
Adenitis . 2 —- — — 
Otitis media (operation) . — — — 1 
Mastoiditis toperation) 3 — — 2 
sheer ` 1 — — — 
Carditis ; — 1 1 — 
Carditis and arthritis oa — 1° — — 
Carditis and rheumatism.. — 1 (D) — — 
Adenitis and rheumatism 3 (1°) — — — 
Rheumatism . 2 — — — 
Sinusitis ; cerebral abscess 1 — — — 
? Mesenteric thrombosis . 1 (D) — — — 
Total 18 3 1 3 
Streptococcus type V. .. 16 3 2 
ty pe A — — — 1 
Untypea = Z 
* Developed a late albuminuria. D =death. 


Commentis.—Īn the six cases ‘‘erythema absent” the 
diagnosis was established as follows :— 


1 case (No. 2); tonsillitis, Feb. 3rd, 1935; desquama- . 


tion, March 6th, 1935. 

l case (No. 45); otitis media-paracentesis type V. 
streptococcus. 
l case (No. 39); 
streptococcus. 

l caso (No. 44); tonsillitis; type V. streptococcus. 
2 cases (Nos. 32, 43); mastoiditis; operation ; type V. 
stroptococcus. 


temperature; headache; type V. 


These six cases without erythema almost certainly do 
not represent the true total in this group when it is 
recognised (see diagram) that there were 48 cases of 
“sore-throat and temperature” and 77 casos of 

“influenza.” 


DR. F. G. HOBSON : WHAT IS SCARLET FEVER FOR THE CLINICIAN ? 


[FEB. 22, 1936 


In the next term there were nine further cases of scarlet 
fever, the streptococcus type III. being demonstrated 
in two cases and an untyped hemolytic streptococcus 
in one case (Table IV.). 


TABLE IV 
Erythema. 
pene ‘ Class- Atypical SS Sur- | | Absent 
rv) n- ape - 
ical. sient, | gical. | 
9 cases 23 sa 6 2 | 1 | — 
Streptococcus type III... 1 1 Be U g 
,» hemolytic 1 = z= pes 
Untyped .. Be . 4 1 1 — 
Complications 1 2 — i — 
Analysis of Complications 
Total=3 (1 in 3) 
Measles ; pneumonia .. ! 1 (D) = — — 
Vincent’ 5 angina .. — 1 — — 
Measles: mastoiditis : 


bilateral operation | 
. \ 
D=death. 


Comments.—1. “Surgical ” mosquito bite June 18th, 
1935; sore-throat; rash June 2lIst. 


2. Atypical cases. 

1 case (No. 59); Vincent’s angina June 24th; faint 
“ bathing drawers’”’ rash June 28th. 
Subsequent desquamation. 

1 case (No. 62) ; measles, atypical rash ? mixed infection ;. 
double mastoid operation ; type IIT. streptococcus. 


3. 1 case complicated by measles, pneumonia, and death, 
showed type III. streptococcus. 


The conclusions which can be drawn from these 
epidemic groups are as follows :— 


1. The appearance of an erythema was fortuitous and 
without special clinical importance. 

2. It was significant only in that it was evidences that- 
an erythrogenic streptococcus was involved. 

3. The early cases of each group which from the epidemio- 
logical point of view should have been isolated had no 
erythema. To notify only the cases with a rash gave a 
false impression of the extent or virulence of each epidemic. 


Bacteriological research is proving that certain. 
strains of streptococci cause epidemics in which severe 
complications are pronounced with or without am 
erythema, and early recognition of prevalence of these 
strains in the community would be valuable. To the 
clinician in charge of a school or family this informa- 
tion would be of special value. Precautionary 
measures can be exercised such as isolation and 
appropriate prophylaxis against dissemination can 
be adopted. The serious or fatal complications of 
streptococcal epidemics in the community in general 
and in schools in particular present a problem as. 
urgent and important as that of diphtheria or any 
other epidemic disease. 


SEPTIC SCARLET FEVER AND SURGICAL SCARLET 
FEVER 


The classical case from which the Dicks isolated 
and proved the infectivity of the scarlatinal strepto- 
coccus may well be quoted :— 


The patient was a nurse who was attending an ordinary 
case of scarlet fever. For two days before the onset 
of her own attack she liad a sore finger. The pus from 
which the Dick cultures were obtained was taken from the- 
finger on the second day of her scarlatinal attack. It is. 
now a matter of history that it was by swabbing the- 
throats of voluntcers with these cultures that the Dicks 
produced two typical cases of scarlet fever. 


THE LANCET] 


DR. F. G. HOBSON : WHAT IS SCARLET FEVER FOR THE CLINICIAN? [FEB. 22,1936 421 


Another case referred to by Dr. C. R. Box 4:— 


A superintendent medical officer at the London Fever 
Hospital, when dressing a suppurating gland in the neck 
of a scarlet fever patient, infected an abrasion on his 
finger. The axillary glands rapidly swelled up accom- 
panied by high fever and a rapid pulse. A hzmolytic 
streptococcus was grown from the blood and in a few 
days he was dead from streptococcal septicemia. In this 
case no scarlatinal rash was seen, but there was no doubt 
as to the source of the infection. 


An Erythema is unusual in septicemia due to a 
Hemolytic Streptococcus. (Compare Case 2 in next 
clinical group, where the portal of entry was in the 
tonsils. ) 

G. B., aged 30, engineer. July 8th, 1935.—Small abrasion 
right thumb, dressed with iodine; scabbed over. 12th.— 
Scab knocked off; iodine applied; on the same day he 
dropped a heavy weight on toes of right foot. 14th.— 
Vivid lines of acute lymphangitis covered with vesicles 
extended from thumb abrasion to axillary lymph glands 
which were acutely inflamed and tender. 15th.—Vivid 
lines of acute lymphangitis covered with vesicles extended 
from injured toe to right inguinal group of glands which 
were acutely inflamed. 16th.—T'ypical general scarlatiniform 
rash ; throat injected ; a superficial dermatitis of the foot 
which developed from the infected toe clefts took some 
three weeks to clear up. 

Comment.—The history suggests that the infection from 
the original wound on the thumb was inoculated while 
dressing the foot. The whole illness was strikingly mild, 
the temperature on one day reaching only 100° F.; apart 
from the dermatitis of the foot convalescence was 
uneventful. 


CASES OF TONSILLITIS WITH A BACTERIZMIA OR 
SEPTICEMIA WITH AND WITHOUT ERYTHEMA 


1. Mrs. D. D., aged 22. July 3rd, 1935.—Delivered 
by midwife; small perineal tear; two stitches. 4th.— 
Rash noted by patient; two or three attacks of shivering. 
5th.—Admitted to hospital: typical scarlatiniform rash, 
acute tonsillitis, pharyngitis, and local adenitis (confirmed 
by M.O.H.), labia tender and edematous; uterus involut- 
ing normally; lochia normal and copious. 6th.—Anti- 
scarlatinal serum 40 c.cm. 7th.—Antiscarlatinal serum 
40c.cm. 8th.—Typical strawberry tongue, rash fading, 
fauces injected ; swab from fauces—non-hemolytic strepto- 
coccus. 1lth.—Blood culture positive, hemolytic strepto- 
coccus. 12th.—Human serum intravenously from 80 c.cm. 
of whole blood. 14th.—Human serum intravenously 
from 650 c.cm. of whole blood. 17th.—Blood culture 
negative; swinging pyrexia. 23rd.—Fluctuant swelling 
over sacrum and trochanter (left) freely incised; nil 
found; branny desquamation. 26th.—Pyrexia con- 
tinued ; blood culture negative. August 6th.—Swelling 
over sacrum again incised; fluid pus containing strepto- 
coccus (untyped); fever subsided. Convalescence 
uneventful. 

Comment.—TI'wo possible portals of infection—fauces 
associated with a non-hemolytic streptococcus; perineal 
tear associated with hemolytic streptococcus. Classical 
picture of ‘‘Scarlet Fever,” associated with a bacteriamia 
due to hemolytic streptococcus, metastatic abscess, and 
recovery. 


2. V. S., aged 42. Nov. 9th, 1932.—Sore-throat. 
11th.— Acute tonsillitis; T. 103° F. 14th.—Fauces clear ; 
two tender glands in posterior triangle of neck (left). 
15th.—Fauces clear; acute rhinitis; glands less tender : 
rigor; T. 104°F. Blood culture: hemolytic strepto- 
coccus in all tubes in 12 hours. 16th-20th. Daily. 
Antiscarlatinal serum intravenous, 50c.cm. Antiscarla- 
tinal serum intramuscular, 15 c.cm. 21st.—Death. There 
was no rash. 

Comment.—Acute tonsillitis, lymphadenitis, septicemia 
due to hemolytic streptococcus without a rash followed 
by death. 


3. S. F., aged 12. 23 out of 75 boys were admitted to 
the school sanatorium between April 29th and July 25th 
with tonsillitis, all with mild attacks and without erythema 


or complications. 
typed. 
July lst-5th, 1934.—Acute pharyngitis (tonsils had 
been removed). 5th-13th.—Pharynx clear; acute 
adenitis. 14th.—Consolidation left apex, small area; 
acute arthritis, left hip aspirated ; (report—polymorphs and 
endothelials). Culture negative. Blood culture positive— 
non-hemolytic streptococcus. The boy was very acutely ill 
and in the course of a few hours’ sleep developed a sacral 
bedsore. 15th.—Effusions into right knee, wrist, andshoulder 
and lefthip. 16th.—Effusions into right and left knees and 
left hip, right and left ankles, right shoulder and wrist. 
17th.— Left apex clear; effusions subsiding. 20th.— 
Effusion into interphalangeal joints, right forefinger ; 
a soft apical systolic murmur became evident about this 
time, and subsequently signs of a definite myocarditis, 
which involved a prolonged convalescence. 
Comment.—Acute tonsillitis, lymphadenitis, bacterizamia 
due to non-hemolytic streptococcus, multiple arthritis, 
carditis, without arash. The case is quoted to emphasise 
the similarity with a clinical picture not uncommon in 
**Scarlet Fever ” associated with arthritis and carditis. 


The streptococcus involved was not 


DISCUSSION AND SUMMARY 


The illustrative clinical cases quoted above prove 
that :— 7 

l. An erythema is inconstant in infections due to a 
hemolytic streptococcus. 

2. It may be a feature of those due to a non-hemolytic 
streptococcus. 

3. Though it is more frequent in infections due to 
hemolytic streptococci, it is a poor guide to the course, 
prognosis, or infectivity of the disease in a given patient. 

4. Infections due to hemolytic streptococci with or 
without an erythema, are generally highly toxic, highly 
infectious, and haveastriking association with sequel of all 
kinds. The appearance of an erythema is probably a 
favourable sign. 

5. An infection due to a non-hemolytic streptococcus 
may have sequele in no way distinguishable from those 
due to a hemolytic strain, whether there is an erythema 
or not. ; 


If these statements and conclusions are sound it 
is pertinent to consider what alterations or modi- 
fications of clinical practice and teaching should be 
introduced. 

Firstly, the executive and primary object of notifica- 
tion is to segregate those liable to spread an epidemic 
disease, and to effect this, suitable hospital accommo- 
dation is provided which must be used when the 
home conditions cannot ensure proper isolation. 

It is admitted by every medical officer of health 
that strict hospitalisation in cases of streptococcal 
fever that develop a rash has completely failed to 
control epidemics, and this is supported by clinical - 
evidence. 

The notification of “Scarlet Fever” as at present 
practised serves no useful purpose; indeed, it is 
probably of disservice from the executive standpoint 
because it confines valuable hospital accommoda- 
tion to a selected group. The accommodation could 
be better employed for cases of streptococcal infec- 
tions selected on clinical grounds or for domestic 
reasons, rather than by an Erythema. A much 
higher standard of isolation is essential because the 
inmates are not all suffering from the same disease. 

Secondly, the public is still prone to regard ton- 
sillitis as a trivial complaint, and is still uninformed 
of the disasters which may follow the neglect of simple 
precautions; the profession has, in this respect, 
neglected its educational function. 

Isolation of the patient in the home, the use of 
separate feeding utensils, and masking or gargling 
by the attendants, is generally neglected and should 
be enforced. To confine patients to bed for a mini- 
mum of 7-10 days, and to examine the urine in the 


« 


422 THE LANCET} DR. JARMAN & MR. ABEL: INTRAVENOUS ANESTHESIA WITH PENTOTHAL SODIUM [FEB. 22, 1936 


third week are two measures of obvious clinical 
value. 3 
-= Thirdly, the use of a swab as a public health measur 
could, with value to the clinician, be used not.only 
to identify the Klebs-Léffler bacillus but also the 
Hemolytic or Non-hiemolytic Streptococci. To know 
the type of streptococcus present in a given case 
would be of real value to the clinician in charge. 
Fourthly, an increasing number of experienced 
clinicians believe that it is of proved value to give 
so-called antiscarlatinal serum in the early therapy 
of infections due to Hemolytic Streptococci to relieve 
symptoms and to prevent complications. The public 
health services should therefore provide the serum 
for use in hemolytic infections on the same basis as 
it provides serum for the treatment of Diphtheria. 


CONCLUSIONS 


1. ‘‘ Scarlet Fever ” even if descriptive of a clinical 
entity has no claim to retention in the clinician’s 
vocabulary of diseases. 

The dermatological or more accurately the vascular 
manifestations of an infection due to a streptococcus 
or a meningococcus are in themselves of minor 
clinical importance. 

2. The term ‘‘ Spotted Fever ” has been expunged 
from scientific medical nomenclature, and the time 
has come for ‘‘Scarlet Fever” to suffer a similar fate. 

The retention of the term ‘‘Scarlet Fever’’ in the 
schedule of notifiable diseases is of no service to the 
patient, the public, or the profession. 


The writer wishes to record his thanks to Dr. G. C. 
Williams, Dr. J. Frankland West, and Dr. A. D. Gardner 
for valuable assistance. 


REFERENCES ' 


. Rolleston, Sir Humphry : Aspects of Age, Life, and Disearc, 
London, 1928. 

. Med. Officer, 1933, xlix. 

Sleigh, J. C.: Jour. of Roy. San. Inst., 1935, 1v., 659. 

Box, C. R.: THE LANCET, 1933, i., 1327. 


UND mi 


INTRAVENOUS ANÆSTHESIA WITH 
PENTOTHAL SODIUM 


By Ronatp Jarman, D.S.C., M.R.C.S. Eng., D.A. 


ANÆSTHETIST TO THE CANCER HOSPITAL ; SENIOR ANJESTHETIST 
TO THE PRINCESS BEATRICE HOSPITAL, GORDON HOSPITAL, 
AND WOOLWICH WAR MEMORIAL HOSPITAL; AND 


A. LAWRENCE ABEL, M.S. Lond., F.R.C.S. Eng. 


SURGEON TO THE PRINCESS BEATRICE HOSPITAL AND THE 
GORDON HOSPITAL FOR RECTAL DISEASES ; ASSISTANT 
SURGEON TO THE CANCER HOSPITAL AND TO 
THE WOOLWICH WAR MEMORIAL HOSPITAL 


It is natural that there should be some hesitation 
about injecting into the circulation a drug which 
cannot afterwards be withdrawn, and therefore 
objection is sometimes taken to the intravenous use 
of barbiturates for anxsthesia. Against this, how- 
ever, we have the fact that they are used in extreme 
dilution and katabolised extraordinarily rapidly, 
leaving no ill-effects behind them. In our opinion 
this makes them less obnoxious than ether, chloro- 
form, or any form of inhalation anesthetic except 
nitrous oxide-oxygen. The avoidance of a sense of 
suffocation and of almost all psychic shock, the 
remarkable freedom from vomiting, and the absence 
of delayed poisoning, together with the complete 
safety of intravenous anesthetics in our hands in 
many thousands of cases, have encouraged us to 
continue this line of clinical research and extend it 
to the use of Pentothal, which we met in America 


sixteen months ago and introduced into this country 
by the kindness of Messrs. Abbotts, while it was 
still in its experimental stage as ‘‘ 8064.” 

The barbiturates used for intravenous anesthesia 
fall into two groups: heavy and light. The heavy, 
including Nembutal, Pernocton, Sodium Amytal 
and Di-dial, are slowly broken down and are found 
in excretions up to 72 hours after administration ; 
accordingly we prefer to use them as narcotics and 
not as general anesthetics. The light barbiturates, 
Evipan sodium, Eunarcon, and Pentothal sodium are 
broken down so fast that barely a trace can be found 
in excretions after 12 hours. For all practical pur- 
poses their effect has passed off in from 3 to 30 minutes, 
according to whether a minimal or normal dose has 
been used. Provided reasonable precautions are 


taken they appear to us to be quite safe for all minor 


operations, and as a means of induction or total 
anesthesia for a very large proportion of major 
operations. 


ADMINISTRATION 


For minor operations—e.g., dental extractions, . 
the opening of boils and whitlows, the removal of 
nails, and the setting of fractures—no preliminary 
medication is needed and only the minimum dose 
required to produce surgical anesthesia should be 
used. Usually 3 c.cm. of evipan or pentothal are 
sufficient. For major operations on patients in an 
institution we use premedication with omnopon and 
scopolamine. 

The intravenous anesthetic may be administered 
in one of three ways: 


(a) As a single dose.—This is used for an operation which 
is likely to last from 10-20 minutes—e.g., cesophagoscopy, 
bronchoscopy, cystoscopy and cysto-diathermy, sigmoid- 
oscopy, and dilatation and curettage. 

(b) Repeated doses.—If the effect of the anzsthetic 
begins to pass off, a second or even third dose may be 
administered by the intravenous route. 

(c) By continuous intravenous infusion. 


Any operation which is found to take longer than 
was anticipated may have its anesthetic supple- 
mented either by a further intravenous dose as 
described above, or by an inhalation anesthetic. 

Pentothal sodium * is supplicd in ampoules each 
containing 1:0 gramme, together with a separate 
ampoule containing 10 c.cm. of sterile distilled water. 
It is a yellow crystalline powder and when 1-0 g. 
is dissolved in 10 c.cm. of water it produces a gaseous 
solution which takes a moment or two to clear and 
is then ready for use. The gas given off during the 
mixing is of the 1,5 type. It is important to see 
that there is no precipitate. We have now used it 
in more than 1000 cases, and may briefly describe 
its effects as follows. 

EFFECTS 


The induction period is as dramatic, smooth, and 
pleasant as with evipan. Most patients go to sleep 
without yawning, but occasionally they yawn as 
with evipan. 

Respiration —One of the most important points 
to note is that in using this drug for surgical anzes- 
thesia the respirations become shallow, but their 
rate and rhythm remain unchanged. If the anses- 
thetic is injected too quickly, the respirations may 


* Thio-barbiturate pentothal sodium has been known under 
the name of thio-barbiturate $064. Messrs. Abbotts, of Chicago 
and Montreal, kindly allowed us an unlimited supply of this 
as well as a small quantity of the closely allied drug thio- 
barbiturate 8076. In view of the excellent results obtained by 
our friends, Dr. A, L. Tatum and Dr. R. M. Waters, both of 
Madison, Wisconsin, we decided to use it in this country, and 
this was done in collaboration with Dr. J. S. Lundy, of the 
Mayo Clinic. 


THE LANCET] DR. JARMAN & MR. ABEL: INTRAVENOUS ANZESTHESIA WITH PENTOTHAL SODIUM [FEB. 22, 1936 423 


become imperceptible, and it is therefore advisable 
to allow a double safety pause during the adminis- 
tration of this drug. When it is carefully injected 
the respiratory depression is not great, and in any 
case is rapidly overcome by healthy young adults. 
In older people the return to normal is delayed. 

The airway is of vital importance, and an appro- 


priate dental prop must be inserted before the anæs-. 


thetic is given. If the respiration becomes too 
depressed oxygen or CO, and oxygen may easily 
be administered via the Hewer's airway, which may 
with advantage be replaced by a Phillips’s airway as 
soon as the patient is unconscious. Throughout the 
injection the angle of the jaw must, of course, be 
supported, with the head on one side or partially 
extended. 

Colour.—Often the patient becomes slightly cyan- 
otic, older patients more than younger. A well- 
maintained airway, with or without a little oxygen, 
soon restores the colour. 

The pulse quickens as soon as the first two or three 
cubic centimetres have been given. It gradually loses 
some of its volume, but returns to normal within a 
few minutes. If strict attention be paid to the 
patient’s colour, the pulse does not become weak. 

The pupil first dilates, but soon becomes normal. 
The corneal and conjunctival reflexes are lost for 
the whole time that the drug is acting as a surgical 
anesthetic. As soon as it starts to wear off, the 

reflexes return to normal. 

No tremors have been seen except where the minor 
operation had been started before complete surgical 
anesthesia had developed. In this case, tremors 


started and took two or three minutes to disappear. * 


Recovery.—Most patients recover a little more 
quickly than with evipan, and their minds are clearer. 
We have observed no case of post-operative restless- 
ness and no cause for anxiety, provided the airway 
has been properly maintained. Varying degrees of 
post-anesthetic drunkenness occur, but this passes 
off more quickly than after evipan. 

Accidents.—If a small or greater part of this solu- 
tion is injected into the subcutaneous tissues there 
will be a little local reaction. It is of course important 
that the syringe and needles are free from all spirit. 
If the drug is given too quickly there is a dangerous 
depression of the respiratory centre. 


ADVANTAGES AND DISADVANTAGES 


The only drug in use as an intravenous anesthetic 
with which we can compare pentothal is evipan, 
and we have no small difficulty in comparing and 
contrasting these. The main differences which we 
have noticed are :— 

1. Induction with pentothal is a little smoother. 

2. Pentothal scarcely ever produces: the twitching or 
jactitation which we have occasionally seen with evipan. 

3. The fall in blood pressure is less noticeable than with 
evipan. 

4. The main disadvantage of pentothal is that it is 
more depressant to the respiratory centre, and for this 
reason we always like to have a McKesson apparatus at 
hand to administer oxygen and carbon dioxide under 
pressure if required. 

5. A few patients lave complained of a sulphurous 
taste or smell for a short time atter the administration of 


pentothal. 
CONTRA-INDICATIONS 


Liver.—These light barbiturates are metabolised 
in the liver very rapidly, and any gross hepatic 
disease or the presence of jaundice is a definite 
contra-indication. 


Low blood pressure.—General feebleness of the 
patient and low blood pressure make it inadvisable 
to use doses liable to cause a definite fall in blood 
pressure. 

Posture.—Owing to the fall in blood pressure with 
all intravenous barbiturates, the recumbent posture 
is the safest for the administration of these anæs- 
thetics. Several untoward effects have been encoun- 
tered in the dental chair even with healthy patients. 

Space.—Lack of availablé space applies only to 
institutions where a large number of patients are to 
be dealt with and where enough room is not available 
to allow all of them to recover sufficiently to return 
home. 

Other barbiturates.—As a general rule it is not 
advisable to give any barbiturate intravenously after 
other barbiturates have been given as premedication. 


ANTIDOTES 


The antidotes to pentothal do not differ from 
those of any other form of general anæsthetic, nor 
are they more often needed. Coramine is by far the 
most reliable drug for collapse and it should be 
used liberally. Five cubic centimetres are the average 
dose, and 10 c.cm. may be given for severe collapse. 
It may be given subcutaneously or intramuscularly, 
or, in a case of emergency, intravenously. It has a 
stimulating effect on the heart and respirations. 
Alpha-lobeline is a direct respiratory stimulant and 
is used in doses of gr. 3/20, or 3/10, either subcuta- 
neously or, in urgent cases, intravenously. Another 
direct respiratory stimulant is carbon dioxide. It 
is given, of course, by mouth, preferably under 
pressure in the proportion of 5 or 7} per cent. CO, 
in oxygen. A cylinder of this mixture should be in 
every operation-room and in every recovery-room. 

Though it has proved possible to kill animals 
with pentothal no pathological changes could be 
discovered in their organs post mortem apart from 
signs of respiratory failure. 


AFTER-EFFECTS 


In our series of over 1000 cases there have been 
no deaths following the use of pentothal sodium, 
nor does any pathological process appear to have 
been aggravated. No patient who has had pentothal 
alone has vomited after an operation. Vomiting 
has occurred in a very small proportion of those 
cases that have had premedication in addition to 
pentothal, but the proportion was no greater than 
after taking an opiate alone, and was much less than 
after an ordinary inhalation anesthetic. 

We regard pentothal sodium as a worthy addition 
to our list of safe and satisfactory intravenous 
anesthetics. 


PRINCESS ELIZABETH OF YORK HOSPITAL, SHAD- 
WELL.—Mr. Meyerstein has promised to pay £5000 for the 
25 acres of hillside at Banstead which face the site where 
the new hospital is to be built. This will keep the 
prospect open for ever. Mr. Meyerstein is also giving 
£10,000 towards the cost of the new building. 


NEw IIOsPITAL FOR SCARBOROUGH.—When the 
new hospital is opened at Scarborough, additional 
maintenance costs will have to be met and the 
authorities have decided to launch a contributory scheme 
under the British Hospitals Contributory Scheme Asso- 
ciation. The new building will have 140 beds, the present 
hospital has 70, and the annual expenditure it is estimated 
will be between £12,000 and £15,000. Under the scheme 
it is proposed that the weekly contribution shall be 3d. 
for adults and 2d. for those over sixty and under 
twenty-one. 


424 THE LANCET] DR. D. N. PARFITT: PSYCHOSES TREATED BY PROLONGED NARCOSIS 


TREATMENT OF PSYCHOSES BY 
PROLONGED NARCOSIS 


By D. N. ParrFitt, M.D., M.R.C.P. Lond., D.P.M. 


DEPUTY MEDICAL SUPERINTENDENT, WARWICKSHIRE AND 
COVENTRY MENTAL HOSPITAL 


The treatment of psychoses by prolonged narcosis 
has been popular on the continent for some years 
and has proved so effective in manic-depressive 
states that a diagnosis of mania or melancholia is 
considered doubtful if no improvement follows 
prolonged narcosis therapy. 


After careful physical investigation and the 


administration of an enema, the patient is put to 
bed in a single room and every effort made to ensure 
absolute quiet. The most favoured drug is Somni- 
faine given in 2 c.cm. doses by intramuscular injec- 
tion in sufficient quantity to ensure continuous sleep 
for 10-12 days, feeding with fluids being carried out 
before each injection and at intervals when possible. 
Poisonous symptoms are unfortunately very common 
and have prevented the more general adoption of 
the treatment. Thus early collapse, or a condition 
similar to “‘ veronal pneumonia,” or great difficulty 
in swallowing combined with cedema of the throat 
and an excessive secretion of mucus, may occur, and 
other less serious or less common symptoms are 
muscular incoérdination, irregular and sometimes 
high pyrexia, a fall of blood pressure, hyperidrosis, 
various rashes, albuminuria with or without casts, 
olguria, anuria, and epileptiform convulsions. Added 
to these is a liability to contract pulmonary infections. 

Investigations at the Cardiff City Mental Hospital 
by Quastel and Wheatley! and Quastel and Strém- 
Olsen * having shown that narcosis interfered with 
the carbohydrate metabolism of brain cells, it was 
suggested that a similar action on the heart, liver, 
and other organs might be responsible for some of 
the poisonous symptoms of prolonged narcosis. 
Strém-Olsen * found that 70 per cent. of patients 
undergoing this treatment showed acetone in the 
urine, while glucose tolerance was lowered and glyco- 
suria common. He consequently treated his patients 
by giving glucose and 10 units of insulin with each 
2 c.cm. of somnifaine and reported that extreme 
drowsiness, cyanosis, coldness of the extremities, and 
vomiting remained in abeyance; though pyrexia, 
albuminuria, oliguria, and leucocytosis still occurred, 
the dangers of prolonged narcosis were in general 
greatly reduced. Strém-Olsen includes a compre- 
hensive review which it is unnecessary to repeat 
and says that the average death-rate had been 4 per 
cent. without insulin, whereas his series of 46 treat- 
ments was without a death. Contra-indications are 
emaciation, cardiac weakness, renal affections, and 
pulmonary diseases, while tachycardia, a severe fall 
in blood pressure, high pyrexia, persistent vomiting, 
and a dusky complexion with shallow breathing and 
extreme drowsiness are indications for the cessation 
of treatment. 

In a later communication Strém-Olsen and 
McCowan ‘ report that of 49 schizophrenics 8'1 per 
cent. recovered and 38°7 per cent. improved ; of 45 
manic-depressives, 37:7 per cent. recovered and 29 
per cent. improved ; and of 13 psychoneurotics 61°5 
per cent. recovered and 15:4 per cent. improved. 

The present report deals with 60 treatments by 
prolonged narcosis given to 56 female patients between 
January, 1934, and June, 1935, 45 treatments being 
carried out with insulin and glucose as well as somni- 


[FEB. 22, 1936 


faine, and 15 with somnifaine and glucose only. 
Four patients had two courses of treatment, one 
each with and without insulin, two being given 
insulin during the first course and two during the 
second. There were 3 deaths in the series, 2 while 
receiving insulin—a death-rate of 5 per cent. Before 
discussing the toxic effects further, a brief summary 
of the results will be given. 


RESULTS OF TREATMENT: DOSAGE 


Psychoneuroses.—Anxiety states, 8 patients. Of these, 
4 showed no change; 1 showed slight improvement, but 
soon relapsed; 1 showed slight improvement which was 
maintained; and 2 showed marked improvement, which 
was maintained. Exhaustion states, 2 patients. One 
showed no change and the other slight improvement which 
was maintained. One case of hysteria was unaltered by 
treatment. 

Mania (11 patients.}—One chronic mania remained 
unchanged. Of the acute cases 1 died; 3 others all 
showed immediate benefit but all relapsed. Of these, 
2 relapsed quickly and have remained hypomanic for 
over a year, while the other remained well for a few 
months, after which an acute relapse was treated by 
somnifaine narcosis with a very excellent result; the 
patient has been perfectly well for over a year. The 
remaining 6 were acute manic types with superadded 
confusion. Two showed no response, 2 improved but 
relapsed, and 2 improved in a very striking manner and 
were discharged from hospital in one and two months 
respectively. 

Melancholia (11 patients)—Of 3 cases of the involu- 
tional type, none showed any response to treatment. 
One was discharged later. Of the others one died and 
one showed no change. Three improved but relapsed, 
and 3 improved considerably and were later discharged ; 


„but the duration in hospital was not strikingly reduced. 


Schizophrenia (19 patients).—In 8 cases there was no 
improvement, and 2 of these had a further course, again 
with no benefit. Three patients improved and were 
discharged from hospital but later returned. One of these 
returns had a second course without benefit. Three 
improved, were discharged, and remain well. One of 
these was a voluntary patient aged 26, who had been a 
certified patient at 22 and had been in hospital for two 
years, afterwards remaining well for nearly two years. 
When seen at an out-patient clinic she had been away 
from work for two months with apathy and odd conduct. 
She was given a 10-day treatment and returned to work 
a week later. 

The last of this group was a chronic patient subject 
to manic episodes of great intensity and duration. One 
of these acute phases was treated with marked success, 
and she was out on parole a few days after the treatment 
finished. 

Paraphrenia (3 patients)—Two menopausal paranoid 
women, aged 44 and 47, whose prognosis was considered 
unfavourable, improved in a very remarkable manner. 
One had been completely stationary for nearly three 
months but after treatment was discharged in less than 
a month, while the total duration in hospital of the other 
was less than two months. A third case, aged 55, improved 
but soon relapsed. 

The last case of this series was a young but chronic 
epileptic, who had been in a state of continued excitement 
for two months. A severe toxicosis resulted in death. 


Altogether, in 60 treatments, definite improve- 
ment was shown 33 times, and in 16 cases 1t was 
maintained at least for a considerable period. The 
average duration of treatment and dosage was as 
follows :— 


Days. Dosage per day. | 
Under 45 with insulin 9:3 5:7 o.cm. 
» 45 without ,, 10°5 53 45 
Over 45 with insulin 8:0 4:2 ,, 
» 45 without ,, 6:9 6:3 


The average dosage is similar to that reported by 
Str6ém-Olsen. If cases whose treatment was aban- 
doned after two or three days were excluded, the 
duration would read appreciably longer. 


THE LANCET] 


DR. D. N. PARFITT: PSYCHOSES TREATED BY PROLONGED NARCOSIS [FEB. 22, 1936 425 


Of the merits of ‘insulin administration a better 
idea can be gained by considering the 4 cases who 
received two treatments each. All were physically 
healthy and between twenty and thirty years of 
age. 


Dosage 
Days. per day. 
c.cm. 
Four treatments with insulin averaged .. 13 .... 58 
; ss without ,, ji eee 10 sede 63 


In no case was the treatment so smooth without 
insulin as when it was employed. l 


TOXIC SYMPTOMS 


Despite the apparent advantage of the addition 
of insulin, toxic symptoms in this series occurred 
irrespective of its use, and there was no greater 
proportion of any particular complication when it 
was omitted. The cases are therefore treated as a 
group. 

The variation in individual reaction to the drug 
was very wide. One patient died after the adminis- 
tration of 12 c.cm. in three days, and another had 
135 c.cm. in fifteen days without the slightest dis- 
turbance. The first and second doses were regarded 
as tests of idiosyncrasy but they never gave useful 
pointers. The largest daily dose was usually 8 c.cm., 
and 10 c.cm. was rarely exceeded. Ström-Olsen 
quotes Stuurman, who regarded preliminary treat- 
ment with morphia and hyoscine as a dangerous 
procedure, and in 4 of this series there were severe 
toxic symptoms in patients who had received morphia 
and hyoscine, including the fatal case following 
12 c.cm., although in none of them had this com- 
bination been given in the 24 hours preceding the 
beginning of treatment. 

About half of the 60 treatments were continued 
for 10-14 days without any symptoms giving rise to 
anxiety. 


General health —There was an average loss of weight 
of 5 lb. per week and a slight fall in the hemoglobin level. 
In 9 cases the treatment was stopped at about the ninth 
day because of a generally toxic appearance without focal 
symptoms, and two of these had some cough and sputum. 

Gastro-intestinal.—_Vomiting from the second to the 
fourth day and perhaps recurring later proved a trouble- 
some symptom in 18 cases, compared with Stré6m-Olsen’s 
10 out of 46. Feeding with peptonised milk, milk and 
soda, and a reduction of glucose, gastric lavage with 
sodium bicarbonate solution, the injection of 7 minims of 
1/1000 adrenaline, of atropine gr. 1/100 to 1/50, or of 
Icoral, one ampoule before feeds, were tried. Icoral 
gave most satisfaction, possibly by raising the blood 
pressure, but the treatment had to be abandoned in 2 cases 
because of this symptom. Tube feeds were also necessary 
for difficult swallowing and an excess of mucus in the 
throat in 6 cases. (In 5 of Strém-Olsen’s 46 cases difficult 
swallowing was conspicuous.) In all, tube feeds were 
necessary in 20 cases, compared with Strém-Olsen’s 3. 
Two patients developed a very sore mouth, and one of 
them had herpes labialis. Constipation was the rule and 
periodic enemata were necessary. 

Carbohydrate metabolism.—Since incontinence of urine 
was very frequent, regular examination of the urine was 
impossible, but only 3 patients receiving insulin and 2 
without insulin were found to be excreting acetone in the 
urine, and it was always in relation to troublesome vomit- 
ing or shortage of fluid intake, but sugar was found in 
one specimen of urine in 6 cases. If the daily intake of 
nutrient fluid is not allowed to fall below 50 oz. the evi- 
dence suggests that acetone will rarely be found in the 
urine. A daily amount of 100 oz. of nutrient fluid was 
always aimed at. The urinary sugar may be explained 
by the large quantity of glucose given. In this con- 
nexion the finding of Begg,® that toxic diphtheria did 
just as well with antitoxin and glucose as if insulin were 
added is interesting. 


_ sweats persisted for several days after treatment. 


The temperature—Of Strdm-Olsen’s 46 cases, 11 had 
troublesome rises of temperature, successfully treated by 
withholding somnifaine for 12 to 24 hours. Ignoring slight 
rises to 100° F. or less, sudden rises of temperature caused 
anxiety in 24 of this series. The rise was most erratic 
and often surprising, in some cases the temperature 
fluctuated almost from the beginning, sometimes it shot 
up to 103° after several days of smooth narcosis, perhaps 
with no other symptoms but frequently with other evidence 
of grave toxemia. When the temperature had fallen 
the treatment might be continued without incident or 
further high temperatures might prevent the continuation. 
of the course. Occasionally the temperature rose even 
to 103° after treatment had ceased. 

The skin.—Hyperidrosis was common, more so at night, 
and was sometimes very profuse ; on one occasion drenching 
Three 
patients developed rashes, one morbilliform and one 
scarlatiniform, distributed irregularly on the back and 
buttocks, and one generalised morbilliform eruption. 
One case developed an abscess of the buttock, which was 
opened and drained without further trouble. l 

Urogenital.—In all, 14 patients developed albuminuria 
and 4 of these had casts, generally granular, at least once, 
but all cleared soon after treatment was suspended except 
one. Of the first 28 cases, 12 needed catheterisation 
for retention, a higher proportion than Strém-Olsen’s 12 
of 46. This often led to cystitis despite stringent pre- 
cautions and in 2 cases the urine became alkaline and 
loaded with phosphates, with abundant albumin, pus cells, 
and organisms, chiefly Bacillus coli, and 5 more developed 
a mild albuminuria with some pus cells and organisms. 
Following the advice of Meerloo ë retention was thereafter 
ignored with much happier results, although 36, 45, and 
50 hours elapsed in 3 instances without urine being passed 
and occasional pus cells sometimes appeared. Two 
patients had retention of urine after treatment, and 
were successfully treated with morphia, atropine, and 
hot fomentations: Incontinence sometimes persisted for 
a few days after treatment, and a few patients seemed to 
derive some satisfaction from this. | 

An excess of urates in the urine was common ; bile 
was found twice and indican once. The blood-urea 
usually rose, but slightly and serious symptoms developed 
with a normal blood-urea content. Two patients men- 
struated during treatment but this was ignored without 
harm. A profuse vaginal discharge was noted only during 
treatment in 7 cases. 

Cardiovascular.—A fall in blood pressure was almost 
uniform, usually about 25 mm. Hg systolic and 20 mm. 
diastolic, but after falling rapidly during the first few 
days it tended to rise and was sometimes almost normal 
at the end of a week. Two patients with a systolic blood 
pressure below 110 mm. collapsed on the second day with 
a rapid feeble pulse, shallow respirations, coma, sweating, 
and a fall of temperature. They were treated with icoral. 
Both were receiving insulin. Strém-Olsen had 2 cases 
of collapse, without insulin, and they recovered without 
treatment. Treatment was terminated in two cases 
because of a rapid pulse-rate, in one case for coupled beats, 
and in 2 for pulse irregularity, one of the latter also 
having puffy hands. Epistaxis occurred once during 
treatment. 


“ Veronal pneumonia.”—The development of a 
condition having every appearance of a serious pneu- 
monia, with very rapid and laboured respirations, 
an increased pulse-rate, high temperature, cyanosis 
and coma, proved the most deadly of complications. 
There were 6 such cases and 2 of the patients died. 
It developed on the second day in 1 case, on the 
third in 2, on the sixth in 2, and on the eighth in 1. 
Of the 6 patients 5 were treated by the method 
recommended by fPurves-Stewart and Willcox,” 
including stomach wash-outs, feeds with coffee, 
glucose and peptonised milk, colon lavage, strychnine 
in large doses, and lumbar or cisternal puncture 
repeated at 12 to 24 hourly intervals. Coramine 
was usually given in full doses in addition and seemed 
to do good. One fatal case was given intravencusly 


426 THE LANCET] 


20 c.cm. of 30 per cent. alcohol hourly for four doses, 
as recommended by Carrière, Huriez, and Willoguet,® 
and this produced profuse sweating and a stronger 
pulse, but failed to delay the end. In the first case 
recovery took place without lumbar or cisternal 
puncture, and cisternal puncture was performed 
once in a fatal case and once in a case that recovered. 
In all these 6 cases consciousness was restored, but 
the toxic process in the liver, kidneys, or heart was 
too advanced for treatment to be successful in 2 of 
them. 

Epileptiform convulsions.—One patient had a 
convulsive seizure 4 days after the termination of 
a 12-day course. The narcosis was without incident, 
and there was no personal or family history of fits. 


THE DEATHS 
. The first death occurred in a case of mania. 


` The patient, aged 32, developed a temperature of 102° F., 
with albumin, abundant casts and sugar in the urine on 
the eleventh day. Treatment was stopped and the patient 
soon began screaming ceaselessly. Rectal paraldehyde 
and numerous stimulant drugs were tried but profound 
exhaustion set in and the patient died on the 13th day 
with a terminal hyperpyrexia of 107°. Sections of the 
heart, liver, and kidneys were examined by Dr. J. Gough 
of Cardiff, who found that the kidneys showed evidence 
of damage to the epithelium of the convoluted tubules, 
many of the cells of which showed necrosis and were 
desquamated. The liver showed cloudy swelling and 
some small arcas of early necrosis. 


The second case was of the pneumonic type, referred 
to above, in an epileptic aged 16. Toxic damage to 
the liver and kidneys was evident. The third dcath 
was also of the pneumonic type. Material from the 
liver and kidneys was sent to Dr. Gough and careful 


CLINICAL AND LABORATORY NOTES 


[FEB. 22, 1936 


examination failed to show any evidence of toxic 
change. The lungs at autopsy were greatly con- 
gested and cdematous but not pneumonic, and since 
consciousness was restored before death, acute toxic 
myocarditis was probably present. Unfortunately 
no microscopic examination of heart muscle was 
made. The patient was aged 47. 

The first fatal case received 80 c.cm. of somnifaine 
in 11 days, the second 12 c.cm. in 3 days, and the 
third 38 c.cm. in 6 days. 


CONCLUSIONS 


Prolonged narcosis often produces definite improve- 
ment—sometimes dramatic improvement—in psy- 
chotic cases. The use of insulin with glucose is an 
advance in treatment, but this form of therapy 
remains dangerous. 


I wish to thank Dr. H. B. Leech, superintendent of 
the Warwickshire and Coventry Mental Hospital, for per- 
mission to report these cases, and Miss Ring, of the 
nursing staff, for her skilful supervision of the nursing 
details, the importance of which cannot be over-estimated. 
I am also very grateful to Dr. Gough, of the pathology 
department of the Welsh National School of Medicine, 
for his reports on post-mortem material. 


REFERENCES 

. Quastel, J. H., and Wheatley, A. H. M.: Proc. Roy. Soc. B., 
1902, exii., 60. 

. Quastel, and Strém-Olscn, R.: THE LANCET, 1933, i., 464. 

. Strém-Olsen : Jour. Ment. Sci., 1933, Ixxix., 638. ` 

. Ström-Olsen, and McCowan, J.M. : Ibid., 1934, Ixxx., 658. 

. Begg, N. D.: THE LANCET, 1935, i., 480. 

. Meerloo, A. M.: Jour. Ment. Sci., 1933, Ixxix., 336. 

. Purves-Stewart, Sir J., and Willcox, Sir W. H.: THE 
LANCET, 1934, i., 6 

. Carriere, G., Huriez, C., and Willoguet, P.: Le Barbiturism 


Aigue, Lille, 1934. 


—_ 


iv.) “1 QD tr me wD 


CLINICAL AND LABORATORY NOTES 


THE IMPERFECTLY MIGRATED TESTIS 
. SOME STATISTICAL DATA 


By PEARSE WILLIAMS, M.D., M.R.C.P. Lond. 


PHYSICIAN TO THE CHILDREN’S HOSPITAL, PADDINGTON GREEN, 
AND THE WILLESDEN GENERAL HOSPITAL, LONDON 


A RECENT article by Spence and Scowen in THE 
LANCET! has brought out the possibility of success 
from treating the undescended testicle with gonado- 
tropic hormone. A factor of importance in deciding 
whether to recommend injection treatment will be, 
no doubt, the age of the patient. This was brought 
out by Denis Browne in a subsequent communication.? 


- In Spence and Scowen’s records of 33 boys treated 
by this method, 25 were under 14 years of age, and 
I believe that in a good proportion of these the 
testicle would have descended naturally without 
hormone therapy. This is not, however, to deny 
the value and importance of the work of Spence and 
Scowen in showing us that we have a new and potent 
means of treating these patients. For some years 
I have been responsible for the health of boys attending 
a large secondary day-school in central London and 
have, in my notes, recorded all cases of undescended 
testis and noted each year the progress made. The 
figures obtained are instructive and I record them as a 
contribution to the subject. They give some indica- 
tion of the age at which stimulatory treatment should 
be begun. In studying the figures we must not forget 


’THE LANCET, 1935, ii., 1335. 
2 Ibid., p. 1484. 


that a number of boys probably had had undescended 
testes which had reached the normal position before 
my first observation. 

The records of 2104 boys were examined. Of 
these, 38 had one testicle undescended (1-8 per cent.) ; 
21 had both testicles undescended (1-0 per cent.). 
The majority were observed up to the age of 16 
and a very few up to theageof 18. The ages at first 
observation were as follows :— 


Age in years. Cases. Age in years. Cases. 
- 9 a 1 12-13 s 11 
9-10 2 13-14 . 8 
10-11 6 14-15 11 
11-12 20 


Of 38 boys in whom only one testicle was 
undescended there was natural descent in 24 (63 per 
cent.); of 21 boys in whom both testicles were 
undescended there was natural descent in 14 (67 per 
cent.). In examining my data however I am able 
to make further observations and corrections. Ten 
boys were not seen by me over a sufficient number 
of years for adequate observation, and six boys fell 
into the second group of Denis Browne in that the 
lack of descent was complicated by the presence of 
a hernia or hernial sac, or operation for such 
abnormality had already taken place. This leaves 
43 boys fully observed, and if the figures are thus 
revised we find that— 

Of 27 boys in whom only one testicle was 
undescended and no complicating factor was present 
there was natural descent in 24 (87 per cent.). 

Of 16 boys where both testicles were undescended 
and no complicating factor was present there was 
natural descent of both in 14 (87 per cent.). 


THE LANCET] - 


The ages at which natural descent occurred were 
as follows :— 
No. of cases. 
ee 


; One Both 
Age in years. testicle. testicles. 
11-12 2 2 
12-13 5 3 
13-14 4 1 
14-15 7 5 
15-16 5 3 
16-17 1 1 


I have not analysed specifically the age of descent 
of each testis in the bilateral cases, but from my 
records can state that up to two years may elapse 
before one testis follows the other into the scrotum, 
or one may descend and the other fail to descend. 
Can we infer therefore that some other factor is 
present other than a lack of gonadotropic hormone ? 

I feel justified in concluding from my observations 
that treatment is not required in these cases until 
puberty is well advanced, and that up to the age of 
16 natural descent is probable. We do not know as 
yet the full implication of injecting powerful hormones 
into the growing boy, and I believe it will be wise 
to refrain from advising their use except from the 
experimental standpoint until it appears evident 
that at a reasonable age—e.g., 16 years—natural 
descent is not occurring. Those boys in whom a 
complicating factor is present require the advice 
of a surgeon as soon as the abnormality is discovered. 


GADGETS IN PLASTER WORK 
By W. Grant WauGu, M.D., F.R.C.S. Edin. 


SURGEON TO THE MONKWEARMOUTH AND SOUTHWICK HOSPITAL ; 
ASSISTANT SURGEON TO THE. ROYAL INFIRMARY, 
SUNDERLAND 


THE use of plaster-of-Paris is becoming rapidly 
more widespread in this country with the adoption 
of Béhler’s methods and the introduction of the 
standard Cellona bandage. The removal of the 
plaster cast at the end of the appropriate period, 
however, still entails the waste of much muscular 
effort, time, and temper, usually on the part of some 
unfortunate ward nurse. Patients with fracture 
themselves say that removing the cast is the most 
painful part of the Béhler technique. I have used 

i this treatment for the 
last six years, after a 
course of study in Vienna, 
and it may be of service 
to describe a few methods 
which, in my experience, 
make the manipulation 
of a plaster cast less of an 
ordeal to both parties. 

l]. Cutting a window.— 
l A window in the plaster 
is often necessary, for example when compound 
fracture has been closed by operation, and it is easily 
cut out if the wound is covered by the lid from a cocoa 
or other tin and the plaster applied over it. The 
lid and overlying plaster are excised before the latter 
has set and the free edges pressed in. A brass lid 
with a rolled edge, and hinged in the centre to fit 
the contour of the limb, has been made for me by 
the Medical Supply Association (Fig. 1). 


2. Cutting instruments.—In addition to the usual 
plaster scissors, two curved cobbler’s knives, with 
external and- internal cutting edges respectively, 


CLINICAL AND LABORATORY NOTES 


[FEB. 22, 1936 427 


are serviceable, while the discarded scalpel from 
the theatre is indispensable ; but let me utter a warning 
against the use of the Bard-Parker type, the blade of 
which is too fragile and may break and lacerate the 
operator’s fingers. The gadget known as the “ jigger 
knife,” which carries the Gillette type of razor blade, 
is, however, safe and very useful; the blades are 


FIG. 2.—The ean The head of the left-hand member 
from the left, and (b) from the right. (c) The tapering end 
to fit the fixing plate. (d) The heads interlocked ; anterior 
view and (e) posterior view. (f) The fixing plate. 

The pins with the fixing plate attached are bent roughly 
to the shape of the limb and foot, and the plaster is applied 
over them. When the plaster is drying it is split down the 
groove between the pins, which are disengaged and lifted out. 
The pins are made from brass wire (No. 8 S.W.G.), the heads 
from 1 in. round brass (size of each, 4x4 x4in.). The pins 
are conveniently 2 ft. long. The plate is of brass (No. 16 
Imp. W.G.), and the tubes loosely fit the ends of the pins. 
The whole instrument is hand soldered. 


sharp and the supply of ammunition is unlimited. 
The small electrically driven circular saw of German 
origin is an ideal cutting instrument—apart from 
the expense. Fretsaw blades are too brittle and 
usually too short, but the old-fashioned bow saw, with 
a 1/16 in. blade and 18-24 in. long, can often be 
used to remove old casts. The blade, covered with 
a soft metal guard, is ‘‘ wangled ° between the limb 
and the cast, the bow attached to the ends, and the 
cast is sawn diagonally outwards. 


3. Splitting the plaster.—‘‘ In every case where a 
plaster cast is applied before the swelling has dis- 
appeared, the cast should be split directly after its 
application.” 1 This is often necessary, and to 
simplify it I have placed two metal knitting needles 
on the fleshy part of the limb, bending them to fit 
the curves and plastering over them; the drying 
plaster is then cut down the ridge between the pins. 
As knitting needles of suitable length and calibre are 
not readily obtainable I have elaborated these into 
an instrument, the details of which are illustrated 
(Fig. 2). The pins are 2 ft. long, with interlocking 
heads, and a slot into which the lower ends fit to 
prevent spreading. These pins I find of great help, 
and I use them as a routine in every cast application. 
They render the splitting of a plaster a rapid and 
safe procedure. | l 


I am indebted to the Medical Supply Association, 
who first made a set of Böhler’s equipment for me 
in 1930, for the skill with which they have interpreted 
these ideas. 


` 1 Böhler, L.: The Treatment of Fractures. Fourth English 
Ed. Translated by E. W. Hey Groves. Bristol, 1935, p. 406. 


428 THE LANCET] 


A CASE OF HAMOPHILIA TREATED 
WITH RUSSELL VIPER VENOM 


By GEOFFREY A. BAKER, M.B. Durh. 


HOUSE PHYSICIAN AT THE TORBAY HOSPITAL, TORQUAY 
AND 
PauL C. Grsson, M.D., M.R.C.P. Lond. 


PHYSICIAN TO THE HOSPITAL 


THE patient, aged 11, a fat boy with a fair 
complexion, was admitted to the Torbay Hospital 
on Oct. llth, 1935. He has one brother who is said 
to be hxmophilic and two sisters who are healtby ; 
no family history of blood disease could be obtained 
from either of his parents. He had been bleeding 
for ten days from the gum round an upper incisor 
tooth. 


On admission he was collapsed and pale. His mouth 
was in a septic condition, the gums were inflamed, and 
he had several carious teeth. A blood examination 
showed: red cells 4,020,000 per c.mm.; hæmoglobin, 
45 per cent.; platelets, 500,000: bleeding time, 34 min. ; 
coagulation time, 74 min, No other physical signs 
were noted. oO 

With an acriflavine mouth-wash (1 in 1000) the gums 
improved and the bleeding stopped, but it recurred a 
few days later; and permanent improvement seemed 
unlikely until the tooth was removed. This and an 
adjacent tooth were extracted on Nov. 23rd under local 
anesthesia. There was no serious bleeding for about 
eight hours; oozing then began and continued steadily 
in spite of plugging with, alternately, adrenaline, turpentine, 
and tannic acid. The blood collected in the receiver 
was clotted, but the clot was soft and friable. On 
Oct. 24th a blood transfusion of 200 c.cm. was given, his 
father acting as donor. Difficulty arose from the fact 
that the boy’s veins were obscured by subcutaneous 
fat, except in the neighbourhood of the wrist. An attempt 
to get into one of these veins with a needle failed and so 
an incision was made just above the wrist. The vein 
was found to be too small to admit even the smallest 
cannula, and another incision was made in the antecubital 
space and the transfusion effected. Both wounds were 
firmly sutured and a pad tightly applied. In spite of this, 
oozing began from both incisions; there were now, 
therefore, three oozing points instead of one. He became 
steadily exsanguinated, but, owing to the impossibility 
of getting blood into his vein without making another 
incision, further transfusion was impracticable. 


On Oct. 26th we decided to try to obtain some snake 
venom. We wired to a firm in London, confirming the 
order later by telephone, when we were informed that 
the order would be executed immediately. At midnight 
a package arrived, but to our dismay it was found to 
contain a supply of antivenin. By this time the boy’s 
condition was getting desperate. . At 9.15 the follow- 
ing morning we telephoned to the pharmacist of 
St. Bartholomew’s Hospital for help. He most kindly 
undertook to see if any venom could be obtained, and, if 
not, to send some of their own supply. At 104a.m. a 
telegram arrived from Messrs. Burroughs Wellcome and 
Co. saying that some Russell viper venom, which had 
been supplied from the experimental stock at the Wellcome 
Physiological Research Laboratorics, Beckenham, Kent, 
was being put on to the 10.30 train for Torquay. It 
arrived at 2.30 p.m. and was applied immediately. From 
that moment we had no further anxiety. Bleeding 
stopped at all three points and did not recur to any serious 
extent. The venom was applied, soaked in plugs of 
gauze, in a dilution of 1 in 10,000; to ensure proper access 
the stitches were removed from the two wounds in the 
arm. During the first 24 hours the venom was frequently 
reapplicd and at first there was some slight oozing from 
the incisions. I think this was because the only way of 
stopping the bleeding before the arrival of the venom was 


CLINICAL AND LABORATORY NOTES 


[FEB. 22, 1936 


by applying continuous pressure, enough to obstruct the 
circulation; when pressure was released there was 
considerable hyperæmia for a time. In the tooth sockets, 
immediately after the venom was applied, a firm elastic 
clot formed. The wounds healed by granulation in about 
three weeks. 

On Jan. 20th, 1936, some bleeding started round the 
left lower canine. The tooth was extracted and the 
socket plugged with venom. There was some slight 
oozing but this was never serious, and it had completely 
stopped by Jan. 23rd. He was discharged from hospital 
on Feb. 3rd. . 


Special points of interest are: (1) The immediate 
hemostasis in the tooth socket. (2) The effectiveness 
at a site where application was not easily sustained ; 
the tooth socket was shallow and could not be packed 
very efficiently. (3) The firmness of the clot; this 
was particularly noticeable in the socket, where the 
clot felt to be of the consistency of rubber. (4) The 
complete absence of any undesirable effects, although 
a considerable amount of the venom tad to be used 
on the arms. 


All these satisfactory effects could be expected 
from the published results of Macfarlane and Barnett,} 
to whom medicine owes this valuable remedy. 


We would express our most sincere thanks to the 
pharmacist of St. Bartholomew’s and to the director of the 
Wellcome Physiological Research Laboratories for the 
promptness with which they came to our help. 


AN UNUSUAL TERMINATION OF 
CIRRHOTIC SPLENOMEGALY 


By J. F. PATERSON, M.R.C.S. Eng. 


CASUALTY HOUSE PHYSICIAN, ST. BARTHOLOMEW’S HOSPITAL 


SPONTANEOUS rupture of the splenic pedicle is so 
unusual that the following case is reported even 
though no elaborate investigations were made. 


The patient, a man aged 27, was riding a motor- 
cycle, when he was seized with a sudden attack of 
upper abdominal pain, felt faint, and dismounted. 
He vomited his previous meal. He was seen by a 
doctor at the roadside who diagnosed a perforated 
peptic ulcer and had him taken to the Norfolk and 
Norwich Hospital. On examination there he was 
found to be severely shocked and pale. The 
temperature was subnormal and the pulse rapid. 
The abdomen was not rigid, but was generally tender 
and doughy. The spleen was easily palpable and 
was firm and smooth. There was dullness in the 
flanks, but the anterior area of liver dullness was 
diminished. There were no enlarged veins on the 
abdomen and the superficial lymph glands were not 
palpable and he was not jaundiced. Intra-abdominal 
hemorrhage was diagnosed and the patient died 
shortly after admission. 


Past history.—At the ago of 5 he was in hospital 
complaining of langour and drowsiness. The cervical, 
axillary, inguinal, and right iliac lymph glands were 
enlarged, painless, fairly soft, movable, and discrete. 
The spleen was enlarged down to the umbilicus and the 
liver was palpable }in. below the costal margin with a 
regular and smooth surface. Blood examination showed 
hemoglobin 60 per cent. and a leucocytosis of 16,000. 
No ditferential count was done. He stayed in hospital for 
three months during which time he developed chicken-pox, 
and on discharge the spleen had apparently decreased in 
size. He remained apparently well until a few months 


Se Macfarlane, R. G., and Barnett, B.: THE LANCET, 1934, ii., 
5. 


THE LANCET] | 


before his death when he began to complain of vague 
upper abdominal discomfort. He was stated always to 
be pale and yellowish. : 


At autopsy a large quantity of blood lay free in the 
peritoneal cavity. There had also been a massive 
hsemorrhage into the retroperitoneal tissues, which 
had apparently come from the pedicle of the spleen 
and blood had burrowed under the splenic capsule. 
The capsule was not ruptured and the splenic artery 
appeared normal. The spleen was diffusely enlarged 
and weighed 420z. The liver was greatly shrunken 


ROYAL SOCIETY OF MBDICINE : PSYCHIATRY 


[FEB. 22, 1986 429 


and weighed only 30 oz. ; it showed advanced cirrhosis 
of the hob-nail type. The other organs appeared 
normal. The lymph glands were not enlarged and 
there was no evidence of external compression or 
thrombosis of the portal vein. It was concluded 
that the hemorrhage was the result of spontaneous 
rupture of one of the veins in the pedicle of the 
enlarged spleen. 


My thanks are due to Mr. J. M. Ridley Thomas and 
Dr. G. P. C. Claridge for their permission to publish the 
case. 


. MEDICAL SOCIETIES 


ROYAL SOCIETY OF MEDICINE 


SECTION OF PSYCHIATRY 


AT a meeting of this section held on Feb. 11th the 
the chair was taken by Dr. H. J. Normay, the presi- 
dent. Dr. E. T. C. SLATER read a paper on the 


Inheritance of Manic-Depressive Insanity 


Reviewing the history of work in this field, he men- 
tioned E. Ridin’s studies on the siblings of manic 
depressives, as yet unpublished, and Hoffmann’s 
work on the children of manic depressives, which 
still remained the basis of much that was taught and 
written on the subject. Hoffmann had found the 
enormous incidence of 30 to 60 per cent. of manic 
depressives among the children of victims of this 
form of insanity. His work was open to criticism, 
largely because of the impossibility of knowing what 
criteria of diagnosis had been used. Hoffmann had 
regarded cyclothymia and hypomanic and depressive 
temperaments, even including ‘‘ quiet humorists,” 
as tainted with manic-depressive heredity, taking an 
extreme Kretschmerian attitude. His figures were 
swelled by a tendency to exaggerate normals into 
abnormals, and abnormals into lunatics. The only 
other work of importance was that of Banse on the 
cousins of manic depressives. The value of his work 
was limited by the large use made of records. Among 
1586 cousins he had found between 24 and 34 per 
cent. manic depressives, 14 per cent. cycloid psycho- 
paths, and 5 per cent. persons likely to carry the 
hereditary factor. Dr. Slater said that his own 
research had been done in the same institute and on 
the same sort of material as Rüdin’s and Hoffmann’s. 
He had selected only cases showing some degree of 
phasic recurrence; at least one clear manic and one 
depressive attack, or at least three separate depres- 
sive or manic illnesses starting before the age of 50. 
The Kraepelin diagnosis had been taken, concen- 
trating on the course rather than the symptoms. A 
surprising feature had been the number of schizo- 
phrenics among the children. The figures had been 
-corrected to allow for the factor of increasing inci- 
dence of the illness with increasing age. Those 
under the age of 20 were neglected as having yet had 
no opportunity of developing psychosis, and those 
between 20 and 50 were reckoned as half.. The results 
showed an incidence of 15 to 20 per cent. of manic- 
depressive insanity among parents and children of 
manic depressives. The higher percentage was 
obtained if a number of cycloid children were 
included ; these might or might not prove to be manic 
depressive in later life. 

The inadequacy of the material, and the difficulties 
of ascertainment and of obtaining irreproachable 
statistics had prevented authors from putting for- 


ward theories of the genetic basis of manic-depressive 
insanity. Hoffmann had suggested the existence of 
three independent factors each carrying different 
weights, a total weight being required to precipitate 
psychosis while a lesser weight made the patient a 
cycloid or cyclothymic. Rosanoff, Handy, and 
Plessett proposed two independent factors: a cyclo- 
thymic autosomal factor and an activating factor in 
the X-chromosome, both dominant. Ridin proposed 
one autosomal dominant and two autosomal reces- 
sives. Luxenburger favoured a theory involving one 
recessive and one dominant. 


These theories were quite premature and served 
no useful purpose. One thing was more or less 
certainly established : that the psychosis was inherit- 
able and that the inheritance followed a dominant 
type. The simplest possible theory depended on a 
single dominant autosomal gene. Until this theory 
was shown to be inadequate, no other could be even 
provisionally accepted. On this theory the expecta- 
tion of manic depressives among parents, siblings, 
and children of manic depressives would be 50 per 
cent. All investigations, however, showed a much 
lower figure. The reasons for the discrepancy were 
many. A study of manic-depressive twins had shown 
that only about 70 per cent. of the uniovular twins 
developed the illness; this gave a direct measure 


of the influence of environment, expressed as 30 per 


cent. The expectation among nearer blood relatives 
was thereby reduced from 50 per cent. to 25 per cent. 
Another factor was inadequacy of investigation, 
probably involving considerable failure of ascertain- 
ment; another was the genotypic milieu. The genes 
had to work, not only in an external environment, 
but also in an internal environment made up by all 
the other genes which constituted the hereditary 
structure. In uniovular twins this milieu was the 
same for both. Genes, moreover, varied in their 
manifestations, some requiring quite special circum- 
stances for a hundred per cent. influence. The degree 
of manifestation bore no relation to dominance, and 
weakly manifesting dominant genes were very 
common. Probably in manic-depressive insanity 
the investigator was dealing with a weak dominant 
gene that manifested itself in only a proportion of 
its carriers. The psychosis would not appear unless 
there were present all the genetic factors necessary 
to allow a hundred per cent. manifestation of the 
manic-depressive gene. There was also the external 
environment, the influence of which was illustrated 
by the greater incidence in women. The great sym- 
ptomatic variability would be partly caused by the 
inclusion of what were not really manic-depressive 
psychoses. No other possible theory would give 
anything like this same percentage of manic depres- 
sives among parents, siblings, and children; it also 
fitted in with Banse’s 3} per cent. for cousins—i.e., 


430 THE LANCET] 


ROYAL SOCIETY OF MEDICINE: PSYCHIATRY 


(rep. 22, 1936 


just about a quarter of the empirical expectation for 
the others. Possibly more than one genetic factor 
could bring about manic-depressive insanity; this 
was known to be true for other inheritable abnor- 
malities. 

A number of observations pointed to a special 
relation between manic-depressive insanity and 
schizophrenia, and the relationship could not be 
altogether explained away on grounds of mistaken 
diagnosis. In 10 out of the 15 cases where manic- 
depressive subjects had been found by Dr. Slater to 
have schizophrenic children, he had been unable to 
find schizophrenia in other members of the patient’s 
family or in that of the husband or wife. Another 
curious thing was that manic depressives were scarcer 
than might be expected among the relatives of schizo- 
phrenics, so that the correlation was in one direction 
only. Manic-depressive insanity did not stand alone 
in this peculiar relationship to schizophrenia; the 
relatives of general paralytics and epileptics also 
showed an increased incidence of, schizophrenia. 
It did not seem likely or desirable to assume that 
there were common factors in each and all of these 
cases. Probably: a number of genetically different 
conditions were included under the term ‘“‘ schizo- 
phrenia,” but in the great majority of cases it was 
a destructive process affecting the whole personality. 
It seemed possible that the gene or genes responsible 
for the development of the schizophrenia would 
find it easier to manifest themselves in a genetic 
milieu which included other hereditary factors pre- 
disposing to psychic disorder, whether those other 
factors had actually manifested themselves or not. 
There was in. genetics no very hard-and-fast line 
between dominance and recessivity. It was quite 
possible that the presence of a manic-depressive 
gene might lend the schizophrenic gene a semi- 
dominance. Some process like this might be respon- 
sible for the strange atypical psychoses halfway 
between manic-depressive insanity and schizo- 
phrenia. If the manic-depressive gene had an acti- 
vating influence on the schizophrenic gene, the 
majority of the schizophrenic children of manic- 
depressives ought to be, so to speak, masked manic 
depressives. In one family where this point had been 
studied, a woman had a perfectly typical recurrent 
‘manic-depressive psychosis; her mother at the age 
of 34 had had an acute illness with many manic 
features which had passed on into chronic halluci- 
nosis with many paranoid ideas, and finally into a 
chronic schizophrenic state in which she had remained 
until her death at the age of 79. Her mother, the 


patient’s grandmother, had been four times in a. 


mental hospital. with recurrent melancholia, and her 
mother, the great-grandmother, had had one or more 
psychotic illnesses. Here were four generations 
showing a typical dominant inheritance with a 
schizophrene suddenly appearing in the middle but 
capable herself of continuing the manic-depressive 
line. Such facts as there were seemed to indicate 
that there was not an indefinite series of gradations 
between the normal and the psychotic. If English 
psychiatrists adopted the view that there was such 
a gradation, they should be clear about their grounds 
for doing so. | 
DISCUSSION — 


The PRESIDENT said that he saw scope for increased 
knowledge of the transmissibility of the manic- 
depressive psychoses in the daily work of psychiatrists, 
-particularly when they were considering the marriage 
of their patients. Interesting studies could possibly 
-be obtained from historical records of royal houses, 


. Kretschmer had 


the conduct of whose members was largely public 
and whose record of intermarriage was clear. The 
emperor Nero was a case in point : his uncle Caligula 
had been insane; Drusus, another uncle, had§been 
epileptic; his grandfather had been a man of great 
arrogance, prodigality, and cruelty ; his father had 
been brutal and reckless of the lives of others; and 
his mother, Agrippina, had been a prodigy of 
immorality. Nero himself had been epileptic and 
had committed suicide in the early thirties. 

Dr. AUBREY LEWIs regarded Dr. Slater’s paper 
as the most important contribution to the subject 
that had yet been made. It was difficult to regard 
manic-depressive ` illnesses as accounted for in any 
single way, whether by a single dominant factor or 
otherwise. In a certain series he had found that 
children with one manic-depressive parent had 
shown a large percentage of cyclothymic and manic- 
depressive conditions, whereas children of two 
manic-depressive parents had shown nothing. lt 
‘was not impossible that a dominant was sometimes 
present and sometimes not. Whether there was a 
recessivity was another matter. He had not been 
entirely convinced by Dr. Slater’s reasoning abcut 
the relationship between the schizophrenia occurring 
in the families—the ascendants or descendants—of 
manic depressives, and the manic-depressive condi- 
tions occurring in the propositi. It was useful to 
consider Kahn’s view that the important factor was 
not so much the presence of schizophrenia as the 
kind of schizophrenia. If it were the recurrent 
kind, one might be dealing with a factor common to 
both conditions which was responsible for periodicity 
and recoverability, and this factor might be found in 
schizophrenic strains also. 

Dr. C. P. BLACKER hoped that the paper would be 
regarded by the genetic historians of the future as 
a piece of pioneer English research. Dr. Slater’s 
hypothesis of a genotypic dominant which was pre- 
vented from manifesting itself as a phenotypic 
dominant through various intrachromosomal, environ- 
mental, and physiological factors was ingenious. It 
was, he thought, difficult to obtain any precise 
information concerning the genotypic milieu, but 
some evidence might be forthcoming about the 
environmental milieu. He asked whether Rosanoff 
or anybody else had been able to point towards an 
environmental factor which might have operated in 
those cases in such a way as to bring out the latent 
genotypic disposition in one pair of twins as against 
the other pair—i.e., whether the manifestation of 
the disease in the affected twin was in any way 


traceable to environmental strain, shock, or episode. 
.He also asked whether Dr. Slater had been led to 


suppose that the indubitable cases belonged more 
to .the pyknic type of bodily formation which 
stated to characterise manic- 
depressive persons. : . 
Dr. T. A. MUNRO said that it was possible to get 
surprisingly accurate information about families in 
rural areas, provided that one asked at least two 
and preferably three informants. Country people 
were anxious to give information about their rela- 
tives, and pleased to think that attention was being 
paid to the insane person in the mental hospital. 
Dr. MEYER-GROSS saw more hope than Dr. Lewis 
and Dr. Blacker of an ultimate explanation of the 
meaning of the genic milieu. This was not only an 
interior milieu but might manifest itself in various 
ways. The different components of the character 
might one day show the milieu which existed in a 
Single person or a number of persons, so that it 


THE LANCET] 


ROYAL SOCIETY OF MEDICINE: MEDICINE 


I 


[FEB. 22, 1936 431 


a SS A a 


could be judged according to the character com- 
ponents. It might then be possible to say something 
about the influence of the genic milieu upon the 
special gene which was being sought. 

Dr. H. CrRICHTON-MILLER stated that he had 
recommended a colleague, who had contemplated 
marriage with a lady whose heredity was suspected 
of a manic-depressive taint, to read ‘“‘ Chances of 
Morbid Inheritance.” From Dr. Slater’s paper it 
appeared that all the data in this book were founded 
on erroneous statistics. That was the kind of experi- 
ence which clinicians had when they came to 


scientific meetings. The moral was obvious: they 


should keep away. 

Dr. C. W. J. BRASHER considered that statistics 
could.only be valuable if carefully corroborated by 
personal interviews and clinical experience. 

Dr. SLATER denied any implication that he wished 
to destroy the standing of Hoffmann or anyone else. 
The great fault of Hoffmann’s work had been that 
he was so Kretschmerian; he would take people of 
a more or less cyclothymic character and say that 
they had a manic-depressive taint; this, though 
possibly correct, was premature. Dr. Slater had 
found his manic depressives definitely above the 
social level of their population. Manic depressives 
tended to be somewhat more pyknic than other 
people. German workers had frequently neglected 
the influence of environment,’ but he doubted whether 
any information would be forthcoming in the near 
future on what special environmental factors had a 
effect on the illness. 


SECTION OF MEDICINE 


AT a meeting of this section held on Feb. 18th 
the chair was taken by Sir CHARLTON BRISCOE, 
the president. 

Dr. OTTO LEYTON opened a discussion on the 
morbid conditions which cause 


Progressive Hyperglycemic Glycosuria 


and the circumstances which modify its course. 
Several organs in addition to the pancreas, he said, 
were involved in impairment of carbohydrate 
‘metabolism; hyperglycemia might be caused by 
over-activity of the adrenal glands brought about 
by anxiety, or hypertrophy associated with basophil 
tumour of the anterior pituitary. Dogs could 
survive removal of the pancreas if the nerves of the 
adrenal glands were cut or the pituitary gland 
removed. 
activate it; an appreciable quantity of insulin 
might be found in the pancreas of a patient dead 
-from diabetes. If the blood of one animal, A, were 
led to the brain of another animal, B, and the blood 
from the pancreas of B conducted to a depancreatised 
animal, C, B’s head being connected to its body 
only by the vagus nerve, it had been shown that 
when sugar was added to the blood of A the blood 
from B to C contained insulin. The complementary 
experiment showed that injection of insulin into A 
caused a rise of sugar in the depancreatised C. Some 
stimulus therefore passed down the vagi to the 
pancreas. The brain centre which could stimulate 
‘the production of insulin could also perhaps inhibit it. 
Section of the splanchnic nerves seemed to make the 
body more sensitive to insulin. Sodium chloride 
might to some: extent replace cortical extract in 
Addison’s disease and insulin in diabetes mellitus. 
Occasionally a case of basophilism lost glycosuria 
.after deep irradiation of the pituitary gland. The 
posterior lobe of the pituitary also elaborated a 


production of insulin. 


Insulin seemed to need something to 


‘pancreas ultimately ended in diabetes. 


í 
substance which neutralised insulin. Trauma as 
well as tumours might lead to hyperglycæmia. The 
thyroid encouraged glycogenolysis, and therefore 
hyperglycæmia, as long as there was glycogen in 
the liver. | 

The question arose whether insulin was essential 
to the metabolism of carbohydrate. There might, 
weight for weight, be more insulin in the kidney than 
in the pancreas of a healthy animal. The experi- 
ments reviewed, said Dr. Leyton, suggested that 
insulin was not essential, or that other cels than 
those in the pancreas could make insulin.. Pancreatic 
cells were very sensitive to toxins, including those 
of the common cold, and to over-stimulation. The 
essential treatment of diabetes, it was now recognised, 
was to rest the pancreas and give it a chance of 
rejuvenating. Amelioration was most probable if 
the sugar content of the patient was kept low. Little 
success had been obtained from pancreatropic 
hormone, but cure had been ascribed to pancrealytic 
serum. A very small number of cases were benefited 
by irradiation of the pituitary. Partial thyroidectomy 
and section of the splanchnic nerves might reduce the 
number of doses of insulin, but did not modify the 
course of the disease. The number of injections 
required could be reduced by giving a suspension of 
insulin in castor oil, or protamine insulinate.. Both 
preparations had a delayed effect. They would, 
however, only act in certain cases. Reduction in 
dosage of insulin might also be possible with a glucose 
diet. 
| THE CONTRIBUTION OF THE ‘“‘ SOIL”? 

Dr. J. GRAHAM WILLMORE stressed the: necessity 
for some constitutional fault in the individual to 
sensitise the soil for the seed. As observed among 
war pensioners, the ‘‘causes’’ of diabetes seemed 
to be: mental stress, resulting in chronic progressive 
endocrine imbalance; retained bits of metal or 
dead bone in old gunshot wounds with recurrent 
flares; unbalanced diet, especially excess of fat ; 
arterial degeneration with good living; and hzmo- 
chromatosis. In some cases stimulation of the 
adrenals through the sympathetic nervous system 
and thyroid caused excessive glycogenolysis, with 
which the pancreas strove to deal. by increased 
Chronic overwork caused 
eventual breakdown. The diabetic pensioners all 
had good war records of constant ‘front line’’ work. 


Gunshot wounds around the pituitary caused endo- 


crine imbalance, but these patients responded to 
insulin as well as others did, provided there was no 


‘intercurrent sepsis to neutralise the effects of insulin. 


Possibly the pituitary secreted a hormone which 
acted as a brake on the pancreas; this might be 
absent in obese young people, and overwork of the 
The patients 
whose old wounds flared up now and again for no 
obvious reason had a different bacteriology every 
time. Not infrequently the flare-up was followed by 
heavy glycosuria and ketonuria requiring temporary 
or permanent administration of insulin. The blood- 
sugar must be kept low, under frequent control © 
investigations, and to do this all sepsis must be 
eradicated. The sugar was more easily controlled 
if the patient received the first dose of insulin- on 
awaking from sleep, instead of after a little activity. 
In the diabetic the liver did not seem to know when 
to stop in producing the glycogenolysis needed for 


the transition from sleep to waking. 


DIFFERENTIAL DIAGNOSIS AND PROGNOSIS 


Dr. H. P. Hiusworti observed that ‘“‘ progressive 
hyperglycemia ”? had never been observed clinically 


432 THE LANCET] 


REVIEWS AND NOTICES OF BOOKS 


(FEB. 22, 1936 


or experimentally; he presumed that it meant 
hyperglycemia progressing beyond normal limits. 
If there were several conditions producing ‘‘ diabetes ”’ 
there must be varying prognosis and treatment. 
It was already possible to distinguish certain clinical 
types of hyperglycemia which were not diabetes 
mellitus. It was impossible at the acute stage to 
distinguish between cellulitis causing glycosuria 
and mild diabetes complicated by cellulitis. Many 
cases of hyperthyroidism had difficulty in dealing 
with sugar. If a patient was mistakenly given a 
diabetic diet and insulin, not being really diabetic, 
his blood-sugar might show a suspiciously “diabetic ” 
curve. On an ordinary diet he would show normal 
curves. It was unsafe to assume that a person 
took a normal amount of carbohydrate by choice ; 
healthy people rarely took above 300 g. of carbo- 
hydrate a day and many people only took 100 g. 
An increase of carbohydrate often abolished post- 
prandial glycosuria. Such cases of mistaken diagnosis 
accounted for reports of the cure of diabetes. If 
they were given insulin the sugar-tolerance curve 
was made very much worse. The curve was high 
in most cases of spontaneous hypoglycemia. A person 
who tolerated large doses of insulin was not necessarily 
a diabetic. 
Dr. T. C. Hunt mentioned the prognosis of hyper- 


glycemic glycosuria as seen in a number of untreated . 


and treated adult cases. Of the untreated, about a 
third got better and only a half got worse. Of treated 
cases about 30 per cent. got worse. The factors 
affecting prognosis might be found in causation or 
course. Of the improved cases only a few were 
overweight or neuropathic, and nearly 70 per cent. 
were over 50 years of age. Of those who did not 
improve, a third were overweight, a half were 
neuropathic, and the majority were under 50. If the 
glycosuria were noticed in the course of an infection 


the outlook was usually good; if it were noticed 
during mental shock, the patient seemed not to do 
so well. An onset associated with dyspepsia was 
found in some cases ; biliary drainage in two of these 
had revealed an associated external pancreatic 
disorder, but, on the whole, stimulation of the external 
secretion did not affect the internal secretion. 


DISCUSSION 


Dr. RonaLpD JONES described experiments he had 
done on pituitary hyperplasia in hyperglycemia, 
which he did not regard as significant. Injection of 
extracts produced no change in the blood-sugar of 
dogs or patients. There seemed in fact to be no 
such thing as a pancreatropic hormone. 

Dr. E. P. POULTON asked for details of the patients 
subjected to deep pituitary irradiation, and observed 
that Joslin had examined severely shocked men 
coming back from the front line and had never found 
glycosuria. Perhaps people reduced their carbo- 
hydrate because there was a pernicious doctrine 
going about that carbohydrates were no good. 

Dr. LEYTON recalled a fat patient who used to 
develop hypoglycemia when normal saline was 
injected. Some people had very poor power of 
storing carbohydrate throughout their lives, and the 
title had been chosen to exclude these stationary 
hyperglycemias. The sugar-tolerance test had been 
abandoned by him as a diagnostic measure, except 
for purposes of exclusion. X ray therapy had only 
been used in cases of basophilism. 

, Dr. WILLMORE observed that his pensioners had 
all been normal before the war and had developed 
diabetes during or soon after it. 

Dr. HimswortTuH said that all over the world since 
1900 there had been a progressive change in diet, 
in the direction of decrease of carbohydrate and 
increase of fat. 3 


REVIEWS AND NOTICES OF BOOKS 


Treatment of Acute Poisoning 


Br H. L. Marriott, M.D., M.R.C.P. Lond., 
Resident Medical Officer, Middlesex Hospital; 
Assistant Physician, Miller General Hospital, 
Greenwich. London: Published for the Middlesex 
Hospital Press by John Murray. 1935. Pp. 45. 5s. 


THE idea of treating a case of acute poisoning 
conjures up for most of us nightmares of stomach- 
pumps, of long lists of poisons and their antidotes, 
of home-made emetics and antidotes, and of the 
indications and contra-indications of gastric lavage. 
It is curious that such anachronisms as are embodied 
in the standard accounts of this important branch of 
medicine have apparently satisfied the inquirer 
for many decades, especially when it is realised that 
for long carbon monoxide has held pride of place among 
the causes of accidental or suicidal poisoning, at any 
rate in this country and in America. 

Dr. Marriott in this monograph strikes at the roots 
of the worn-out doctrines repeated from text-book 
to text-book and builds a new and rational concept 
based on the treatment of several hundred patients 
at the Middlesex Hospital. He has assumed reason- 
ably enough that even if the identity of the poison 
is known, the antidote is either not remembered or 
is not at hand. The principles underlying the 


successful treatment of acute poisoning are found in 
the three questions which the medical attendant should 
put to himself in every case: Is the patient 
asphyxiated or suffering from poisoning by a gas? 
If the poison was not gaseous, how did it enter the 
body? Is life endangered by coma, dehydration 
or dechloridation, pain, or delirium, and convulsions ? 
It is a measure of the success of Dr. Marriott's 
elucidation of these matters that the substance of his 
principles could be condensed into small compass, 
for of all branches of medicine, this is one in which the 
physician is called to deal with a desperate emergency 
with little time to think and even less to look up 
references. But here is not merely a reconstruction 
of indications; there is supplied, with chapter and 
verse, the exact technique of the various procedures 
to be used by the physician. Furthermore, the 
author has devised a new method of gastric lavage 
which if adopted as a routine should save many a 
patient recovered from his poison from death through 
broncho-pneumonia. Medicine is already indebted 
to Dr. Marriott and his collaborator, Dr. A. Kekwick, 
for the method of blood transfusion by the drip 
method which he published in our columns last year 
(THE LANCET, 1935, i., 977) and which has rapidly 
gained general recognition as the method of choice in 
suitable cases. We now have to thank him for a 
work which reduces to order and reason a section 
of medicine hitherto disorderly and irrational. 
This manual is a landmark in the literature of 
the therapeutics of poisoning. 


THE LANCET] 


Diseases of the Chest 


By J. ARTHUR MYERS, M.D., Professor of Medicine, 
Preventive Medicine, and Public Health, Minnesota 
Medical School. New York: National Medical 
Book Co. Inc. London: H. K. Lewis and Co. 
Ltd. 1935. Pp.385. 13s. 6d. 


A GENERATION ago tuberculous infection was 
considered to be almost universal by the time adult 
years were reached, and a positive tuberculin reaction 
was only considered important in quite young children- 
Prof. Myers takes up an entirely different position. 
He argues that as the dangerous reinfection type 
of tuberculosis can only occur after the tissues have 
been altered by the primary infection, all positive 
Teactors should be kept under careful observation. 
In such cases an X ray film of the chest should be 
made at least every year and preferably every six 
months on persons after the age of 10 years. Heim- 
beck’s observation that amongst young nurses it is 
mainly those who have escaped a childhood infection 
who became ill with pulmonary tuberculosis does 
not fit in with Prof. Myers’s theory, and it is a pity 
that this work is not even referred to. Until more 
definite evidence is brought forward to show that 
tuberculous disease is less prone to affect those who 
escape childhood infections, the expenditure of the 
very large sums of money, which would be required 


to keep some millions of healthy positive reactors. 


under medical supervision, does not seem justifiable. 
The remainder of the first section of the book deals 
with the physical signs and symptoms and treatment 
of pulmonary tuberculosis; the advantages of 
early treatment by artificial pneumothorax are 
stressed and the indications for the various procedures 
of thoracic surgery are clearly given. 

Non-tuberculous diseases of the chest are the 
subject of the second part of the book. Both serum 
treatment and artificial pneumothorax receive favour- 
able mention in the treatment of lobar pneumonia ; 
in the latter procedure not more than 200 to 300 c.cm. 
of air should be introduced at a time; two or 
more refills may be necessary at intervals of 12 to 
24 hours. i 

In the discussion of the treatment of bronchiectasis, 
empyema, and pulmonary abscess, conservative 
measures are first described, but the indications for 
surgical intervention are also given and a brief account 
of the methods used. Diseases due to mould-like 
bacteria, true moulds, and yeast-like fungi are dealt 
with in a short but adequate chapter illustrated by 
several skiagrams of these rare diseases. The conclud- 
ing chapter on diseases due to inhalation of dust 
brings into association such ill-assorted conditions 
as hay-fever and silicosis. The book is well illustrated 
and has a full index as well as a bibliography, mainly 
American, at the end of each chapter. 


4 


Painful and Dangerous Diseases of the Ear 


By R. R. Woops, M.B., F.R.C.S.I., Surgeon in 
Charge of the Ear, Nose, and Throat Department, 
Sir Patrick Dun’s Hospital, Dublin. London: 
Humphrey Milford, Oxford University Press. 
1936. Pp. 188. 15s. 


A DIFFICULTY which confronts the specialist in a 
teaching hospital is to decide how best to impart a 
useful knowledge of his subject to the future prac- 


d 
; 


REVIEWS AND NOTICES OF BOOKS 


t 


[FEB, 22, 1936 433 


titioner. If he attempts to cover the whole of the 
specialty in the limited time available, the instruction 
is likely to be superficial and allows far little dis- 
crimination between matters of clinical importance 
and those with which the general practitioner is rarely 
concerned. 

Mr. Woods has written this book to fill the gap 
between the larger manuals of otology, which contain 
much material of interest only to the specialist, and 
the student’s handbooks, which tend to treat essential 
subjects with insufficient detail. He has fulfilled his 
intention most admirably, and has produced a lucid 
account of the common forms of suppurative disease 
of the ear, for his plan amounts essentially to a 
description of these affections. We could have wished, 
however, that more consideration had been given to 
the important point of when to operate in acute 
mastoiditis. Mr. Woods does say that ‘‘it is inadvis- 
able to operate on a case of mastoidism, for the course 
of the disease after operation may be stormy,” but 
he fails to emphasise the fact that operation for acute 
mastoiditis is rarely necessary in the first week or 
ten days from the beginning of the otitis, that a 
proportion of these cases recover without operation, 
and that the course after over-early operation is 
likely to be tempestuous. We have seldom read a 
clearer exposition of the intracranial complications of 
aural disease, while the short final chapter on the 
cerebro-spinal fluid is most valuable. It is wise to 
have made no attempt to describe details of the 
major operations, but an account of their after- 
treatment would have been helpful. There are some 
good illustrations in the text, and 24 coloured 
pictures showing the otoscopic appearances of various 
conditions of the drum. 

We recommend this book to the practitioner 
who wishes to gain a sound knowledge of the more 
important forms of aural disease that he is likely to 
encounter. 


1935 Year Book of the Eye, Ear, Nose, and 
Throat 


By E. V. Z. Brown, M.D., Professor of Ophthal- 
mology, and Lovis Botruman, M.D., Assistant 
Professor, University of Chicago; GEORGE E. SHAN- 
BAUGH, M.D., Clinical Professor Emeritus ; ELMER 
W. Hacens, M.D., Assistant Clinical Professor ; 
and GEORGE E. SHAMBAUGH, Jr., M.D., Clinical 

` Instructor of Otolaryngology, Rush Medical College 
of the University of Chicago. Chicago: The Year 
Book Publishers; London: H. K. Lewis and Co., 
Ltd. Pp. 638. 10s. 6d. 


THIS issue of the Year Book, which consists as 
usual of abstracts from the current literature, discloses 
this year no notable advances or striking new methods 
but gives evidence of great activity in the exploration 
of the fields covered by these specialties, and par- 
ticularly of research into the intricate physiology of 
both the hearing and balancing functions of the 
labyrinth. The abstracts are well chosen and well 
written and, as in former years, shrewd editorial 
comments on the more important of these add to 
their value. The editors plainly show their dislike 
of early operation in acute mastoiditis. They quote 
statistics from an article in an English journal of 


-91 cases, in 73 of which the duration of the otitis 


media varied from two to eight days; of these cases 
five died from meningitis, one developed suppurative 
parophthalmia, and the average time of complete 
healing with a dry ear was ten weeks; and they very 


434 THE LANCET]. 


REVIEWS AND NOTICES OF BOOKS 


[FEB. 22, 1936: 


properly point out that these figures would be very 
much improved if operation were delayed, when the 
duration to complete healing is normally about three 
weeks. This is a convincing argument against early 
operation in acute otitis, but we believe that the 
editors are not correct in thinking that early operation 
is practised frequently in England. A number of 
_articles dealing with malignant disease of the throat 
and its treatment by surgery, diathermy, and radia- 
tion are summarised, and are a useful guide to the 
present position of the treatment of these conditions. 
Indeed, the Year Book, with its very full index, is a 
most valuable book of reference to the newest work. 


1. Commoner Diseases of the Skin 
By S. Witrram BECKER, M.S., M.D., Associate 
Professor of Dermatology in the University of 
Chicago. New York: National Medical Book 
Co. Inc:; London: H. K. Lewis and Co., Ltd. 
1935. Pp. 283. 13s. 6d, 

2. Common Skin Diseases 
Third edition. By A. C. RoxpurGuH, M.D., F.R.C.P., 
Physician in charge of the Skin Department, and 


Lecturer on Diseases of the Skin, St. Bartholomew’s - 


Hospital, London: H. K. Lewis. 1935. Pp.377. 15s. 


1. THE claim advanced by the author that ‘ inten- 
sive study of functional diseases in all fields of medi- 
cine has tended to clarify and simplify the study of 
dermatology,” does not solve or appreciably lighten 
the many problems of the therapist, although it 
opens up new avenues for research. 

This is not a book for beginners. A knowledge of 
histology is presumed, for no microscopic appear- 
ances, even of the fungi, are portrayed. A discursive 
style is adopted throughout, headings and sub- 
headings are avoided, and the aim appears to be to 
interest rather than instruct. The subject matter 
is considered in 26 chapters. The first is given to 
the care of the skin and scalp, in which the author 
stresses the differences of response of the ichthyotic 
and the seborrheic person. The second chapter 
discusses the complexities of the eczema-dermatitis 
group, under the general heading, Toxic Dermatoses 
of Epidermal Origin, and succeeds in presenting 
a fairly comprehensible picture of this still somewhat 
obscure reaction. Infantile eczema is included in 
this section, and the paragraphs on differential 
diagnosis, prognosis, and treatment are models of 
brevity and succinctness. ‘‘Stasic’’ (? static) ulcers 
of the leg afford the author an excellent opportunity 
of proving his originality. ‘‘ Most of our patients 
with leg ulcers do not have varicose veins, and most 
of those being treated for varicose veins do not 
have leg ulcers.” Aphorism or epigram—the state- 
ment will be substantiated by all who have had 
much experience in the O.P. clinic, and are not the 
slaves of text-book assertion. Chapter V., which is 
constantly referred to in the rest of the text, is 
essentially a monograph on the neurodermatoses, 
which evidently have been especially studied by the 
author. A diagrammatic representation ‘of his con- 
clusions (facing p. 64) will provide the reader with 
much food for thought, and a commonsense plan 
on which to base his treatment of an increasingly 
frequent epidermal syndrome. The following two 
chapters extend this field of functional skin disease 
to a degree which to ‘those graduating from the 


schools of Hebra or Unna may appear somewhat . 


dangerous, Pruritus ani, and pediculosis vulva, 
pediculosis capitis, dyshidrosis (surely a retrograde 
step 7), and “neurotic °’ excoriations are all included 
and given pride of place in this group. Beginners 


who come across this work should beware of adopting 
too literally opinions, which to the seasoned observer 
seem more conjectural than convincing. Succeeding 
chapters on the papulo-squamous eruptions, physical 
(e.g., light produced) dermatoses, vascular, pyogenic, 
mycotic, and parasitic diseases follow more orthodox 
lines. A chapter on the “skin in industry” and an 
appendix of simple formule conclude a volume 
which will prove of value to the more advanced 
student or teacher of an increasingly important 
branch of medicine. 

2. The practitioner will find in this book, which 
has achieved three editions in as many years, all the 
information he is likely to need on the practical side 
of dermatology, and more than he is likely to be 
able to apply in therapeutics. The illustrations are 
excellent, and have been increased in number. A 
new feature, and one that must have’ given the 
author much labour, is the duplication of all. pre- 
scriptions in metric as well as in apothecaries’ weights 
and measures. It is one which is certain to appeal 
to the continental reader, and maybe, render a 
translator’s task less difficult. The addition of a 
paragraph on gold dermatitis, now supplied, was 
badly needed, for it is probably one of. the most 
frequent if not the most troublesome of all drug 
eruptions at the present time. As an introduction 
to the study of dermatology there is no better manual 
in the English language. 


.Prescription Writing and Formulary 


The Art of Prescribing. By CHARLES SOLOMON, 
M.D., Assistant Clinical Professor of Medicine, 
Long Island College of Medicine. London: J. B. 
Lippincott Company. 1935. Pp. 351. 2ls. 


NEARLY every text-book of prescribing published | 
in the last thirty years has deplored the habit of 
using ready-made formule, particularly those dis- 
pensed in compressed form as tablet, pills, and so 
forth. It has been reiterated that if the physician 
is to be independent of the complex pseudo-mysteries 
of the drug factory, he must be able to write a pre- 
scription, with the implication that the education 
of the medical student is defective, in so far as it 
relates to prescription writing. Dr. Solomon evi- ` 
dently subscribes to this opinion, and has prepared 
this volume with a view to providing a sound scientific 
basis for prescription writing. The work is indeed 
wonderfully complete. The introductory chapter 
includes a brief account of the history of the pre- 
scription, a discussion of a number of important 
practical considerations, and a useful review of methods 
of administration. The second part contains every- 
thing anyone need know about prescription writing, 
including dosage and incompatibility.. The rest of 
the book consists of a formulary which contains a 
very large number of prescriptions of the more 
commonly used drugs. These are arranged systema- 
tically according to the therapeutic effect expected 
of the drugs, and are printed both in Latin and in 
English.. The author is careful to point out that 
they are not intended to be set or standard pre- 
scriptions, but rather to illustrate the simplicity of 
rational prescribing. At the same time, the young 
practitioner will find in them a comprehensive source 
of information. To add to the usefulness of the 
formulary, an index of prescriptions. according to 
symptoms and diseases has been included, as well 
as a general index. The book as a whole perhaps 
contains too much information for the needs of the 
medical student, but should prove a handy work 
of reference for the practitioner. 


4 


THE LANCET] 


THE LANCET 


LONDON : SATURDAY, FEBRUARY 22, 1936 


THE CENTLE SURGEON 


Our readers will be grateful to Mr. Faaaz, 
Hunterian orator this year, for his scholarly picture 
of one of the great figures of Victorian surgery. 
JOHN HILTON was a truly great man, but, lacking 
perhaps the spectacular personality of many of 
his contemporaries, he has never received that 
recognition which his merits demand or his influence 
on surgical thought and practice would justify. 
His name is known to every student in Hilton’s 
method of opening an abscess; his lectures on 
Rest and Pain are familiar in name to the majority, 
and in substance to the more industrious. But 
his contribution is more than a technical device and 
a series of clinical observations, many of which 
have been disproved by later knowledge. The 
quotation which heads the oration gives a clue 


to the spirit that animates all HiLTon’s writings, 


a spirit that shows him to have been a scientific 
and thoughtful surgeon, perhaps the first of a type, 
which, it is to be hoped, characterises the best 
of surgery to-day. To say that he was the first 
implies no disparagement of JOHN -~ HUNTER. 
HUNTER was an intellectual giant ; he moved and 
thought on a higher plane than other men, and the 
standards by which we judge them seem to fit 
him not at all. But his great and restless spirit 
was engaged upon the problems of disease in general, 
while Hrox’s gentle and practical mind studied 
the more intimate problems of Nature’s own 
surgery as exemplified in the patients who came 
under his care. HILTON was no mean anatomist, 
as his numerous dissections, immortalised in wax 
` by the art of JoserpH Towne, bear witness to-day. 
But he was very much more. His interest in the 
body was not confined to the study of its dead 
framework, and to the discussion of theories as 
` to how structures ought to work which had ceased 
to do so; he watched these same structures in 
life, striving to learn for himself how they carried 
out their duties in health, and how they attempted 
to repair their injuries. He was the first physio- 
logical surgeon, set apart from his fellows by his 
faith rather than his works. They study attack, 
he defence; they consider what can be done to 
an organ, the limits of its endurance, the best 
approach to it, the instruments and methods of 
anesthesia suited to the enterprise they contem- 
plate ; he considers how it works in health, how 
its working has been modified or vitiated by 
disease or injury, how it is attempting to repair 
or circumvent the damage it has suffered, how best 
he himself can aid these efforts, or how imitate 
the normal function if repair is impossible. His 
handling is characterised by a regard for the 
tissues as purposeful, almost sentient agents of 
repair. Above all things he is gentle. 


THE GENTLE SURGEON 


- healed him.” 


\ 


[FEB. 22, 1936 435 


Many, especially those who have passed through 
the wards within the last five years, will consider 
that gentle handling is the aim of every surgeon. 
That this spirit should be abroad to-day is the 
greatest monument to Hui~tTon’s influence, for 
it has not always been so. Surgical history 
indeed contains the names of others who thought 
as Hi~tron, of men who have spoken as did 
AMBROSE Park: “I dressed his wound; God 
But most of the older surgeons were 
men of action rather than of thought, as they had 
to be before anzsthesia or antiseptics were known. 
The tales that come down to us are of uncouth 
choleric men, of retorts whose discourtesy has made 
them classic, of bold and skilful but brutal manipula- 
tions, of blood and agony, of boastful self-assertion, 
of fierce quarrels, of chicanery and nepotism. It 
might have been expected that gentleness would 
come when anesthesia had abolished the need 
for speed ; but the same agent made more extensive 
operations possible, so that the need for speed 
remained. With the coming of asepsis, a whole 
new field of operative work, as yet unexplored, 
was thrown open. Bold and untried adventures, 
such as the early exploration of the abdomen, 
could only be carried through successfully, at 
a time when anesthesia was still understood 
imperfectly and shock not at all, by surgeons who 
worked at lightning speed. We therefore find 
that during the first few years of this century the 
ultra-rapid operator was undisputed king of surgery, 
or at any rate of surgical practice. Slashing 
his way through tissues in a manner that would 
horrify the student of to-day, he was able to 
show that the operations which have since 
been perfected were possible. His patients survived, 
his ventral herniæ were closed by others; and 
his methods have since been changed beyond 
recognition. 

It is perhaps unduly optimistic to say that 
rough surgery is extinct to-day. Human nature, 
and especially adolescent human nature as 
exemplified by the medical student, will always 
prefer the spectacular to the artistic, and the 
gentle surgeon is often a gentle man. He may 
find to his- chagrin that the best students flock 
where the blood flows most freely, where the 
shouts are the loudest, where instruments are 
thrown about the theatre, where “look and see,” 
the infallible solvent of diagnostic difficulties, 
ensures an abundant succession of tours de force. 
Yet he has his reward when the same men, older 
and wiser, come to him as house surgeons and 
registrars to learn those details of tissue kindness 
which are unseen from the gallery. For this 
Hiltonian surgery is taught and propagated by 
apprenticeship. Men speak of Halsted technique, 
Lane technique, Moynihan technique, each meaning 
the same thing, the standard of work of a great 
master at whose side he has studied, a standard 
whose only criterion is that the tissues shall be 
treated with the greatest gentleness, subjected to 
the least damage, replaced carefully, apposed 
accurately—in short, that they shall bear the least 
trace of the surgeon’s passage. Such methods 
gain adherence by their results rather than their 


the disappearance of the old operating “ theatre,” 
suited for the dramatic in surgery, and its replace- 
ment by what is almost an operating temple, where 
the faithful can study essential detail. Their 
performance is made possible by better anzsthesia 
and more highly skilled assistance, which have 
eliminated the need for hurried work, so that only 
its quality need be considered. Their perpetuity 
is assured by a new school of young men, trained 
in the use of their hands at a time when they can 
acquire the touch of an artist. 

The change, like all important changes, has been 
gradual, but on a ten-year period it is obvious 
enough. During the last decade operating by the 
clock has become a bad joke, traumatic muscle 
cutting and nerve damaging incisions in the 
abdominal wall have disappeared, hemostasis 
has become universal, strong antiseptics, purga- 
tion and starvation, have been abolished from 
the surgical ward. If we made the interval 
of survey 20 years instead of 10, we might have 
to admit that the surgical registrar of to-day is 
a better operator than the leading surgeon of 1915. 
There is still room for improvement, particularly 
in the technique of those operations which are not 
considered to be major surgery. Hemorrhoids 
are still torn rather than dissected out; the 
average operation for hernia is still coarse, 
traumatic, and unphysiological; and even the 
gentle surgeon is often content to apply his 
principles to the deeper layers only, forgetting the 
physiology of the skin and subcutaneous tissues. 
Yet the day is clearly not far distant when all 
operations will be done with the unhurried 
exactness of the surgeon-neurologist, when all 
scars will be the invisible line of the plastic surgeon. 
For the beautiful scar is more than a work of art. 
Wherever placed it is proof of healing, not merely 
without sepsis but without any recognisable 
reaction of repair; it is a guarantee of lasting 
comfort for the patient and of untainted soil for 
the man who may have to come afterwards. It 
is the signature of the gentle surgeon. 


SHORT-WAVE THERAPY 


Since J. W. ScHERESCHEWSKY published his 
first papers on short (wireless) wave therapy in 
1926 the subject has become one of clinical and 
scientific interest, owing to the many reported 
discoveries and the claims for effective treatment 
which have been made by research workers and 
clinicians. While the application of the new 
therapy requires technique as exacting as that of 
X ray treatment, it is desirable for all of us to be 
aware of the principles on which it is based. 
Short-wave therapy has come to mean treatment 
with electromagnetic oscillations of very high 
frequency, corresponding to a wave-length of 
2 to 20 metres. The energy is produced by an 
electronic tube generator or a spark-gap apparatus, 
the principle in each case being similar to that of 
the wireless transmitter, with the fundamental 
difference that the energy so produced is not 
radiated by an antenna but is utilised in the body 


SHORT-WAVE THERAPY 


ee E S E 


[FEB. 22, 1936 


of the patient in the following way. The character- 
istic feature of a so-called resonance-circuit, 
consisting of self-inductance coil and condenser, 
is the fact that when the self-inductance and the 
capacity bear a certain simple relation to the wave- 
length the most part of the produced energy is 
absorbed. It is always possible to satisfy this 
numerical condition and thereby to bring the 
resonance-circuit into tune with the generator 
by suitably adjusting either the coil or the capacity. 
In short-wave therapy the part to be treated is 
brought into the condenser field, thereby becoming 
part of the dielectric and also part of the tuned 
resonance-circuit. The metal electrodes or con- 
denser plates make no direct contact with the 
skin, being separated from it by glass or some other 
insulating material, and whereas in other electrical 
methods of treatment the electric energy may be 
regarded as flowing through the body, in short- 
wave therapy it appears to act directly on each 
element of the tissue between the plates. The 
amount of energy absorbed in this manner at a 
given point depends on a number of more or less 
independent factors, such as uniformity of field, 
dielectric constant, high-frequency conductivity, 
colloidal structure, potential gradient, but to the 
best of our present knowledge it is practically all 
converted into heat. Theoretically the choice 
of wave-length is a critical factor, but experts are 
not in agreement how this effect of wave-length 
is to be utilised in treatment.. Substances with 
different physical constants, placed in the condenser 
field under the same conditions, are heated to 
different degrees ; for each substance there is a 
definite wave-length with which, for a given field 
strength, the heat produced is maximal. If a 
mixture of different substances is brought into a 
condenser field, one or other of them can be heated 
differentially, provided the proper wave-length 
is selected, whatever its position in the field in 
relation to the other substances. 

Now the human body consists of a number of 
tissues with different physical constants—fat, 
muscle, bone, blood, and so on, and if the facts 
just mentioned are accepted it should be possible 
to heat one tissue differentially whatever its 
position in the body. This has been done in 
treatment of the kidneys within the intact body— 
it was found possible to coagulate kidney-tissue 
without burning the skin—showing how potent a 
weapon has been put in our hands with which to 
influence deep-seated processes. Indeed, the 
importance of the new.therapy lies in the possibility 
which it provides of introducing large quantities 
of thermal energy into the interior of the body 
without unduly heating the skin and the superficial 
fat. Much research too has been done on the 
influence of short waves on animals, bacteria, 
colloids, and: other biological substances. One 
of the chief problems was to find out whether 
the effects produced were due exclusively to the 
production of heat, or whether there might be a 
“specific ”’ effect which cannot be attributed to 
heat. Opinion is fairly divided on the point, 
but it seems that the behaviour of bacteria and 
certain chemical efiects can only with. great 


THE LANCET] 


difficulty be explained without presuming some 
form of specificity. | 

Important as these problems are, the practitioner 
is more anxious to be told what kind of disease 


can be successfully treated by short-wave therapy . 


and what advantages, if any, the treatment may 
have over other methods of applying heat. It 
may, we think, be taken for granted that the 
possibility of direct heat formation in any déep- 
seated organ must. have important consequences. 
The range of indications is widened by the inclusion 
of organs which could not be reached by diathermic 
treatment ; chronic inflammation in bones, joints, 
tendons, sinuses, and internal organs, including 
the lung, is known to have responded favourably 


to short-wave therapy, -and sometimes’ where: 


every other treatment had failed. Striking results 
are claimed for sciatica and neuritis, and some 
diseases of the arteries, and whereas diathermic 
currents cannot be applied with impunity to 
acute inflammatory processes, short-wave therapy 
scored its first successes in the treatment of boils, 
carbuncles, and cellulitis. Those who -wish to 
pursue the subject further will find excellent and 
detailed information in several books recently 
reviewed in our columns.! 


SEX AND CULTURE 


THE word ‘sublimation,’ borrowed from 
chemistry, has been adopted by psychologists to 
describe the process by which the energies of 
sexual impulses which are denied direct outlet 
can be applied to non-sexual or social ends. In 
the years immediately following the war, when 
the writings of FREUD were being actively debated 
in this country, the conception of sublimation did 
something to mitigate the harshness of, psycho- 
analytic theory, and it was much stressed by 
those who desired to reconcile the lessons of 
medical psychology with the religious and moral 
aspirations of civilised man. But few attempts 
were made to bring the idea of sublimation as 
understood by psychologists into relation with 
the new science of social anthropology. A note- 
worthy contribution to this aspect of the subject 
was made by Mr. J. D. Unwn, Ph.D., in a long 
and painstaking treatise? embodying ideas which, 
previously summarised, had already evoked critical 
and appreciative discussion. The suggestion, he 
tells us in a preface, had been put forward by 
analytical psychologists that, if social regulations 
forbid direct satisfaction of the sexual impulses, 
the emotional conflict thus generated is expressed 
in another way, and that what we call civilisation 
has been built up by compulsory sacrifices in the 
gratification of innate desires. His monograph is 
the result of an attempt to test this hypothesis 
by reference to cultural data. 

The task is one of quite unusual difficulty and 
complexity. The first and perhaps the most 
formidable difficulty which confronted the author 
xvas to devise satisfactory criteria of what respec- 
tively constitutes cultural progress and sexual 


= 1 See THE LANCET, Nov. 16th, 1935. pp. 1125-26. 
2 Sex and Culture. London: Humphrey Milford, Oxford 


“LCL niversity Press. Pp. 676. 36s. 


SEX AND CULTURE 


[FEB. 22, 1936 437 


opportunity. The available evidence fell under 

two main headings—historical and anthropological. 
The historical evidence was found to be too 
unwieldy, partly because of its bulk and partly 
because of the cultural stratification which exists 
in all civilised societies and makes it impossible 
to generalise about the cultural stage reached by 
any civilised society taken as a whole. Dr. UNWIN 
therefore confined himself to anthropological data. 
When we talk about the cultural stage reached 
by an uncivilised society, what do we mean ? 
The following restricted definition is presented : 
“We can sum up the matter,” he writes, “by 
saying that to the members of every uncivilised 
society a certain power . . . manifests itself ... in 
the universe, and that steps are taken to maintain 
a right relation with it.... The evidence is ‘that 
different societies conceive of these powers in 
different ways and adopt different methods in 
their efforts to preserve a right relation with 
them. The manner in which the powers are 
conceived, and the steps which are taken to maintain 
this relation, constitute the cultural condition of a 
society in the sense in which the phraze is used 
throughout this thesis” (our italics). Uncivilised 
societies are then divided into three groups— 
described as deistic, manistic, and zoistic— 
depending on whether they build temples—which 
are carefully defined (deistic), whether they pay 
post-funeral attention to their dead without 
building temples to them (manistic), and whether 
they do neither. Much careful thought and 
writing is devoted to describing and differentiating 
these three cultural conditions. But a definition 
of what is meant by sexual opportunity is no less 
necessary to the argument. Dr. UNwin found it 
necessary here to limit his discussion to the 
prenuptial opportunity afforded to females ; 
evidence of an objective, or, as Dr. UNWIN prefers 
to call it, a behaviouristic character, is only 
available here, and he points out that the limita- 
tion is not as arbitrary as might at first appear, 
because the sexual opportunity afforded to males 
in a given society is a reflection and corollary of 
that afforded to females. First, young women 
(and therefore young men) may be sexually free, 
being checked in no way from any sexual activity 
or play ; secondly, prenuptial intercourse may be 
limited, for a young woman, to a certain man 
(the restriction imposing correlative restrictions 
on the males in her community); lastly, the girl 
may be compelled to maintain her virginity until 
she is married, it being required that tokens of 
virginity be required on the nuptial mat. In 
assessing these groupings, the existence of certain 
specific exogamic relations and prohibited degrees 
are always taken into account and no notice is 
taken of the compulsory continence inflicted by 
these. The remarkable conclusion emerges that 
the correlation between the cultura] stage attained 
by a given society and the degree of prenuptial 
restraint imposed upon its females is complete. 
Throughout the 80 societies of which the required 
information was available it was found that each 
of the three types of sexual opportunity was 
invariably accompanied by one of the three types 


~ 


438 THE LANCET] 


of cultural behaviour. Societies which permitted 
prenuptial freedom were in the zoistic condition ; 
those which inflicted an irregular or occasional 
continence were in the manistic condition, and 
those which insisted on complete prenuptial con- 
tinence were in the deistic condition. In each 
society the converse obtained; the correlation 
found indeed was so complete as to astonish the 
author, who, in his preface, declares that if he had 
realised, when he embarked on his task, how 
greatly he would have to revise his social 
philosophy, he might have hesitated to begin it. 
At a recent meeting of the medical section of 
the British Psychologica] Society Dr. UNwimn’s 
conclusions * were keenly though sympathetically 
discussed. Their extraordinary importance, if true, 
for all departments of human aspiration and 
endeavour was acknowledged by Prof. J. C. FLUGEL, 
who described their implications as at once hopeful, 
startling, puzzling, and depressing. Hopeful because 
the work implied a new phase in coöperation 
between anthropology and clinical psychology. 
Startling because the definiteness of the results 
was without parallel within the domain of the 
purely human sciences. Puzzling because they 
went too far; for, if the correspondence between 
sexual limitation and cultural achievement was 
so complete, psychologists must all have been 
wrong about the existence of other factors. Depress- 
ing because of the unpleasing clarity with which 
the ethical alternatives of pleasure or progress 


3? Dr. Unwin’s address at this meeting has since been pub- 
lished as a brochure, ‘* Sexual Regulations and Cultural 
Behaviour ’”? (Humphrey Milford, pp. 62, 2s. 6d.), which is a 
ee of the evidence and conclusions contained in his 
reatise. 


THE WORD ‘f VENEREAL’’ 


[FEB. 22, 1936 


as the summum bonum were put before the human 
race. ‘“‘To puritans of all denominations,” he 
said, ‘‘as well as to the more fanatical enthusiasts 
for progress, Dr. Unwin’s views should be most 
welcome, since they seem to provide at once ample 
“scientific ’ justification of the demand for purity 
and abstinence together with a sure recipe for 
further cultural advance. These same views, how- 
ever, are likely to cause consternation in bohemia.” 
And at the same meeting Mr. R. E. Monry-KYRLE, 
Ph.D., questioned the validity of the causal relation 
which might be thought to subsist between com- 
pulsory sexual continence and social progress. They 
might both be collateral effects of some other cause. 

Dr. Unwin’s book is the product of ten years 
of industrious research. It marshals a wealth 
of carefully digested facts. It is written with 
a clearness and conciseness very rare in works 
of this length. The author is acutely conscious 
of how, in anthropology as well as in psychology, 
loose thought can be embodied in a loose usage 
of words. The precision with which he defines 
his terms and phrases, while making difficult. 
reading of some of the chapters, will provide 
intellectual pleasure to many critical readers. 
Some no doubt will extend the field of comparison 
to other manifestations of sex and to other aspects 
of culture. Some will analyse the same data to 
see whether they cannot be interpreted in other 
ways. Whatever may be the outcome Dr. UNWIN 
has shown himself a pioneer in a new and very 
interesting branch of statistical sociology, and his 
book may well exercise an important though 
unobtrusive influence upon social and moral 
thought in the next generation. 


ANNOTATIONS 


THE WORD ‘“VENEREAL” 


A CHANGE in the title of the American Journal of 
Syphilis and Neurology to the American Journal 
of Syphilis, Gonorrhea, and Venereal Diseases leads 
to discussion, in the January number, on the meaning 
of ‘‘venery”’ and ‘“‘venereal.’? Strictly speaking 
the terms refer to the worship of Venus, and so their 
connotation covers the art of love in wedlock as well 
as outside it. But the ‘‘ Oxford English Dictionary ”’ 
brands them with the stigma of lust in quotations 
as early as 1610; and there is no doubt that popular 
feeling for centuries has limited their meaning to 
illicit intercourse and the diseases that arise there- 
from. The six generally recognised as venereal are 
syphilis, gonorrhmwa, chancroid, lymphogranuloma 
inguinale, scabies, and pediculosis pubis; and it 
will at once be observed that most of them can be 
acquired without any suggestion of venery. It is 
therefore natural that well-meaning people should 
wish to drop a word which casts a slur on the good 
name of many innocent people. With this in mind 
attempts have been made from time to time to 
suppress altogether the word venereal as an “ offensive 
outworn relic of the Victorian age.’ Indeed it has 
been said that the association in the lay and medical 
mind between venereal disease and sexual guilt is 
so close that no great advance in control is likely 
to take place until the name has been changed. 

Now it is a common weakness of human nature 
to try to substitute a new or more respectable word 


for one that has lost its character. Sometimes the 
effort is successful, especially if it is a new word such 
as Fracastor’s ‘“‘syphilis’”? for Morbus Gallicus. 
Sometimes it is tolerated, as when we substitute 
hospital for infirmary or asylum. Sometimes it is 
just stupid, as when we say “‘ officer’ for policeman. 
A recent manifestation of this futility is the suggestion 
that venereal diseases should be called “social 
diseases.” If such an attempt were made all we 
should succeed in doing would be to degrade a comfort- 
able pleasant word like ‘social’? without making 
any difference to the public outlook on the conditions 
in question. For our part therefore we are not in 
favour of suppressing the word venereal, covering 
as it does a well-defined group of diseases, several of 
which can be acquired together. Instead we think 
that it will survive, because of its age and usefulness. 
One regret, however, may nevertheless be associated 
with this belief. Those of us who have strong 
feelings about the marriage of Greek and Latin might 
be tempted even to sacrifice venereal if we could 
thus guarantee to slay the barbarous hybrid 
“ venereologist.”’ 


DEATHS ATTRIBUTED TO ANAESTHESIA 


THE second Embley memorial lecture delivered 
at Melbourne in September last! gave Dr. Z. Mennell, 
its deliverer, an opportunity for expressing his views 
on several questions both of the physiology of anæs- 


1 Med. Jour, Australia, 1935, xxii. (2), 801. 


THE LANCET] 


thesia and of matters germane to the practice of 
anesthetics, such as coroners’ inquiries. After paying 
due attention to Embley’s well-known work in con- 
nexion with the cause of death from chloroform, the 
lecturer gave interesting and valuable examples of 
causes of death during anzsthesia which are probably 
often overlooked because they are not sought for 
with the microscope, by which means alone they can 
be detected with certainty. Two causes, ‘of which 
he cited examples and in illustration of which he 
showed slides, are fat embolism and air embolism. 
The symptoms exhibited by a patient who died on 
the operating table were so unlike those attending 
other fatalities which Dr. Mennell had seen associated 
with anesthesia that he found himself unable to 
give the coroner any opinion as to the cause of death ; 
nor was this demonstrable from the post-mortem 
inquiry until days after, when slides had been pre- 
pared by Prof. Dudgeon. These showed fat embolism 
to such a degree that, the lecturer said, ‘‘there must 
have been several pounds of liquid fat present.” It 
is not very unusual for deaths during anesthesia to 
be unexplained by the naked-eye post-mortem 
examination, and the conclusion is commonly drawn 
that the death resulted from a fatal effect of the 
anzsthetic, presumably on heart or respiration, 
which is not demonstrable after death. Dr. Mennell 
has done a service if he has enforced on all concerned 
the need for more searching inquiry into the causation 
of these ‘“‘anæsthetic ” fatalities. 


TREATMENT OF ENLARGED PROSTATE WITH 
MALE HORMONE 


THE thesis that some kind of endocrine dysfunction 
is responsible for benign enlargement of the prostate 
has attracted much attention from experimentalists 
in recent months, and was briefly discussed in our 
columns as recently as Feb. 8th (p. 321). The 
general opinion is that the hyperplasia is a response 
elicited by cestrogen compounds, but McCullagh 
and Lower? elaborate a contrary view that it 
results from imbalance between two separate normal 
testicular hormones, secreted by the seminiferous 
tubules and by the interstitial cells. It will be 
recalled that Dr. Paul Niehans accepted this view 
in his paper recommending treatment by “‘ Steinach’s 
ligature II”; but it must be admitted that the 
evidence in favour of the existence of two such 
hormones is still somewhat indirect. Gonadectomy 
in both male and female rats leads to enlargement 
of the pituitary and to enhancement of its gonado- 
tropic powers. If two rats, the one castrated the 
other normal, are experimentally combined in para- 
biotic union, the accessory reproductive organs of 
the normal animal become hypertrophic, presum- 
ably because its gonads are stimulated by the excess 
of gonadotropic hormone elaborated by the castrated 
animal’s pituitary. If, however, enough male hor- 
mone is injected into the castrated animal to save 
its prostate from hypertrophy, its pituitary does not 
become over-active, and the accessory reproductive 
organs of the normal member of the parabiotic 
pair do not enlarge. These observations show that 
testicular hormone influences both the accessory 
reproductive organs and the pituitary, and the 
presumption is that while its effect on the accessory 
organs is to increase their activity, its effect on the 
pituitary is an inhibitory one. 

McCullagh argues that two distinct substances, 


Cleveland Clin. Quart., January, 1936, 
Ibid., p. 11. 


oe D. R.: 


a ? Lower, W. B.: 


TREATMENT OF ENLARGED PROSTATE WITH MALE HORMONE 


improvement of his patients. 


[FEB. 22, 1936 439 


with sharply different functions, are responsible 
for these separate effects. This opinion is founded 
chiefiy on changes observed after irradiation of 
rats’ testes with X rays. Such irradiation leads to 
degeneration of the tubular elements, while the 
interstitial tissue remains normal and the accessory 
reproductive organs hypertrophy. The pituitaries 
of the irradiated animals also become over-active, 
in the same way as the pituitaries of castrated animals. 
Thus a single experimental procedure enhances one 
testicular function (promotion of growth of the 
accessory organs) and depresses another (inhibition 
of pituitary hyperactivity). Indications of similar 
differential changes in testicular function are provided 
by other experiments, and McCullagh therefore 
concludes that the interstitial tissue of the testis 
elaborates a hormone which governs the well-being 
of the accessory reproductive organs, while the 


. tubular system produces a hormone which prevents 


the pituitary from becoming gonadotropically hyper- 
active. As he himself points out much remains to 
be done, not only in the provision of new data, but 
also in the confirmation of older findings and in the 
resolution of conflicting observations, before this 
hypothesis can be regarded as sound. Despite 
these uncertainties, however, McCullagh and Lower 
advance the following conception of the etiology 
of benign enlargement of the prostate. The condition, 
they suggest, is due to insufficient production by the 
testes of a hormone—to which they give the name 
“ inhibin ”—which normally prevents the hypophysis 
from secreting too much of its gonadotropic principle, 
and to a consequent hypophyseal over-activity which 
stimulates excessive production of the testicular 
hormone concerned with the growth and maintenance 
of the accessory reproductive organs, including the 
prostate. If this view of the stiology of enlarged 
prostate is correct, the obvious treatment for the 
condition is administration of the testicular substance 
‘ inhibin.” This substance, however, has never 
been isolated ; and accordingly, in his investigation 
of 76 patients, Lower had to compromise by giving 
each the equivalent of 60 grammes of fresh beef 
testicular material daily. Some of the patients 
at the beginning of the trial suffered from complete 
retention of urine, while others had nocturnal 
frequency and varying amounts of residual urine. 
Nevertheless as many as 48 reacted favourably, 
the improvement of symptoms being usually manifest 
within a week or ten days after treatment was started, 
and the maximum being reached within 4-6 weeks. 
But unfortunately the improvement was almost 
entirely symptomatic, for the size of the prostate, 
as determined by rectal examination, had as a rule 
not altered, nor had any histological. changes been 
induced.® 

Although he does not favour it, Lower is alive to 
the possibility that his therapy may actually have 
been an unimportant factor in the symptomatic 
This is undoubtedly 
the safe view to take in the absence of any knowledge 
of the efficacy of crude testicular extracts when given 
by mouth. In any case, even assuming that the 
treatment was of value, it is obvious that the material 
administered may have been useful not because of its 
problematical inclusion of a substance ‘‘ inhibin,” 
but because of the male hormone proper which it 
almost certainly contained. The etiological hypo- 
thesis postulated by McCullagh and Lower is in no 
way supported by whatever success their treatment 
material was 


3 Lower does not state how histological 


obtained. 


440 THE LANCET] 


may have gained, since male hormone is also indicated 
in the management of benign enlargement of the 
prostate on the view that the condition results from 
the prolonged activity of cestrogens. It is idle, 
however, to speculate, in the present state of 
knowledge, on these various issues. One thing 
only is plain. Several hypotheses regarding the 
setiology of enlarged prostate have implied that male 
hormone would be of use in the treatment of the 
condition. Information about the chemistry and 
biology of male hormone compounds has also 
multiplied rapidly in the past year. It is time, there- 
fore, that male hormone was given a fair and adequate 
clinical trial in those conditions which experimental 
work suggests may benefit from its use. 


WHOOPING-COUGH AND THE PUBLIC 
IN spite of unanimous medical opinion, and the 


evidence of statistics to the contrary, the public. 


of most countries continues to regard whooping- 
cough as a disease of little account. Dr. F. Barbary, 
of Nice, in a communication! to the Paris Academy 
of Medicine, deplores the indifference shown in the 
rural districts of France. Evidently an optimist 
then, he is disappointed now, seeing that since he drew 
attention to the matter ten years ago nothing has 
‘been done. Dr. Barbary alludes to the well-known 
fact that the actual numbers of cases and deaths 
from whooping-cough far exceed those known to 
the sanitary authorities. From personal inquiry 
he found that, although very few cases had been 
notified voluntarily, several hundreds of children 
had been attacked by the disease in the district 
he surveyed and of these many had died from 
pneumonia or broncho-pneumonia, the true cause 
of which, namely whooping-cough, had not been 
revealed on the certificate. Dr. Barbary advocates 
the education of the public by means of addresses and 
handbills. In his view, it is essential to explode 
the legend of the eflicacity “ du fameux changement 
d’air,’’ since removal of the child results not in the 
amelioration of the attack but in the spread of 
infection to a fresh locality. He deprecates, too, 
the practice of permitting children suffering from the 
disease to play with others in the street. At intervals, 
games are interrupted while the sufferer, during a 
‘paroxysm, sprays his playmates 
It should be impressed upon the public that a few 
minutes’ contact with an infective child are sufficient 
for the transmission of a disease which, far from being 
trivial, may result in fatal complications. Dr. Barbary 
declares for compulsory notification in order that 
specific measures may be taken for the detection of 
suspects and the protection of contacts. Early 
diagnosis is facilitated by the cough-plate method 
and should be followed by isolation. For the contacts 
Dr. Barbary advocates either passive immunisation 
by means of convalescent serum or active immunisa- 
tion by means of vaccines. 

The problem of the control of whooping-cough 
in rural France presents the same features in urban 
England. It is true that in the large cities a com- 
mencement towards its solution has been made by 
hospitalisation upon a fairly large scale; at the 
present time, for example, not far short of 700 
children suffering from whooping-cough are in the 
wards of the infectious diseases hospitals of the 
London County Council. Since, however, as is the 
case in measles, patients are removed to hospital 
only when the phase of maximum infectivity has 
passed, hospitalisation is mainly a curative measure. 


1 Bull. Acad. de Méd. de Paris, 1936, cxv., 192. 


- WHOOPING-COUGH AND THE PUBLIC | 


with infection. 


[FEB. 22, 1936 


Vaccine prophylaxis, when adequately attested, may 
provide the real solution of the problem if the public, 
as the result of education, agrees to the necessity. 


A PIONEER OF ACTINOTHERAPY 


A MEMORIAL to Albert Jesionek in the Münchener 
medizinische Wochenschrift of Jan. 3lst is a worthy 
tribute to the work and personality of an outstanding 
dermatologist of modern times. In this country he 
will be remembered chiefly for the remarkable results 
he obtained in all forms of cutaneous tuberculosis 
by purely ‘‘ natural” means—viz., diet and sunlight— 
at his Lupusheilstatte at Giessen. In this achieve- 
ment his clinic was probably unique, for his energies 
were concentrated on the dermatoses; neither 
pulmonary nor articular cases, as in many other 
‘“ biological” institutes, shared the available space 
and facilities. Jesionek was a long way ahead of his 
time in formulating his problems and visualising them 
broadly as biological. He was no slave to this or 
that type of diet, lamp, or local application, and he 
was rarely seen at medical congresses with some new 
gospel of cure or prevention. He preferred the quiet 
atmosphere of his now famous institute at Giessen, 
and consistently refused the offer of larger and more 
important spheres of scientific activity. He will be 
remembered with Finsen, Rollier, and the other 
pioneers for his services to actinotherapy and the 
management of cutaneous tuberculosis. 


ASPIRATION FOR MAMMARY ABSCESS 


DISSATISFIED with the results of incision and 
drainage in a carefully controlled series of 42 cases 
of abscess of the breast, Mr. R. J. V. Battle and 
Mr. G. N. Bailey resorted to aspiration and lavage 
of the abscess cavity.! As irrigating fluid they used 
at first “bouillons vaccins,’ and later Dakin’s 
solution, and they report results from aspiration 
which compare favourably with those of incision. 
To their recommendation of aspiration as a routine 
treatment there are exceptions—notably the very 
large abscess that results from neglect of a small, 
localised one, and the diffuse cellulitic type of infection 
which shows poor localisation and severe constitu- 
tional reaction from the start. The combination 
of a virulent infection with a poor physical condition 
probably accounts for the incidence of this type of 
breast infection. In general, Battle and Bailey 
believe that the cause of breast abscess is engorge- 
ment followed by infection of the stagnant secretion 
by organisms present in the ducts or gaining access 


to them by way of the nipple. Cracks of the nipple 


increase the liability to infection in so far as pain 
leads to curtailment of suckling and hence to engorge- 
ment. Aspiration is most successful when infection 
remains localised, but watch must always be kept for 
multiple infection. Where the suppurative process 
is of the cellulitic type it is better to incise and explore 
with the finger until all pockets have been opened into 
one main cavity. Before starting aspiration, the 
baby is taken off the affected breast, which is emptied 
by a pump. Battle and Bailey use a 25 c.cm. syringe 
and a needle of 2-5mm., and they have two or three 
of such needles in readiness. They prefer a syringe 
with a Luer fitting instead of the Record, which is 
too narrow in calibre. The breast surface is cleansed 
with ether, and a point with definite fluctuation. 
or, in patients seen before this is present, a point of 
maximun tenderness, is selected. Novocain (2 per 
cent.) is injected through the tissues down to the 
abscess cavity. The wide-bore needle is inserted, 
the pus aspirated, and an equal quantity injected 


1 Brit. Jour. Surg., January, 1936, p. 640. 


THE LANCET] 


* of Dakin’s solution, diluted half and half with water. 
A sling supports the breast and the patient is 
re-examined in 24 hours. Further aspiration and 
injection is undertaken if pain returns from increased 
tension in the breast, if tenderness persists or returns, 
and if the temperature does not fall satisfactorily. 
Two or more areas of tenderness can be aspirated 
separately and the Dakin’s solution washed to and 
fro between the cavities. Repeated aspiration is 
required in most cases. Incision is necessary if, in 
spite of repeated aspiration and careful search for 
hidden loculi, the condition fails to settle. 

‘“ Bouillons vaccins’’’ were given a fairly extensive 
trial and the results were satisfactory. The method 
used was that described by V. Riche and E. Mourgue- 
Molines, except that non-specific vaccines were 
employed in some cases, and, incidentally, with 
results superior to those with the ‘ bouillon vaccin 
No. 31” recommended. Special permission from the 
Ministry of Health is required to import these products 
and customs duties have to be met. Dakin’s solution 
was found to be more practicable and to give good 
results, hence it was preferred. Weaning of the 
baby and the provision of extra nourishment and 
of general ultra-violet radiation proved useful in 
some of the more severe cases. 


RESPIRATORY EFFICIENCY TESTS FOR EACH 
LUNG SEPARATELY 


MENTION has already been made in these columns 
of the bronchoscopic methods devised by Jacobæus 
and his colleagues whereby the vital capacity and 
other measurements could be obtained individually 
for the right and left lungs. Bezancgon and his 
associates recently reported! to the French Academy 
of Medicine their experiences with a modification 
of the original scheme. To avoid any risk of injury 
they have employed a standard bronchoscope of 
normal calibre (7 mm.) and catheterised the lungs 
consecutively rather than simultaneously as in the 
method devised by Jacobæus. Once the broncho- 
scope is in the main bronchus insufflation of a rubber 
bag round its end blocks all exit of air except through 
the tube, and the expired air can be collected and 
analysed so as to give exact data on pulmonary 
ventilation. The present communication is based 
upon the examination of 30 patients most of whom 
suffered from pulmonary tuberculosis. A close 
connexion was usually found in this condition between 
X ray findings and the measurements of pulmonary 
ventilation, but the functional activity of a diseased 
lung sometimes turned out to be higher than radio- 
graphy had indicated. This could either mean that 
this lung was less damaged than appeared, or, alter- 
natively—since figures obtained were not absolute 
but relative for the two lungs—that the apparently 
sound side was not contributing to the total pul- 
monary ventilation as large a share as radiographic 
and physical examination would suggest. Interesting 
comparisons are made between pulmonary and renal 
disease as estimated by efficiency tests. For example, 
in pulmonary tuberculosis lesions apparently limited 
to a relatively small area have been found to be 
associated with a substantial decrease in functional 
activity, whereas patients with lung abscesses 
apparently involving a large area of tissue may show 
comparatively little change in the proportion of 
pulmonary ventilation carried out by the diseased 
and the normal lungs. The same thing happens in 
the kidney, where non-tuberculous suppuration 
causes less interference with renal efficiency than a 


Bull. de l’Acad. de Méd., 1936, cxv., 12. 


? Bezancon, F., et al.: 


AMBULANCE SERVICES IN ETHIOPIA 


. have their sufferings ended by their comrades. 


[FEB. 22, 1936 441 


tuberculous lesion. An extreme example of inter- 
ference was seen in a patient with a neoplasm of 
the lung in whom respiratory function was almost 
suppressed on the affected side. 

More work is required to clear up the many unsolved 
problems. For instance, separate study of the venti- 
lation of each lung often shows that elimination of 
carbon dioxide and intake of oxygen are diminished 
in different proportions, and the question arises 
whether there can be a different respiratory quotient 
for the two lungs. 


AMBULANCE SERVICES IN ETHIOPIA 


THE British Red Cross Society’s second ambulance 
unit, destined for Gondar on the north-western front, 
landed at Port Sudan on Feb. 16th. The oflficer-in- 
charge is Dr. Percy James Kelly, C.B.E., and he is 
assisted by Dr. Robert Blackwood Robertson. Three 
non-commissioned officers, formerly R.A.M.C., accom- 
pany the unit and two Indian sub-assistant surgeons 
are proceeding from Kenya to join them, as well as 
nine native dressers. Captain Strudwick, the trans- 
port officer, is already in the Sudan making all 
transport arrangements—a vital and extremely 
difficult task. It is expected that the unit will have 
reached Gondar and be ready to begin work early in 
March. Meanwhile the first. unit,! under Mr. John 
Melly, has moved from Dessie, where it was originally 
stationed, to Waldia, and treated 2000 cases in the 
fortnight following its arrival. It is now preparing 
to move some sixty miles further north to Quorem 
on Lake Ashangi to work as a clearing station for 
wounded from the Makale front. Mr. Melly reports 
that the unit is working smoothly, in spite of rains 
and almost insuperable transport difficulties. Unfor- 
tunately, however, it is found that the very severely 
wounded, being unable to walk, never reach a dressing 
station at all, and either die from their wounds ne 
The 
wounds of those who reach the unit—many of them 
caused by bombs—are always in an advanced state 


-of sepsis and immediate amputations are often 


necessary. The civil population are beginning to 
bring in their sick at the rate of some 90 new out- 
patient cases a day, and the members of the unit 
are called upon to treat many types of tropical disease. 
The varied equipment with which the unit is furnished 
is standing them in good stead, but a portable X ray 
set has been found to be a necessity, and a set which 
is being specially manufactured will be dispatched 
within a few weeks in the charge of an experienced 
radiologist. Public response to appeals for funds, 
including a broadcast address by the Very Rev. 
H. R. L. Sheppard, has covered the expenses already 
incurred in dispatching the two units, but money 1s 
still urgently needed to ensure that their work shall 
be adequate and uninterrupted throughout a campaign 
which at best is bound to cause widespread suffering 
for many months to come. This work is carried on 
under difficult and dangerous conditions and the 
units have to depend entirely on supplies sent from 
this country, so that the British Red Cross Society 
has to find at least £3000 a month for their main- 
tenance in the field. l 

It is also announced that a party of British nurses 
is being formed under the leadership of Gertrude 
Lady Decies to join the Ethiopian Red Cross in the 
war zone. This is separate from the British Red Cross 
units (composed only of men) and no general appeal 
for funds has yet been made; but a sum of £2000 is 

1The first unit is como’ of the following medical men: Mr. 


Jobn Melly, F.R.C.S., Dr. A.C. W. Barkhuits, Dr.C. E. Bevan, 
Dr. W. 5. Empey, Dr. J. W.S. Macfie, and Dr. Jobn Perverseff. 


442 THE LANCET] 


A PIONEER ALMONER 


[FEB. 22, 1936 


needed, of which a quarter has already been sub- 
scribed. Among other voluntary efforts of the same 
kind we may lastly mention the veterinary unit 
organised by the R.S.P.C.A., which has lately sailed 
with all that is necessary to staff and equip a field 
hospital for 250 sick animals. 


A PIONEER ALMONER 


Miss Anne Cummins died on Feb. 8th, 1936; her 
life’s work remains vigorously alive. In the future 
she will be remembered, not as the first almoner, 
for the profession was actually ten years old when 
she was appointed at St. Thomas’s Hospital in 1905, 
but as the first almoner with imagination vivid 
enough to realise the potentialities of hospital social 
work and in large measure to turn her vision into 
reality. She saw the work not as a series of sporadic 
acts but as an essential hospital service ancillary to 
medicine and nursing and for the benefit of all 
patients. So quickly did she inspire others with 
her belief that in 1909, only four years after she had 
started her work at St. Thomas’s Hospital among 
the out-patients, she was able, thanks to the newly 
formed Northcote Trust, to carry systematised social 
work into the wards and into special departments, 
finally creating in the hospital a complete system of 
medico-social service which still remains in many 
ways unique. This success was largely due to the 
enthusiasm for the work and loyalty to her ideals 
that she was able to kindle in successive generations 
of her staff. Those who came to her for wise advice, 
whether patients, fellow-workers, nurses, or doctors, 
always left her fortified and stimulated. Her influence 
extended far beyond the bounds of the hospital. 
Since 1905 Miss Cummins has played a part in almost 
every big movement touching the health of the 
people. Very early she stressed the special import- 
ance of social work for the patients suffering from 
tuberculosis and venereal disease, and was respon- 
sible for starting the special hostel connected with 
St. Thomas’s and for the liberal and educational 
lines on which it has been run. The development of 
maternity and infant welfare centres owed much to 
her; and it was she who arranged that fathers as 
well as mothers came to classes and lectures at the 
little welfare centre near the hospital. Miss Cummins 
had nothing parochial in her outlook; she saw the 
hospital as part of a larger whole. She worked 
continuously for codperation and understanding 
between State and voluntary organisations, and 
knew how to give as well as to get the best from 
societies and individuals for the patient in need. 
From the first she strove for the adequate training 
for almoner’s work, and her own preparation for the 
work at St. Thomas’s Hospital was both long and 
arduous. In 1907 she was instrumental in forming 
the Institute of Hospital Almoners for the selection 
and training of students and for maintaining pro- 
fessional standards of work, and after her retirement 
from St. Thomas’s Hospital in 1929 her work for the 
institute was perhaps her greatest interest. She 
lived to see the profession of hospital almoner spread- 
ing over the whole of Great Britain, not only in volun- 
tary, but in municipal and mental hospitals, and the 
development in at least one of our dominions of an 
institute for training on the English pattern. 


SERUM TREATMENT OF TYPHOID FEVER 


Last year Mr. A. Felix, D.Sc.,! and Dr. C. J. 
McSweeney 2 reported in our columns the results of 
early trials of a new antityphoid serum prepared by 
Dr. Felix, and at a meeting of the fever hospitals 


2 TuE LANCET, 1935, i., 799. ? Ibid., 1935, i., 1095. 


group of the Society of Medical Officers of Health on 
Jan. 3lst the same workers gave an account of their 
further experiences. Felix’s investigations with Weil 
on the H- (flagellar) and O- (somatic) antigens have 
long been familiar, and more recently he has identified 
in Bacillus typhosus a third antigenic component 
which he calls the Vi-antigen. While O-antigen is 
chiefly responsible for toxic symptoms, the Vi-antigen 
is specially associated with virulence, and he main- 
tains that a therapeutic serum to be of value must 
contain effective amounts of both O- and Vi-anti- 
bodies. Clinical trials of his new serum in Palestine 
and Egypt have been “definitely encouraging ”’ ; 
both toxemia and pyrexia were favourably influenced. 
Comparative trials by Dr. Samy Bey Sabongi of 
Cairo of commercial serum containing O-antibody in 
low titre, special serum with O-antibody in high 
titre, and a third serum containing both O- and Vi- 
antibodies are held to have demonstrated the 
superiority of the last. The same kind of serum, at 
first unconcentrated but later concentrated and of 
very much higher Vi- and O-titres, has been used by 
Dr. McSweeney in Dublin in 19 cases of typhoid 
fever. Although in 10 of these there was unequivocal 
evidence that the period of pyrexia was shortened, 
McSweeney found that the effect of the serum upon 
toxemia was more striking and more constant than 
its effect on temperature. Indeed he considers it so 
potent a weapon in combating toxemia that its 
routine use is justified, especially if toxzemic features 
are in evidence. In the course of the discussion 
Dr. E. W. Goodall recalled the use of Chantemesse’s. 
anti-exotoxic serum (1906) and MacFadyen and 
Hewlett’s anti-endotoxic serum (1908); the latter he 
had used with good results, and he had also seen 
benefit from the injection of vaccines. From the 
examination of 66 case-records he concluded that in 
25 instances Felix’s serum had proved beneficial, 


_ but whether the Vi-serum was superior to the O-serum 


a 


he was not sure. Dr. A. Joe, who had also examined 
the records, said he thought that, on the whole, the 
results were encouraging and that a good case had 
been made out for extensive clinical trials of the 
new serum, which, he added, might now be obtained 
commercially. Hitherto the serum has been injected 
intramuscularly, but Dr. Stanley Banks suggested 


that still better results might be obtained from intra- 


venous or intraperitoneal injection. Dr. McSweeney, 
who admitted to less courage, did not share this view. 


WE regret to announce the death on Feb. 7th of 
Dr. Priestley Leech, consulting surgeon at the Royal 
Halifax Infirmary, and medical officer in charge of 
the Venereal Diseases Clinic. 


On Thursday, Feb. 27th, and on the following 
Tuesday at 5 p.m. Dr. E. L. Middleton will deliver 
the Milroy lectures to the Royal College of Physicians. 
He will speak on industrial pulmonary disease due 
to the inhalation of dust, with special reference to 
silicosis. 


Sir Lenthal Cheatle will deliver the Hunterian 
oration of the Hunterian Society at the Mansion 
House at 9 P.M. on Monday, Feb. 24th. His subject 
will be John Hunter’s Time and Ours. 


AMIDOPYRIN, after May Ist next, will not be on 
sale to the public except on medical prescription. 
That is the day on which the new Poisons List and 
Rules come into force, and the decision was announced 
last week by the Iome Secretary in reply to a question 
in the House of Commons (see p. 456). 


THE LANCET] 


[FEB. 22, 1936 443 © 


PROGNOSIS 


A Series of Signed Articles contributed by invitation 


LXXXIX.—PROGNOSIS IN ENLARGEMENT 
OF THE SPLEEN * 


THE spleen is a composite organ, composed of 
several tissues which are also to be found elsewhere 
in the body, and the diseases which involve the 
spleen affect these tissues not only in the spleen but 
wherever else they occur. The main tissues which 
make up the structure of the spleen are :— 

1. The hemopoietic or blood-forming tissues—occurring 
in the bone-marrow and spleen-pulp and (in conditions of 
disease) elsewhere as well, e.g., the liver. 

2. The lymphoid tissues—occurring in the spleen as the 
Malpighian bodies, and elsewhere as the lymphatic glands 
and lymphoid nodules abundantly scattered through the 
organs. 

3. The reticulo-endothelial tissues—occurring as the cells 
lining the splenic sinuses, as the Kupffer cells of the liver, 
in the bone-marrow, and elsewhere. 

4. The vascular structures—arteries with their peculiar 
endings in “ ellipsoids,”’ veins, blood-sinuses. The spleen 
is in direct connexion with the portal venous system, and 
is of necessity involved in diseases and abnormalities of 
that system. 

5. The supporting tissues—capsule, trabecule, and reti- 
culum of the pulp. 


Thus the real problems of prognosis arise in diseases 
affecting other parts or tissues of the body, but in 
which the same tissue in the spleen takes a share. 
It may be, and often is, that splenic enlargement is 
the most obvious clinical sign, but the prognosis is 
that of the whole disease. The real crux of prognosis 
is accurate diagnosis, and this may be excessively 
difficult. I have, in association with various co- 
workers (Cashin, McMichael, Salah), investigated a 
large number of spleens removed in Great Britain 
by operation or at necropsy, and have published 
accounts of attempts to classify them on a patho- 
logical basis. Many of them have been enormously 
enlarged, but some have been normal in size. So far 
it has been found quite impossible to make any 
clinical classification of real value to physicians, and 
in only a minority of splenic conditions can an 
accurate diagnosis and a name be given. 

In practice, however, prognosis can conveniently 
be considered under three headings—namely, what 
happens: (1) when the spleen is left alone; (2) when 
splenectomy has been performed successfully from the 
surgeon’s point of view ; (3) when other treatment, such 
as by X rays or drugs or other measures, is employed. 
‘The conditions in which the various essential tissues 
of the spleen are involved, and the prognosis in each, 
will be considered in relation to these three lines of 
treatment. 


‘Hemopoietic and Lymphoid Tissues 


It is convenient to consider the hemopoietic and 
lymphoid tissues together. Here we are concerned 
vith prognosis in all the leukemias, and certain of 
the anemias. It is perhaps easiest to include acho- 
l uric jaundice in this group also, but no one at present 
knows the real causation of this fairly common 
disease. 

The prognosis in all the varieties of acute leukæmia 
is bad, and no treatment applied to the spleen or 
©lsewhere is of any avail. In the chronic leukemias 
(both myeloid or spleno-medullary and lymphatic), 


* Enlargement of the spleen associated with tropical diseases 
iss not discussed in this article. 


treatment applied to the spleen has a notable effect 
on prognosis. We have seen in the last decade an 
enormous improvement in the results of X ray 
therapy in these diseases. Everyone is agreed that 
the prognosis as regards the general health of the 
patient is vastly improved; not everyone is agreed 
that the span of life is actually prolonged. The 
problem is difficult because of the great variation 
in the expectation of life in untreated patients, 
particularly those suffering from chronic lymphatic 
leukemia. I am convinced myself, from my own 
observations, that in chronic myeloid leukzmia life 
is actually prolonged, in addition to good health 
being temporarily restored, by radiotherapy. As 
to chronic lymphatic leukæmia, an individual phy- 
sician does not see enough cases to enable him to 
form a proper judgment. Instead of being anzemic 
invalids patients may now hope to continue 
active work for five, six, or even seven years 
in the myeloid variety, and still longer in the 
lymphatic. My longest case of myeloid leu- 
keemia is still alive at the end of seven years. Never- 
theless, it must be admitted that in all chronic cases 
of leukemia the ultimate prognosis is bad, and the 
onset of hemorrhages generally shows when the end 
is approaching. A point of interest is that it seems 
to be treatment by X rays to the spleen alone which 
is of value in myeloid leukemia, although so far as 
we know the actual disease is chiefly in the bone- 
marrow. It does not seem to matter much whether 
the spleen becomes shrunken to nearly normal size 
by the therapy, or remains large—the good result 
is the same. In chronic lymphatic leukemia, of 
course, the position is different, and here X ray 
therapy should be applied both to the spleen and to 
every lymphatic gland found to be enlarged. 

Hodgkin’s disease is a difficult problem in prognosis, 
for if left untreated 1t may run an acute or a very 
chronic course. Its xtiology and even its nature are 
still obscure. In the spleen it involves the lymphatic 
elements (the Malpighian bodies), and elsewhere the 
lymphatic glands and all lymphoid structures. How 
does X ray therapy affect the prognosis in this 
disease ? Opinions vary, but my own is that in the 
more chronic cases well-applied X ray therapy, 
carried out in the closest association with the clinical 
laboratory, is of great value in prolonging life. This 
close correlation, with regular blood counts, is essen- 
tial. Care must be taken, when treating the enlarged 
glands and the spleen, that the blood-destroying 
effects of X rays are not carried too far, to produce 
both severe anemia and leucopenia, and actually 
hasten the end. In the past most of us have made 
mistakes in this way. 

Splenectomy has no influence on the prognosis 
either in the chronic leukemias or in Hodgkin’s 
disease. 

Erythremia (Osler-Vaquez disease) is a disease 
associated with great splenic enlargement. In this 
condition splenectomy is valueless, X ray therapy 
offers little help, and blood-destroying agents such 
as phenyl-hydrazin are uncertain and at times even 
dangerous because of our difficulty in knowing when 
the hemolytic action of the drug will stop. Sympto- 
matic treatment by repeated venesection is the only 
method which has proved regularly helpful in my 
hands, and I believe improves prognosis in that it 
tends to prevent well-known complications. 


‘444 THE LANCET] 


Acholurie jaundice (congenital or, rarely, acquired) 
may be dealt with here for convenience. We 
know that clinically these patients suffer from 
periodic attacks of blood destruction, resulting in 
hemolytic anemia and hemolytic jaundice, and that 
the spleen is enlarged. We know too that in a test 
carried out under entirely artificial conditions the 
washed red blood corpuscles, deprived of their 
plasma, are unduly ‘fragile’? when compared with 
the red blood-cells of normal people. Whether the 
red cells are unduly fragile, in the same sense, within 
the body, and when bathed in plasma, is quite a 
different problem, no matter how important the test 
may be for diagnostic purposes. We also know that 
splenectomy breaks some link in the chain, and 
prevents, nearly always, the return of the sudden 
“ blood crises,” with blood destruction and jaundice. 
I formerly believed that splenectomy was an abso- 
lute cure for these blood crises, but a single case 
still under observation has shown me that the rule 
is not invariable. For practical purposes, however, 
splenectomy is a true clinical cure for this disease, 
although when tested after the operation the red 
cells remain throughout life as fragile as ever. 

Prognosis as regards life when splenectomy is not 
carried out is more difficult to assess, but itis known 
that many cases of untreated acholuric jaundice 
live long lives. Various complications, however, 
such as gall-stones, may ensue at quite an early 
age. Broadly speaking, the view is now held that 
splenectomy is indicated, and that when it has been 
successfully carried out a prognosis of continued good 
health can be predicted. 

The problem of the prognosis of purpura hamor- 
rhagica, in its relation to the spleen, may also be 
considered here. I have examined the spleens 
removed by operation from a number of these cases, 
and in none ‘was the organ enlarged, nor could any 
microscopic abnormality be made out. Here, if we 
see aright, is a disease involving the blood-platelets, 
and their production or destruction, in some unknown 
way. Splenectomy generally raises the platelet 
count, and it is for this reason that splenectomy has 
been used in severe and recurrent cases of purpura. 
It seems true to say that in purpura hemorrhagica 
splenectomy may be a truly life-saving measure ; 
but it is also true that splenectomy does not, in all 
cases, prevent the recurrence of a low platelet count, 
and a return of the disease. 


_ Reticulo-Endothelial Tissues 


_ Diseases involving these tissues, in the spleen 
and elsewhere, include the abnormalities of lipoid 
storage, described by Gaucher, Pick, and Niemann, 
and also the lipoid splenomegaly sometimes asso- 
ciated with diabetes. The spleen is here involved 
merely as part of a much more generalised abnor- 
mality in function of the reticulo-endothelial system 
of the body. The prognosis, except in diabetes, is 
on the whole bad, and is certainly, in my experience, 
uninfluenced by any treatment, even splenectomy. 


Vascular Structures and Supporting Tissues 


This includes the largest group of splenomegalies 
met with in Britain, and nomenclature is almost as 
difficult as prognosis. This is the group formerly 
referred to in our literature as Banti’s disease, or 
splenic anwmia, but a better pathological description 
would be hepato-lenal fibrosis. The origin of the 
splenomegaly is quite unknown, but it seems evident 
that changes in the vascular structures of the spleen 
are of great importance. In one group of cases of 


PROGNOSIS IN ENLARGEMENT OF THE SPLEEN 


res. 22, 1936. 


this kind, indistinguishable clinically from others, 
the vascular lesion is actually outside the spleen, 
and complete thrombosis of the main splenic vein 
or even of the portal vein is found at necropsy. In 
most cases, however, the vascular changes are within 
the spleen itself, and are associated with a gradually 
progressive diffuse fibrosis. The crucial point in the 
prognosis is the fact that the liver also tends to be | 
involved, developing fibrosis and ultimately a true 
cirrhosis. The question of whether the spleen changes 
come first and the liver changes second is obviously 
of great importance. It is generally believed that 
this is indeed the order in most, if not all, cases, and 
this influences both treatment and prognosis. So 
far as we know at present, our only chance of pre- 
venting the progressive changes in the liver is to 
remove the spleen, and it is generally impossible in 
the earlier stages to know; without surgical explora- 
tion, whether the changes in the liver have begun. 
There are two schools of thought at present, one 
favouring splenectomy and one against it. The 
only alternative to operation is X ray treatment, 
and my personal view is that this is valueless. 

How can a reasonable decision be made as to 
whether splenectomy should or should not be per- 
formed? Only a very extensive experience could 
help, and few people see, throughout their clinical 
life, sufficient cases to enable them to formulate 
definite rules. It is certain that astonishing results 
have followed splenectomy in the most unpromising 
cases, when the liver has been proved to be cirrhosed, 
and even when ascites has set in. On the whole, 
however, it must be said that at present the prognosis 
in this group is poor as regards duration of life, and 
the average expectation under any treatment is no 
more than five years. 


Prognosis of the Operation of Splenectomy 


Obviously a physician is more concerned with the 
results of successful splenectomy than with the opera- 
tion itself. Of the operative technique, therefore, 
I need say little except that shock in the ansmic 
patient may be considerable, and that a blood trans- 
fusion while the patient is on the operating table 
is, in my view, highly desirable. Two surgical risks 
are worth mentioning here. Very rarely the splenic 
vessels in the pedicle are abnormal in their distri- 
bution, and instead of one splenic artery and one main 
splenic vein, there are several, This greatly increases 
the surgical risks unless the surgeon is aware of it. 
The only other problem is due to perisplenitis and 
adhesions, especially to the under surface of the 
diaphragm, and when these are extensive fatal 
oozing of blood may ensue, in spite of the most 
careful surgical precautions. It is in these cases 
that the simple operation of tying the splenic pedicle, 
without removing the spleen itself, is to be recom- 
mended. This operation has already been carried 
out with success, and a simple atrophy of the spleen 
results. 

The most frequent and serious post-operative risk 
is thrombosis of veins, and no operation on the spleen 
should be attempted when the blood-platelet count 
is much above the normal 300,000 per c.mm. Fol- 
lowing splenectomy the platelet count tends to rise, 
and if it reaches 700,000 per c.mm. or more the 
possibility of thrombosis in any vein, but particu- 
larly in intra-abdominal veins, at once arises. The 
thrombosis, if extensive, may be fatal in itself, or 
lead to haemorrhage from increased pressure in 
neighbouring veins. 


(Continued at foot of opposite page) 


THE LANCET] 


(FEB. 22, 1936 ‘445 


SPECIAL ARTICLES | 


MEDICINE AND THE LAW 


_ $6 Psychic Pain ”’ 


INJURY entitling a workman to compensation 
need not be pliysical and visible injury. In a recent 
Manchester case a porter, while moving .a bale of 
cloth weighing about 50 1b., had fallen and strained 
his back nearly a. year ago. He was in bed for three 
weeks and then’ attended hospital until December. 
He complained of great stiffness in the lower part 
of the back; he walked in a very bent position and 
very stiffly and always used a stick. Examination 
disclosed no injury; X ray photographs showed a 
completely normal condition. The employers refused 
to pay compensation after Nov. 18th. The work- 
‘man asked the court to order renewal. A medical 
witness, called by the employers, said he thought 
the workman had made up his mind he would never 
get better; the man himself was the greatest obstacle 
to recovery ; he had got the habit of expecting pain 
whenever he moved his limbs ; it was a “‘ psychic ” 
pain. The judge said there had been a persistent 
complaint of pain and there was no accusation of 
_ malingering; the ‘psychic’? pain was the result 
of a physical pain, and the physical pain was the 
result of the accident in the course of the man’s 
employment. An order was made for compensation 
from the date of discontinuance last November. 

It is nowadays too late to contend that a workman 
cannot have compensation if his disability is due 
merely to the state of his nerves or to his loss of will- 
power. In another recent ‘case, heard at Langport 
county court in. Somersetshire, a gardener had 
slipped on some stone steps while carrying two 
buckets and had received injury to his back and 
ribs. When the visible effects had disappeared the 
workman still complained of pain and loss of sleep. 
His doctor advised him to try light work in his garden. 
The man found he could pull up a few weeds but 
could do no digging. The Medical Referee, acting as 
assessor, advised the court that it was a case of 
true neurosis. No fracture was shown by the X ray 
photographs. The physical disability had passed 
off, but the fact that the man had both the accident 
and the pain seemed to make him quite honestly 
associate the one with the other. The Medical 
Referee thought the pain would gradually disappear. 
The man ought to put in as much work as he could 
in his garden; if he did so, he ought not to suffer 
at all in three months’ time. The judge held that 
the man was suffering from a nervous result of the 
accident which, so long as it existed, incapacitated 
him from work. “I think he has within his own 
command the power to cure himself; he has no need 
to wait till some sympathetic employer finds him 


e e ae ee oe 


(Continued from previous page) 


Just as in hepatic cirrhosis of the ordinary kind, 
hematemesis from rupture of veins in the wall of 
the stomach, or in the cesophagus, is by no means 
infrequent in cases of chronic splenomegaly, quite 
apart from operation. It must be stated that splenec- 
tomy does not entirely remove this risk, and that 
hematemesis has been known to occur at intervals 
for years after successful splenectomy. 


J. W. McNEE, M.D., D.Sc., F.R.C.P., 
Physician to University College Hospital. 


the exact work which will prove his cure.” 
workman was entitled to compensation and a lump- 


‘gettlement. 


_ tooth out of the lung. 


a suitable job. He has a garden in which he can do 
The 


sum payment of £50. was offeréd and accepted in 
The court thus went as far as it could 
in the direction of advising the man to take up work 
again. There are decisions which prevent a court 
from reducing the award of compensation (in the 
absence of misconduct) in order to put pressure 
upon a workman to exercise his will-power and to 
tackle a job of work once more. 


Damages against Dentist 


At Chester assizes last week substantial damages 
were awarded against a dental surgeon in respect 
of injuries sustained by reason of a tooth passing 
down the patient’s throat after extraction and 
entering the lung. There was evidence that the 
method of plugging the patient’s mouth was satis- 
factory and that the teeth were counted immediately 
after the operation. One tooth was then said to be 
missing and it was found in the lower jaw. Apparently 
the count was incomplete. Mr. Justice Lawrence 
had to consider the relative responsibility of dentist 
and anesthetist. He held it to be the duty of the 
dentist to see that the pack used was a proper pack . 
and one which would prevent a foreign body from 
passing down the patient’s throat. The patient was 
afterwards seriously ill and eventually coughed the 
He was now well, but he had 
suffered displacement of the heart, and his lungs had 
become hardened and deteriorated. A verdict of 
£800 damages, with special damages of £280, was 
awarded. 

Fall on Polished Floor 


Last J uly Mrs. Weigall was awarded £2826 damages 
in Mr. Justice Horridge’ s court against the Governors 
of Westminster Hospital for injuries sustained through 
a mat slipping on a polished floor in the hospital’s 
annexe at Jitzjohn’s-avenue, Hampstead. She had 
been to the premises to visit her son who was a patient. 
Having seen him, she went into another room to 
interview the consulting surgeon about bim. She 
said she put her foot on a mat near the fireplace and, 
the mat suddenly slipping on the highly polished 
linoleum, she fell and broke her thigh. Her left 
Jeg was now an inch shorter than the right. The 
judge held, last July, that. the hospital authorities 
ought to have known that there was unusual danger 
in placing the mat unsecured on a highly polished 
floor ; there had been a failure of duty towards the 
plaintiff ; she had not been guilty of any contributory 
neghgence. At the trial in July Mrs. Weigall 
admitted in evidence that in 1911 all the toes of 
both her feet were amputated except her big toes; 
but she denied that on this account she was the less 
able to keep her balance. The defendants had 
sought to explain her fall as due to a sheer accident 
for which they were not responsible. The legal 
position depended upon the plaintiff’s right to be 
there. Was she invited to be in the place where 
she met with the accident, or was she merely there at 
her own risk ? 

The Court of Appeal dismissed the Westminster 
Hospital’s appeal last week. Two judges held that 
Mrs. Weigall was an invitee. She was visiting the 
hospital on an express or an implied invitation. 
Her son was undergoing treatment ; she was paying 
a fee to the hospital and also to the consulting surgeon ; 
there was a contract under which she had an implied 


446 THE LANCET] 
right to visit her son and to consult the surgeon about 
him. The hospital was therefore under a duty to 
take reasonable care to make the premises safe and 
to prevent danger of which it knew or ought to have 
known. One member of the court, Mr. Justice Eve, 
expressed the view that Mrs. Weigall was a mere 
licensee and not an invitee. The opinion of the 
majority holds the field. 


SCOTLAND 


(FROM OUR OWN CORRESPONDENT) 


THE THIRD STAGE OF LABOUR 

At last week’s meeting of the Edinburgh Obstetrical 
Society Dr. Chalmers Fahmy read a communication 
on the management of the third stage of labour. 
After speaking of the normal mechanism of placental 
separation, he made a strong plea for allowing the 
third stage to take place spontaneously and without 
any interference. In the great majority of cases, he 
pointed out, the placenta separates without difficulty 
in less than an hour, and even if separation is delayed 
for two hours or so, there is seldom much bleeding if 
the uterus is not manipulated. He emphasised the 
dangers of prematurely employing Credé’s method 
of expression : the uterus should be left entirely alone 
untilthe signs are clear that the placenta has separated, 
and not until these signs are present should any 
attempt be made to deliver the placenta, even though 
the third stage lasts two hours or more. Hemorrhage 
in this stage is common if early manipulation of the 
uterus is practised; it is uncommon if nature is 
allowed to take its course. The indications for 
expressing the placenta from the uterus are hemor- 
rhage, and a placenta delayed for many hours. That 
expression should always be attempted after 50-60 
minutes is a view held by many, but Dr. Fahmy 
believes this plan to be unwise. A placenta which is 
adherent at the end of an hour, he said, might not 
be adherent at the end of the second or third hour. 
If Credé’s method fails, there is hemorrhage to a 
degree which leads immediately to manual removal. 
Experiences were cited showing the safety of leaving 
the placenta in utero for some hours when the patient 
can be kept under observation by the nurse or doctor. 
Many examples were given of patients with “* adherent 
placenta °” being sent to hospital after frequent 
attempts by Credé’s manceuvre had failed. Such 
patients were generally shocked and had bled freely 
as the result of the attempts; as a rule, the treatment 
adopted in hospital had been one of rest by morphia. 
The placenta was usually found in the vagina some 
hours later. 

Dr. Fahmy disagreed with the statement, often 
made, that the mere retention of the placenta 
frequently causes shock; such a development was 
rare. Laceration of tissues and frequent attempts at 
Credé’s expression were the common causes of shock 
in the third stage. He stated his belief that the early 
adoption of methods to express the placenta was the 
cause of much postpartum and third-stage hæmor- 
Thage; such would seldom be seen if more patience 
were exercised after the delivery of the child, whether 
the delivery had been spontaneous or instrumental. 
Manual removal of the placenta either at home or in 
hospital should be avoided if at all possible; if the 
placenta were left to separate spontaneously, the need 
for such interference would seldom arise. A policy 
of patience that is advocated by all for the second 
stage of labour should be upheld during the third 
stage also. 


SCOTLAND.——PARIS 


(FEB. 22, 1936 


PARIS 


(FROM OUR OWN CORRESPONDENT) 


LES CAUSES PRINCIPALES DU MALAISE MEDICAL 


WHILE most of us get no further in our diagnosis 
of the present malaise médical than to the generalisa- 
tion that there is something rotten in the State of 
Denmark, the biologist, Auguste Lumiére, has taken 
us a step onwards by quoting certain illuminating 
statistics. One reason why the general practitioner 
now sits twiddling his thumbs for lack of a more 
constructive occupation is that crowds of potential 
patients, tuberculous or conceivably tuberculous, now 
attend tuberculosis dispensaries or take refuge in 
sanatoriums, preventoriums, and allied institutions. 
In 1934 there were 834 dispensaries in which more 
than a million and a half visits were paid. Of the 
890,056 persons presenting themselves at these dis- 
pengaries in this year, only 335,199 were found to be 
tuberculous. Further, in the same year, 1,221,955 
visits were paid in the patients’ homes by visiting 
nurses. Institutions of the sanatorium class provided 
72,561 beds. 

Other statistics, produced by the Phare Médical de 
Paris for January, reveals a big leakage of the general 


practitioner’s sources of revenue in quite a different . 


quarter. In 1920 the number of days spent in the 
hospitals of Paris was 1 million. In 1933 this number 
had risen to 13 millions—an average increase of 
1 million per year. It has been calculated that 
about half these hospital patients are paid for by the 
national insurance scheme out of accident insurance 
funds, or are able to pay out of their own pockets. 
If the cost of each day in hospital is some 40 francs, 
it will be seen that the total sum the taxpayers have 
to contribute towards the treatment of the sick 
members of the community is thumping big. It is, 
however, an ill-wind that blows nobody any good, 
and though the taxpayer bleeds and the general 
practitioner starves, the sick themselves are almost 
to be envied. 
EUTHANASIA 

On Feb. 6th Dr. Thierry de Martel, the brain 
specialist and chief surgeon to the American Hospital 
in Paris, was the guest of honour at the weekly lunch 
of the American Club. He said that euthanasia had 
many defenders, but was not yet accepted by the 
legislature of any country. Might not the day 
come, he asked, when the doctor would be permitted 
to give death painlessly, and even agreeably, to the 
sick who asked for it? Even if euthanasia was to 
become legal, he did not think its benefits would be 
as often sought as was commonly supposed, for, in 
his opinion, men cling to life, no matter how little 
of it remains to them or how painful it may be. 
Only once in the course of his career had a patient 
been sincere in his request for death. 


THE HIPPOCRATIC OATH FOR DOCTORS OF 
MEDICINE 


Two French universities have recently decided to 
require the Hippocratic Oath of medical students 
before they graduate in medicine. The faculty of 
medicine of Bordeaux adopted this measure from 
Jan. Ist, 1936. The text of the Oath must be printed 
at the end of each thesis, and when it is defended, 
the candidate must read the Oath standing before 
the jury. The French faculties of medicine which 
now require the Hippocratic Oath of candidates in 
medicine are those of Paris, Nancy, Strasbourg, 
Bordeaux, Montpellier, Marseilles, and Algiers. 


THE LANCET] 


UNITED STATES OF AMERICA - 


(FROM AN OCCASIONAL CORRESPONDENT) 


AN ENEMY OF QUACKS 


THE American Medical Association announces that 
Dr. Arthur J. Cramp is retiring after thirty years’ 
service at its headquarters. Born in London in 1872 
the first child in a large family, he was educated at 
Sir Walter St. Johns and became junior clerk in a 
London steamship office; but at the age of 19 he 
abandoned that path of fame and emigrated to the 
United States. After an American college education 
he became a teacher and occupied his spare time 
in contributing a weekly newspaper column. He 
graduated from the Wisconsin College of Physicians 
and Surgeons in 1906, and after a brief experience of 
medical practice became attached to the staff of the 
Journal of the American Medical Association. Very 
soon after that he developed what was first called 
the Propaganda and Reform department and is 
now known as the Bureau of Investigation. The two 
volumes ‘‘ Nostrums and Quackery ”’ represent only 
a small part of his efforts in this field. His office has 
investigated over 200,000 quacks and quack remedies 
and maintains a complete file of the records from 
which information is supplied daily to federal and 
State health officials, educational institutions of all 
kinds, editors of magazines and newspapers, and the 
less easily bamboozled members of the general public 
who prefer not to swallow every remedy that is 
baited with a testimonial. 


The work will go on, but to those of us who have 
known it throughout many years the Bureau will 
never be the same without its genial, courteous, 
passionately efficient director. Some of his many 
friends will dare to expect that even in retirement in 
his new Florida home he will continue to wield his 
effective pen. A third volume of ‘‘ Nostrums and 
Quackery ’’ is badly needed ! 


THE SERVICES | 


ROYAL NAVAL MEDICAL SERVICE 


Surg. Comdrs. A. G. Taylor to Drake for R.N. Hospital, 
Plymouth; T. J. O’Riordan and R. J. Inman to Drake 
for R.N.B.; H. L. P. Peregrine to Osprey. 

Surg. Lt. Comdrs. G. Rorison and L. J. Corbett to 
Shropshire. 

Surg. Lt. Comdr. L. Lockwood, M.V.O. (Royal Aus- 
tralian Navy), to President for course. 

Surg. Lts. H. G. Silvester to Kempenfelt, A. J. Glaze- 
brook to Arethusa, and W. J. F. Guild and J. G. Slimon to 
President for course. 

E. R. Sorley, J. M. Sloane, T. F. Crean, W. P. E. 
McIntyre, E. T. S. Rudd, E. H. Rampling, E. E. Malone, 
L. P. Spero, and C. B. Nicholson to President for course. 

The following have been appointed Admiralty Surgeons 
and Agents: Weston-super-Mare, Mr. E. R. Clutterbuck ; 
Coventry, Surg. Lt. Comdr. W. P. Elford, R.N.V.R. ; 
Newquay, Mr. D. R. Mitchell; Enfield Lock, Mr. H. P. 
Warren ; Guernsey, C.I., Surg. Lt. Comdr. B. S. Collings, 
R.N. (retired); Emsworth, Hants, Surg. Capt. H. P. 
Turnbull, R.N. (retired); and Haslemere, Mr. C. W. 
Jenner. 


ROYAL NAVAL VOLUNTEER RESERVE 


Proby. Surg. Sub-Lt. R. R. Prewer promoted to Proby. 
Surg. Lt. 


ROYAL ARMY MEDICAL CORPS 


Temp. Commissions.—The undermentioned to be Lts. ; 
C. W. Maisey, Maj. G. M. Lewis, from R.A.M.C, (T.A.), 


UNITED STATES OF AMERICA.—THE SERVICES 


LMS. 


[FEB. 22, 1936 447 


and relinquishes the rank of Maj., H. Ferguson, A. T. 
Marrable, R. J. G. Morrison, and F. T. Moore. 


REGULAR ARMY RESERVE OF OFFICERS 


The undermentioned having attained the age limit of 
liability to recall cease to belong to the Res. of Off.: 
Lt. Cols. W. J. E. Bell, D.S.O., F. T. Dowling, and G. R. 
Painton, and Maj. T. W. O. Sexton. 


TERRITORIAL ARMY 


Capt. R. Lodge resigns his commn. 

Capt. A. J. Will to be Maj. 

V. H. Sarland (late Lt., I.M.S.) to be Capt. 

K. M. Morris (late Offr. Cadet, Edinburgh Univ. Contgt. 
(Med. Unit), Sen. Div., O.T.C.) to be Lt. 


ROYAL AIR FORCE 
Flight Lt. F. E. Lipscomb to R.A.F. Station, Northolt. 


INDIAN MEDICAL SERVICE 


Maj. J. E. Ainsley to be Lt.-Col. 

Military Cross.—Temp. Capt. Patit Paban Chowdry, 
M.B., B.S., late I.M.S., for distinguished services rendered 
in the field in connexion with the Loe-Agra Operations, 
N.-W. Frontier of India, Feb. 23rd to April 13th, 1935. 

The names of the following have been brought to notice 
by the Commander-in-Chief in India, for distinguished 
services rendered in connexion with the operations :— 

I.M.S.: Maj. A. H. Craig, M.B., Ch.B., No. 3 Field 
Ambulance; T/Capt. P. P. Chowdry, M.B., B.S. ; T/Capt. 
S. P. Bhatia, M.B., B.S., M.R.C.S. 

InD1IaN Hospitat Corrs: No. 1/A/3451 Naik Guahar 
Singh, No. 3 Field Ambulance. 

The undermentioned officers have vacated appts. in 
India :— 

D.D.M.S.—Maj.-Gen. J. F. Martin, C.B., C.M.G., 
C.B.E., K.H.S., Brit. Serv. 

A.D.M.S.—Maj.-Gen. A. W. M. Harvey, K.H.S., 

D.A.D.H.—Maj. J. W. F. Albuquerque, I.M.S. 

The undermentioned appts. have been made in India :— 
: eee ere eae A. W. M. Harvey, K.H.S., 

.M.S. 
Maj.-Gen. G. A. D. Harvey, C.M.G., Brit. Serv. 


COLONIAL MEDICAL SERVICE 


Dr. W. Barnetson has been appointed Medical Officer, 
Uganda, and Dr. G. L. Timms, Medical Officer, Kenya. 


DEATHS IN THE SERVICES 
The death occurred on Feb. 17th at Plymouth of 


‘Lieut.-Col. THomas HERBERT CoRKERY, R.A.M.C. retd. 


He was born at Poona in 1861, and qualified in 1884 with 
the Scottish double diploma. He joined the Army as a 
surgeon in January, 1886, accompanied the expedition 
to Manipur in 1891, receiving a medal with clasp. He 
also served in Burma 1891-92, and with the expedition 
to Kachin Hills, for which he received a clasp. On 
retiring from the active list in 1906 with the rank of 
lieut.-colonel he was employed at Exeter until 1911, and 
three years later was recalled to service during the European 
war. 


THE American Academy of Arts and Sciences 
announces that the first award of the Francis Amory 
septennial prize, which is offered for contributions 
of ‘‘extraordinary or exceptional merit” to our 
knowledge of the diseases of the human generative 
organs, will be made in 1940 if work of sufficient 
merit is put forward. The total amount of the 
prize will exceed ten thousand dollars, and it may be 
given in one or more awards. There will be no 
formal nominations and no essay or treatise will be 
required; but the committee invites suggestions, 
and these should be sent to the Academy at 28, 
Newbury-street, Boston, U.S.A. 


448 THE LANCET] 


[FEB. 22, 1936 


CORRESPONDENCE 


MEDIASTINOTOMY FOR SURGICAL 
EMPHYSEMA 


To the Editor of THE LANCET 


Sir,—Generalised surgical emphysema may or 
may not be a clinical rarity when associated with 
pulmonary tuberculosis, as in the case reported in 
your current issue. It may, however, be a fatal 
condition when it complicates either disease or 
injury. The fact that such cases may be saved by 
the early performance of the (almost minor) operation 
of suprasternal (collar) mediastinotomy does not, 
strangely enough, seem to be generally appreciated, 
even amongst surgeons. A simple incision, immediately 
above the sternum, down to and through the deep 
fascia, allows the air, often pent up under considerable 
tension, to escape freely. The operation may be 
done with the patient in bed, and, if not withheld 
too long, the way in which a hitherto generalised 
emphysema will subside within a few hours can 
only be described as dramatic. 

I am, Sir, yours faithfully, 
GEORGE A. MASON. 

Newcastle-upon-Tyne, Feb. 17th. 


CHILD BORN WITH A FOREIGN BODY IN 
THE HEART 


To the Editor of THE LANCET 


Sir,—Drs. Eaton and Corbet, having found at 
autopsy a small metallic foreign body in the right 
ventricle of a new-born child’s heart, suggest with 
assurance that the object must have been within the 
uterus at the time of conception, and that the embryo 
“ grew around it.” Although gold and silver intra- 
uterine contraceptives may fail in their purpose and 
appear as neonatal decorations, it is difficult to see 
how this particular foreign body, which was 3 by2mm., 
came to be lying free within the right ventricle of 
what we take to be an otherwise normal heart, if 
we have to rely on your correspondents’ suggestion 
that the embryo must have virtually wrapped itself 
around the object. The heart is already well 
developed though tubular after 26 days or so, at 
which time the whole embryo would only be of the 
size of the foreign body ! One cannot imagine inclusion 
of such a body and the subsequent development of 
anything like a normal fœtus. Surely a more reason- 
able explanation is that the object, lying within the 
uterus, was involved between true and capsular 
decidua and thus came to be incorporated in the 
blood sinuses of the placenta, whence it became 
dislodged, probably during the commotion of labour, 
and passed via umbilical vein to the right heart. 


I am, Sir, yours faithfully, 

Guy’s Hospital, S.E., Feb. 17th. J. R. AUDY. 

TRANSMISSION OF RELAPSING FEVER BY 
TICKS IN PALESTINE 


To the Editor of THE LANCET 


Sır, —It has been suspected since the late war 
that there is a relapsing fever in Palestine transmitted 
by ticks. The fowl tick, Argas persicus, which is 
widely disseminated in Palestine, has been wrongly 
suspected. Recent investigation of a small outbreak 
of relapsing fever in Kfar Vitkin, south of Hedera 
in the coastal plain, showed that all infections could 
be traced to acave infested with Ornithodorus papillipes. 


Ticks collected in the cave readily transmitted 
spirochetes to rats in the laboratory. This tick 
produces a local analgesia while biting and there is 
therefore no reaction (scratching) on the part of the 
victim. Coxal fluid and feces are not excreted during 
feeding. Transmission is therefore obviously by 
bite, and contamination plays no part. The entry 
of spirochetes into the skin from the proboscis of 
infected ticks was demonstrated experimentally, 
Three infected ticks (adults) were fed on a human 
being during an intermission between two relapses; 
immediately after feeding the puncture wounds were 
examined and spirochetes demonstrated in smears 
stained with Giemsa. A similar experiment performed 
on a clean rat gave an identical result; spirochetes 
were easily demonstrated in the smears and the rat 
subsequently became infected. 


We are, Sir, yours faithfully, 
S. ADLER, O. THEODOR, 
H. ScCHIEBER, 


Department of Parasitology, the Hebrew University, 
Jerusalem, Jan. 29th. 


PURIFICATION OF THE HAZMOPOIETIC 
FACTOR 


To the Editor of THE LANCET 


Sir,—In your annotation last week there is a slight 
misunderstanding as to the “maximally effective 
dose ”?” of Dakin and West’s liver fraction. A single 
dose which is effective for the production of maximal 
reticulocyte responses is not necessarily sufficient 
to produce an increase of red blood-cells at a maximum 
rate over periods of from 10 to 20 days or more. It is 
therefore incorrect to compare the single doses of 
80-150 mg., which in Dakin and West’s series usually 
produced maximal reticulocyte responses, with the 
average amount (359 mg.) which, given in divided 
doses to 11 of our cases, was followed by a certain 
average rate of red blood-cell increase in 40 days, 
since, in the former series, data regarding the red 
blood-cell increases following the reticulocyte crises 
are not available. A comparison of reticulocyte 
responses following single doses of material is given 
in Table II. of our paper, and the conclusion is that 
for the production of maximal reticulocyte responses 
single doses in excess of 100-200 mg. are usually 
required.—We are, Sir, yours faithfully, 

C. C. UNGLEY, E. J. WAYNE, 
L. S. P. DAVIDSON. 


Newcastle-upon-Tyne, Feb. 14th. 


HOSPITALS AND THE RATES 
To the Editor of THE LANCET 


Sir,—My attention has been drawn to a serious 
inaccuracy in a statement on the rating of hospitals 
made to our last court of governors. In a comment 
upon the wide variation in assessments throughout 
the country the Newcastle hospitals were cited as 
among those either not rated or subsided by municipal 
authorities. This is not the case. My board regret 
that this unfortunate slip has caused trouble to the 
management of the Royal Victoria Infirmary, and 
would be grateful if you would publish this correction. 


J am, Sir, yours faithfully, 
S. R. C. PLIMSOLL, 


Secretary-Superintendent, The Middlesex Hospital, W.1. 
Feb. 18th. 


THE LANCET] 


STAMMERING NOT A SPEECH DEFECT 


Miss KATE EmiIt-BEHNKE writes: “I have read 
with great interest the annotation on this subject 
in your issue of Jan. 25th (p. 208). If the dictum 
‘Define your Terms’ had been acted upon in the 
past in the consideration of stammering the fatal 
error would not have been made of regarding it as 
a defect of speech. By ‘defect’ is generally under- 
stood a permanent disability, which in its application 
to speech indicates an ever-present inability to 
articulate some letter correctly, such as lisping, whereas 
there is no letter that a stammerer cannot at times 
enunciate perfectly. Curiously enough, this very 
variability in its incidence has contributed to the 
misconception as to the true nature of the trouble, 
leading to two assumptions both of which prevent 
treatment being undertaken in the early stages, when 
it can be speedily and permanently overcome. One 
assumption is that the trouble will be outgrown, 
a view which is encouraged by the fact that as 
stammerers grow older they become adroit at evading 
words which present a difficulty and substituting 
others. The second assumption is that the stammer 
is due to carelessness, the latter idea being very 
naturally fostered by there being many occasions 
on which no stammering is present. 

‘* Undoubtedly stammering is in essence a neuro- 
pathic condition, and suitable treatment should be 
applied directly there is any sign of it, when it will 
yield to psychic handling combined with ‘ relaxing’ 
and quiet deep breathing exercises. If the trouble 
is not attended to derangement of the entire 
musculature of respiration, phonation, and articula- 
tion follows, leading not only to the establishment 
of the ‘fear’ complex but to wrong muscle action, 
both of which can, later, only be conquered at the 
cost of considerable expense, time, and patience. 
The resultant derangement is so great and so obvious 
that it has led to the serious error of adopting 
elocutionary treatment which is not only useless, 
but in the majority of cases makes the trouble far 
worse by focusing the stammerer’s attention on 
symptoms and not on the cause. 

«It was formerly held that it was useless to 
attempt treatment before the age of ten. Present- 
day knowledge enables it to be applied as early as 
three or four years of age—in other words, when 
the trouble first appears.” 


THE GRINSTEAD SERPENT 


‘‘ ALBUS” writes: ‘‘ Objections have been made 
to the symbol of the serpent surmounting the 
Grinstead Hospital, as it has been held to be the 
symbol of evil. It is true that the serpent is 
introduced into the story of the Fall as the symbol 
of evil united with wisdom, because it was under this 
form that he beguiled Eve. Revelation xii.. 9, states: 
‘ And the great dragon was cast down, the old serpent, 
he that is called the Devil and Satan, the deceiver 
of the whole world.’ Serpents were early recognised 
to be dangerous and the idea arose to escape evil 
by propitiating the power that was behind it; hence 
serpent worship, a form of superstition widely spread. 
Good qualities were then attributed to the object 
of worship, especially the power of healing; this 
may have determined the display of a brazen serpent 
as the means of curing the snake-bitten Israelites. 
Large snakes were usually kept in the shrines of 
Esculapius and appear sometimes to have been 
regarded as the God himself; patients in the shrines 
had visions in which some action is taken by snakes 
or dogs. The snakes thus seen in dreams were 
connected with healing and not evil. 

‘ Superstition has clustered round snakes. The 
ssnake has been regarded as a symbol of hygiene 


THE GRINSTEAD SERPENT.—VITAL STATISTICS 


[FEB. 22, 1936 449 


because he shed his skin so frequently while renewing 
his health. The snake is also a symbol of eternal 
life in the form of a living ring when the snake has 
his tail in his mouth. In Hindu mythology, said 
Monier-Williams, the Sanskrit scholar, a curious 
race of serpents, half human, half divine, called 
ee Sg is supposed to exist in the regions under the 
earth. 

“The caduceus is a subject of controversy. It 
has been used as a medical emblem in, for example, 
the French military corps, our own R.A.M.C., and 
the arms of Dr. Caius, the second founder of Gonville 
and Caius College. The usual emblem employed is 
a staff around which two serpents are interlaced, 
though one serpent only is occasionally present 
as in the R.A.M.C. emblem. The medical connexion 
of course is that the device is accepted as the sign 
manual of Atsculapius, although the original emblem 
of Atsculapius was a club with one serpent coiled 
round it, symbolising the snake’s power of renewal. 
The staff with two serpents coiled round it was not 
connected with medicine originally. It was the 
device borne by the messengers of the gods, especially 
Mercury ; in its original form the staff was surmounted 
with a knot of ribbons for which later two intertwined 
snakes were substituted. As however no existing 
activities are represented by the action of the 
messengers of the Gods in’ conducting souls to the 
world below, the staff, now with intertwined serpents, 
has come to stand for the art of medicine. The 
application of the term caduceus or wand of Mercury 
to the staff.and serpent of Epidaurus which symbolises 
sculapius is therefore erroneous. There is a more 
commonplace and humorous interpretation of the 
rod with its interlaced snakes; it has been held to 
signify concord between merchants in competition ; 
the serpent has always symbolised astuteness, 
eloquence, and seductiveness, qualities in keeping 
with this commercial interpretation of the caduceus.” 
A fine large example of the wand can be seen on the 
new metal outer door of the Bank of England. 


INFECTIOUS DISEASE 


IN ENGLAND AND WALES DURING THE WEEK ENDED 
FEB. 8TH, 1936 


Notifications.—The following cases of infectious 
disease were notified during the week: Small-pox, 0 ; 
scarlet fever, 2270; diphtheria, 1370; enteric fever, 
23; acute pneumonia (primary or influenzal), 1472 ; 
puerperal fever, 44 ; puerperal pyrexia, 132 ; cerebro- 
spinal fever, 17; acute poliomyelitis, 2; acute polio- 
encephalitis, 1 ; encephalitis lethargica, 6 ; dysentery, 
32 ; ophthalmia neonatorum, 82. No case of cholera, 
plague, or typhus fever was notified during the week. 

The number of cases in the Infectious Hospitals of the London 
County Council on Feb. 14th was 4257, which included : Scarlet 
fever, 1012; diphtheria, 1094; measles, 816; whooping- 
cough, 697; puerperal fever, 19 mothers (plus 14 babies) ; 
encephalitis lethargica, 283; - poliomyelitis, At St. 
Margaret’s Hospital there were 20 babies (plus 6 mothers) 
with ophthalmia neonatorum. 

Deaths.—In 121 great towns, including London, 
there was no death from small-pox, 1 (0) from enteric 
fever, 54 (5) from measles, 7 (0) from scarlet fever, 
28 (10) from whooping-cough, 39 (4) from diphtheria, 
45 (24) from diarrhoea and enteritis under two years, 
and 85 (11) from influenza. The figures in paren- 
theses are those for London itself. 

The mortality from influenza is on the wane, the total deaths 
for the last ten weeks, working backwards, being 85, 98, 104, 
89, 110, 110, 80, 67, 62, 45. The deaths this week are scattered 
over 44 great towns, Bristol reporting 5, Manchester and Bir- 
mingbam each 4, Halifax, Liverpool, St. Helens, Sheffield, and 
Stoke-on-Trent each 3, no other great town more than 2. 
Manchester had 10 deaths from measles, Liverpool 7, Salford 
and Bristol each 4. Whooping-cough caused 5 deaths at Bir- 
minghum. Deaths from diphtheria were reported from 25 great 
towns, 4 from Hull, 3 from Newcastle-on-Tyne, 2 each from 
Wood Green, Reading, Middlesbrough, St. Helens, Salford, 
Wakefield, and Swansea. 

The number of stillbirths notified during the week 
was 272 (corresponding to a rate of 40 per 1000 
total births), including 38 in London. 


450 THE LANCET] 


[FEB. 22, 1936 


a 


OBITUARY 


SIR CHARLES BALLANCE, K.C.M.G., C.B., 
M.S. Lond., F.R.C.S. Eng. 
CONSULTING SURGEON, ST. THOMAS’S HOSPITAL 


THE death occurred, as we announced last week, 
on Saturday, Feb. 8th, of Sir Charles Ballance, the 
distinguished surgeon and neurologist, consulting 
surgeon to St. Thomas’s Hospital. He had been in 
delicate health for some time, though his final illness 
was not a long one. 

Charles Alfred Ballance was the eldest son of the 
late Charles Ballance, of Stanley House, Clapton. 
The father died in 1873 leaving four sons and four 
daughters, the eldest son being ‘only 17 at the time. 
The family had lived in Taunton previous to migra- 
tion to London, and 
Charles Ballance went 
to Taunton College and 
for a period on the 
continent for his early 
education before enter- 
ing St. Thomas’s Hos- 
pital as a student. It 
is an interesting fact 
that the three younger 
brothers followed their 
senior’s example in the 
choice of a profession, 
the surviving one being 
Sir Hamilton Ballance. 

Ballance entered St. 
Thomas’s Hospital in 
1876 and was from the 
first a distinguished 
student. He took the 
English diplomas in 
1879, and in 1881 gradu- 
ated as M.B. Lond. with 
first-class honours in 
each subject, and B.S. 
as gold medallist. In 
. the following year he 
obtained the diploma of 
F.R.C.S. Eng. and the 
degree of M.S., when he 
was again gold medallist. 
At St. Thomas’s he filled 
a series of resident posts, 
becoming later surgical 
registrar to the hospital 
and demonstrator of anatomy. He spent the time 
of waiting in anatomical and bacteriological research 
in London and in Leipzig, where he attended the first 
bacteriological course opened in the university, a 
veteran experience to which he would often allude. His 
first staff appointment at St. Thomas’s came promptly 
—it was that of assistant aural surgeon, and in the 
same year he was elected assistant surgeon to the 
West London Hospital. He was also appointed 
examiner in elementary anatomy at the Royal 
College of Surgeons of England where he delivered 
in 1889 the Erasmus Wilson Lecture on the ligation 
of arteries. This lecture indicated the direction 
which Ballance’s first original researches had taken, 
and in our columns last week Sir Charles Sherrington 
described graphically the intensity with which 
Ballance and Walter Edmunds worked out their 
valuable and practical conclusions. These researches 
were followed up by the eager quest with S. G. 
Shattock for parasitic protozoa, hoping thus to 


SIR CHARLES BALLANCE 
[Photograph by Elliott & Fry 


determine the etiology of malignant disease. As 
is known, despite the elaborate pains and time 
expended, no conclusive results were reached. 
But Ballance became known to the surgical world as 
a coming man, and to this position he was aided by 
his writings. He contributed to Heath’s “ Dictionary © 
of Surgery ” the article on meningocele and encepha- 
locele, and that on injuries and diseases of the scalp ; 
in the Transactions of the Pathological Society he 
wrote, in association with Shattock, on the intimate 
pathology of cancer; to the Journal of Physiology 
he contributed in collaboration with Sherrington a 
paper on the genesis of scar tissue; while other 
papers, all the result of personal investigation, 
appeared in the Transactions of the Medical Society, 
of the Clinical Society, 
and frequently in the 
St. Thomas’s Hospital 
Reports. The Erasmus 
Wilson Lecture became 
the foundation of a book 
written in collaboration 
with Edmunds, who was 
the first medical super- 
intendent of St. 
Thomas’s Home — an 
excellent surgeon and a 
keen experimental in- 
vestigator. The joint 
work proved that the 
results up to that day 
of operations upon great 
arteries were unsatisfac- 
tory, the danger of 
secondary hemorrhage 
being a pressing one, 
and the authors set out 
to show how such fail- 
ures came about and 
how they could be 
avoided. An elaborate 
series of experiments 
continued over six years 
was detailed in the 
treatise. Ballance wrote 
also soundly on various 
directions of aural prac- 
tice in Allbutt’s “‘ Sys- 
tem of Medicine’’ and 
in the St. Thomas's 
Hospital Reports, and in the Transactions of the 
Medical Society of London and those of the Medico- 
Chirurgical Society. In 1891 Ballance was appointed 
surgeon to the National Hospital for Paralysis and 
Epilepsy where he worked with Victor Horsley with 
whom he had previously been associated at the 
Browne Institute during Horsley’s superintendency. 
His claims to the appointment were strong. 
Ballance’s experiments on nerve-suture and nerve- 
grafting were elaborate. On this work he was engaged 
for many years, in collaboration with Sir James 
Purves-Stewart, the publication of the results being 
however delayed by Ballance’s absence at the South 
African war. They appeared at last in 1902 in 
an illustrated ‘quarto volume in which the experi- 
ments were fully described, the process of degenera- 
tion in the peripheral nerve after injury and of 
regeneration in a divided nerve being carefully 
set out, while a good historical résumé and biblio- 
graphy were appended. The experimental work was 


THE LANCET] 
afterwards explained by the authors at a meeting 
of the Royal Medico-Chirurgical Society, where in 
the discussion which took place Sherrington, Mott, 
Rickman Godlee, and other experts debated at 
length the conclusions of the authors, which were 
found to be of high practical value. 

In a large number of public deliveries Ballance 
throughout his career informed his hearers of neuro- 
logical progress and of the methods employed by 
himself and those with whom he worked. Such an 
address was delivered at Brighton in 1907 when 
he gave a vivid account of his personal experiences 
in cranial surgery. Comparing the indications for 
opening the abdomen with those for opening the 
skull, he pointed out that the diagnosis of intra- 
cranial disease is the far more complex problem, 
while exploratory operation cannot be conducted 
with the same rapidity and completeness. Thus he 
found the maxim that diagnosis should precede 
operation to be true only of those diseases where 
the signs, Symptoms, and course can be fully com- 
prehended ; where danger will attend delay provi- 
sional diagnosis must be acted upon, while the most 
eminent neurologists will occasionally differ as to 
the localisation of a brain tumour. He recorded 
cases where intracranial intervention had been called 
for by the obvious conditions found, and paid a 
tribute to the value of X ray photography at the 
stage which it had reached 30 years ago. The 
address was a good example of the speaker’s power, 
frequently displayed, of dealing with large subjects 
clearly and succinctly, a faculty which he kept 
throughout his life—instances, the Lister Memorial 
Lecture, the MacEwen Memorial Lecture delivered 
in 1930 at Glasgow where the university conferred 
upon him the LL.D. degree, and the address on the 
progress of surgery delivered in 1906, as president of 
the Medical Society of London. l 

Ballance’s contributions to medical literature, if 
published in volume form, would have shown him 
a prolific author, but although he might have con- 
structed many books by compilation, only two stand 
to his individual name—viz., “‘ Points in the Surgery 
of the Brain and Membranes,” and “‘ Essays on the 
Surgery of the Temporal Bone.” The latter, published 
in 1919, was a massive production, for the subject 
was dealt with in two large volumes, while the 
format and illustrations compelled its issue at a 
very high price. The valuable display of plates 
offered a possible substitute for study in the museum 
and post-mortem room, while the text was erudite, 

the result of ripe experience and high literary capa- 
city. The volumes traversed the history of the 
surgery of the temporal bone and described in detail 
the intracranial complications of the pathology of 
the region. The book was written as a plea for the 
better recognition of the importance of aural surgery 
and the provision of additional beds for aural 
patients. 

Ballance had important and intimate relations 
with the Royal College of Surgeons of England. The 
Erasmus Wilson Lecture he delivered shortly after 
he obtained the Fellowship, while early in his career 
he was appointed an examiner in anatomy. And 
at this end of his life he was working at the labora- 
tories of the College at Down with undiminished 
interest in neurological research. He was elected 
to the council of the College in 1910, was a 
member of the court of examiners for ten years, and 
of the council for 16 years, becoming in 1920 vice- 
president of the College. In 1919 he delivered the 
Bradshaw Lecture upon surgery of the heart (THE 


OBITUARY 


[FEB. 22, 1936 451 


LANCET, i., 1, 73, and 134), in 1921 the Thomas 
Vicary Lecture on the history of surgery of the brain 
(THE LANCET, 1922, i., 111, 165), and in 1933 delivered 
the Lister Memorial Lecture, in which he showed 
that his early investigation into the cause of malig- 
nant disease was still vivid in his mind. In the 
address he described the work done with Shattock on 
the appearance of incubated carcinomatous cells, 
to which Sir Charles Sherrington referred last week, 
and on this occasion the Lister medal was conferred 
on him for his distinguished contributions to surgical 
science, an honour shared with his friends Harvey 
Cushing and Watson Cheyne. | 

Ballance had worked with Cushing on more 
than one occasion in America; latterly he spent a 
long period in the States where full opportunities 
for experimental work were afforded him, and where 
his position as a neurologist stood very high. Unfor- 
tunately this visit coincided with the sudden and 
acute dislocation of financial affairs in the United 
States, and although Ballance worked with his 
usual thoroughness, his physiological experiments 
were necessarily impeded for want of material. 

Ballance was the first president of the Society of 
British Neurological Surgeons. ‘‘ He founded the 
society,” says Mr. Geoffrey Jefferson, “‘ but charac- 
teristically refused to hold office for more than one 
year, insisting on relinquishing office for Mr. Wilfrid 
Trotter. The society replied by making him honorary 
president.” Mr. Jefferson also writes in admiration 
of Ballance’s enthusiasm maintained to the end of 
his life for the fields of investigation which he had 
cultivated. ‘‘ He was,” he says, “a regular attendant 
at meetings, and at the age of 77 he journeyed to 
Edinburgh and Aberdeen to show his films of experi- 
mental nerve anastomosis; and later to Manchester. 
He belonged to an age in neuro-surgery which 
is past, and his chief value in discussion was his 
reminiscence of famous happenings of bygone days. 
Nevertheless his comments on current trends and 
events were always most trenchant, and though he 
admired the past his wits were definitely in the 
present. He endeared himself to us all by his friend- 
liness, his encouragement, and the genial banter of 
his conversation.” Prof. Archibald Young writes in 
similar vein of “‘ the generous readiness and enthusiasm 
with which Ballance received new work by a junior 
colleague. In the deliberations of the Society of 
British Neurological Surgeons his searching but kindly 
criticism was always welcomed. In spite of advancing 
years he remained very much the young man, and in 
his latest years did some of his most remarkable work 
on nerve anastomosis and regeneration.” 

Ballance had a distinguished war record. He was 
called up on the outbreak of hostilities with the rank 
of colonel, A.M.S., and did valuable service in the 
Mediterranean during the war years, stationed in 
Malta. He was several times mentioned in dis- 
patches, and in 1916 was made C.B. (Mil.). The 
University of Malta gave him a medical degree. In 
1918 he was made K.C.M.G. 

We have here a picture of a singularly consistent 
career. Ballance vowed himself to surgery almost as 
a boy, and never deviated from the obligations. In 
the ward and in the operating room, as in the labora- 
tory, he was single-hearted in his search for the 
truth. He was a man of wide reading, as would 
appear from the quotations in his numerous addresses, 
but in everything that he wrote he kept the same 
unswerving path, the same determination to advance 
medical knowledge by the records of experiment and 
observation. 


452 THE LANCET] 


Sir Charles Ballance married in 1883 Sophia 
Annie, daughter of the late Alfred Smart, of Black- 
heath, who died ten years ago. They had one son 
and several daughters, but the son, Dr. Alaric 
Ballance, to his father’s intense grief, died quite 
young in 1932, 


. ADOLPH BRONNER, M.D. Heidelb., M.R.C.S. Eng. 


THE death occurred on Feb. 7th at the age of 75 
of Dr. Adolph Bronner, well known as ophthalmologist 
and laryngologist. He was a profuse contributor 
both to English and foreign journals on his specialties, 
and his work at Bradford earned him a wide reputation. 


Adolph Bronner was born in 1860 the younger 
son of the late Dr. Edward Bronner, who founded, 
in coöperation with the late Dr. John Bell, and with 
the financial assistance of Sir Jacob Behrens, the 
Bradford Royal Eye and Ear Hospital. He was 
educated at Bradford High School and Bradford 
Grammar School, receiving his medical training 
at the universities of London, Heidelberg, Freiburg, 
and Berlin. He graduated at Heidelberg as M.D. 
in 1884 and in the following year took the diploma 
of M.R.C.S. The early direction of his studies was 
indicated by an appointment at the Royal London 
Ophthalmic Hospital and by an M.D. thesis 
on sympathetic ophthalmia. Appointed surgeon 
to the Bradford Eye and Ear Hospital in 1886 in 
succession to his father, he later became laryngologist 
at the Bradford Royal Infirmary. His contributions 
to the Transactions of the Ophthalmological Society 
covered a large range of subjects, while other papers 
which attracted attention will be found in the 
Archives of Otology (New York) and in the Transactions 
of the International Medical Congress at Rome of 
1894 where he acted as secretary to the laryngological 
section, and in those of the international meetings 
of otologists held at Paris in 1889, Berlin in 1890, 
and London in 1899. To the British Medical Journal 
and to these columns he also contributed many 
sound and interesting clinical papers, giving always 
practical information. 

Bronner was deservedly held in high esteem by 
his Bradford colleagues and was at one time president 
of the Bradford Medico-Chirurgical Society and at 
another president of the Leeds Medico-Chirurgical 
Society. At the time of his death he was consulting 
surgeon both to the Bradford Royal Eye and Ear 
Hospital and consulting laryngologist to the Bradford 
Royal Infirmary. 


Prof. F. W. Eurich writes: “Dr. Adolph Bronner 
had retired only 13 years before his death but so 
great had been the changes in the professional life 
of Bradford that there are now not a few to whom 
he has been little more than a name. There will 
however be many former patients who remember 
him as their benefactor and friend and they will be 
widely scattered for they came not from the West 
Riding only but from the Yorkshire dales and neigh- 
bouring counties. After the death of his father 
Dr. Edward Bronner, his elder brother took the 
family practice, leaving Adolph Bronner to devote 
himself to diseases of the eye, ear, and throat. He 
built upon foundations laid by his father but soon 
made a great name for himself both among his 
colleagues and the public. It could not have been 
otherwise for he combined with deep knowledge and 
with great skill as an operator a cheeriness and a 
kindness of heart which won him the affection of all. 
` Even in the thronged life of hospital practice he was 
never brusque. He would care for more than the 


OBITUARY 


[FEB. 22, 1936 


special trouble for which his advice was sought, and 
many a sovereign and even now and then a five- 
pound note would be passed surreptitiously to some 
needy patient. When he retired from hospital 
practice a tablet commemorating his great services 
was placed beneath that dedicated to the memory 
of his father in the entrance-hall of the Bradford 
Eye and Ear Hospital. A year or two later he left 
Bradford to enjoy his hobbies—golf and fishing, but, 
a bachelor, he never settled anywhere, coming back 
at last to die in the city he had served so well.” 


ALFRED SAMUEL GUBB, M.D. Paris, D.P.H. 


WE regret to learn the death of Dr. Alfred Gubb, 
who 50 years ago was very well known to many of his 
London colleagues ; for the last 30 years he practised 
on the continent, mainly in Algeria. 

Alfred Gubb was born at Abingdon in 1857, the 
son of Edwin John Gubb, a lecturer in science. He 
received his medical education at the Westminster 
Hospital, where he was Bird prizeman and a medallist, 
and later at the University of Paris, where he 
graduated in medicine in 1885. He was appointed 
resident obstetric assistant to the Westminster 
Hospital and then for a year was resident medical 
officer at the French Hospital in London. He had 
a considerable continental connexion, held a post 
as medical adviser to the Belgian Consulate and 
for some time was English correspondent of La Semaine 
Médicale. From 1898 to 1903 he was editor of the 
Medical Press and Circular, with which journal he 
maintained his connexion until quite recently as 
a translator of articles fram the French. To The 
Lancet he made occasional contributions, either 
in connexion with materia medica or with obstetric 
medicine. These subjects furnished him with the 
material for a useful little book ‘‘ Aids to Gynecology ” 
and qualified him to edit Griffith’s ‘‘ Materia Medica 
and Pharmacy.” More than 30 years ago Gubb 
decided to practise abroad and at first spent half 
the year in Aix-les-Bains and the remainder in 
Algeria. From Algeria he made from time to time 
interesting communications on the climate, flora, 
and natural features of the country. Some of those 
he put together into pamphlets or albums, as he 
elected to call them, because of their profuse illustra- 
tions, and he maintained for a period a close associa- 
tion with British practitioners wishing to send 
patients abroad. He died on Feb. 3rd at Mustapha 
Supérieur, Algiers. 


ETHEL MILLER VERNON, M.D. Lond. 


THERE died on Jan. 19th Dr. Ethel Vernon, a 
prominent woman practitioner who had been in 
general practice in Westminster for over 30 years. 
She was the eldest daughter of Thomas Heygate 
Vernon. Three members of the family entered the 
medical profession, the others being Dr. Horace 
Vernon, a well-known authority on hygiene, and 
Mr. Arthur Heygate Vernon, a skilful and successful 
surgeon at Bournemouth, whose death occurred 
last year. 

Ethel Vernon was one of the earliest women to 
qualify through the London School of Medicine for 
Women, obtaining the L.S.A. in 1897 and four 
years later graduating as M.D.Lond., at that date 
an unusual distinction. At the London School of 
Medicine for Women she was demonstrator of 
physiology, while she acted as house surgeon and 
house physician at the New Hospital for Women 
and as assistant anesthetist at the Royal Free Hospital. 


THE LANOET] 


She then went into private practice, midwifery 
occupying most of her time at the commencement. 


In this capacity she became the adviser and in many 


cases the personal friend of a large number of her 
patients, her success as family counsellor being 
due not only to clinical accomplishment, but to 
close understanding of the domestic problems which 
arise in households where the daily cares weigh 
heavily on the mother. She carried her sympathy 
to a high level of personal responsibility, denying 
herself to assist the sick mother or child and often 
placing her seaside home at their disposal. For over 
20 years she worked hard for the promotion of child 
welfare, was medical adviser to the Borough-road 
Infant Welfare Centre, the Sutton Nursery School, 
and Highgate School for Girls, while since 1919 she 
had been medical officer to two Westminster welfare 
centres. She shortened her life by her devotion to 
her work. A woman of unusually robust constitution 
and physique, she remained at work throughout the 
recent severe cold period and succumbed unexpectedly 
to an attack of pneumonia. The memorial service 
held at St. Martin-in-the-Fields proved by the large 
congregation of mourners the esteem and affection 
in which she was widely held. 


RICHARD VERNON FAVELL, M.R.C.S. Eng. 


Dr. Richard Favell, who died on Feb. 4th aged 55, 
was a student at St. Bartholomew’s Hospital, where 
he took the double English diploma in 1906 and held 
the appointments of house surgeon and resident 
midwifery assistant. He was also president of the 
Abernethian Society. He was a member of a well- 
known Sheffield family and at the beginning of his 
professional career practised in partnership with 
his father, Dr. Richard Favell, senior. He continued 
in practice at Sheffield for a time and acted as anæs- 
thetist to the Sheffield Royal Infirmary, but retired 
some 12 years ago to Cornwall, living at St. Buryan, 
where his death occurred. In Cornwall he held many 
public offices, while he was a keen educationist and 
an accomplished archeologist and _horticulturist. 
He had been High Sheriff for the county where he 
was a considerable landowner, and was an F.S.A. 
Scotland. 


HUGH MILLER GALT, M.B. Glasg. 


WE regret to announce the death on Feb. 14th, 
at his home in Jersey, of Dr. Hugh Galt. Born at 
Kilmarnock and educated at Kilmarnock Academy, 
he entered the University of Glasgow as a medical 
student, graduating as M.B., C.M. with honours in 
1891 and being also a prizeman. He was for a time 
house surgeon and house physician at the Western 
Infirmary, Glasgow, and then went into the service 
of the P. and O. Company. Later he acted for a time 
as dispensary physician at the Infirmary, obtained 
the D.P.H. in 1896, and that of F.R.F.P.S. Glasg. 
in 1898. He was appointed professor of forensic 
medicine and lecturer in hygiene at St. Mungo’s 
College, Glasgow, and was for a period dean of the 
medical faculty, and pathologist and lecturer on 
hygiene at the Glasgow Royal Infirmary. His 
services as examiner were frequently in demand, 
for he acted in this capacity both in medical juris. 
prudence and in hygiene for the Scottish Conjoint 
Board, and in medical jurisprudence for the Royal 
Faculties of Glasgow. Some 25 years ago Galt left 
Glasgow and going to Brighton was appointed 
pathologist to the Stephen Ralli memorial laboratory 
at the Royal Sussex County Hospital. He took an 


OBITUARY 


. Lancaster 


[FEB. 22, 1936 453 


active part in the Brighton and Sussex scheme for the 
prevention of venereal disease, while his services as 
an expert witness were often in demand. During 
the war he was attached with the rank of captain, 
R.A.M.C., to the 2nd Eastern General Hospital, 
Brighton. 

Galt, who was for a period Crown medico-legal 
examiner for Glasgow and Lanarkshire, had made 
during his career as a jurisprudent an enormous 
number of post-mortem examinations and given 
medical evidence in several sensational trials. He 
retired from practice two years ago. — 


RICHARD JOHN MORRIS, C.B.E., M.D. Durh., 
M.R.C.P. Lond. 


THE death occurred at Harrogate on Jan. 23rd 
of Dr. R. J. Morris, after a long and painful illness 
bravely borne. 


Richard John Morris was born at Rosscarbery, 
Co. Cork, and received his education at the Diocesan 
School, Rosscarbery, and Queen’s College, Cork. 
After graduating as L.S.A. in 1884 he settled 
in practice at Lancaster. Here he joined the 
Volunteer Battalion of the King’s Own Royal 
Regiment from which he retired in 
1910 with’ the rank of Major. An excellent rifle 
shot, he captained the Irish International Twenty 
Team at Bisley from 1896-1900. After his marriage 
in 1895 he entered St. Bartholomew’s Hospital and 
qualified as M.R.C.S., L.R.C.P. in 1900, subsequently 
taking the M.D.Durh. and M.R.C.P.Lond. He 
studied at Bordeaux under Prof. Bergonié, and then 
settled in Harrogate as a spa physician. In 1915 
he was appointed to the Northern Command Depôt 
at Ripon with the rank of Lieut.-Colonel. For his 
services he was made Commander of the Order of 
the British Empire. At the end of the war he had 
a severe illness from which he never entirely recovered ; 
but in spite of ill-health he continued with his 
practice, and during this period was successively 
chairman of the Harrogate division of the British 
Medical Association and president of the Harrogate 
Medical Society. 

Dr. Morris was a good sportsman and a good friend ; 
he will be much missed by those who knew him best. 
He leaves a widow for whom sympathy will be felt. 
There are no children. 


LLOYD MIDDLETON BOWEN-JONES, 
M.R.C.S. Eng., D.P.H. 


THE death occurred on Feb. 2nd of Dr. Lloyd 
Bowen-Jones, of Carmarthen, who was well known 
in his district, having been medical officer of health 
for the borough for 33 years and of the Carmarthen 
rural district for a still longer period. The son of 
the Rev. Richard Bowen-Jones, J.P., he received 
his medical education at Guy’s Hospital, where he 
was for a time resident obstetric physician. He 
acted as house physician at the Seamen’s Hospital 
before returning to his native Wales to practise. 
There he held other local appointments in addition 
to those mentioned, and was in particular a pioneer 
in the fight against tuberculosis. He was personally 
responsible for large subscriptions to the erection 
of the West Wales Sanatorium, and when the institu- 
tion was taken over by the Welsh National Memorial 
Association he became chairman of the house com- 
mittee, while a ward opened at the sanatorium was 
named after him. Dr. Bowen-Jones was 83 years 
of age at the time of his death. 


454 THE LANCET] 


PARLIAMENTARY 


[FEB. 22, 1936 


NOTES ON CURRENT TOPICS 


School Home Work and Children’s Health 


Tue House of Commons on Feb. 12th agreed 
without a division to a motion by Mr. Radford that 
it is undesirable for school-children to have their 
evenings occupied with home work to the exclusion 
of rest and recreation, and that, whenever practicable, 
-~ preparation on the school premises should be sub- 
stituted for home work. Among many striking 
examples of abuse of home work he cited the testi- 
mony of a vicar whose choir boys attended a grammar 
school where so much home work was given that 
the boys had to work on Sundays in order to be 
ready for Monday. It was, he thought, extra- 
ordinary that such a state of affairs should be tolerated 
for, children of tender years by a nation so solicitous 
of their welfare when they were a little older.—Sir 
Ernest Graham-Little, in supporting the motion, 
said it was a reproach to a teacher if the child was 
required to do much home work; teachers were, 
however, handicapped by the size of their classes.— 
Mr. G. A. Morrison was more anxious for girls than 
boys in view of Sir Henry Hadow’s observation 
that if one gave a girl too much to do she broke 
down but if one gave a boy too much tø do he did 
not do it.—Mr. Potts, while agreeing that home 
work might be useful, thought there was a reasonable 
limit beyond which if they overworked children’s 
brains they were doing more harm than good.— 
Mr. Lees-Smith said the reason for overpressure, 
the curse of secondary education, was the school 
certificate examination, schools being judged by the 
number of their matriculation successes.—Mr. Oliver 
Stanley, in a sympathetic reply, said the Board of 
Education was actually in the middle of a compre- 
hensive inquiry into the whole question of school 
home work. The Government were determined to 
gee that whatever was wrong was remedied. 


Extension of Milk Subsidy Scheme 


In the House of Commons on Feb, 17th the financial 
resolution in connexion with the Milk (Extension 
of Temporary Provisions) Bill was considered in 
Committee. 

Mr. RAMSBOTHAM, Parliamentary Secretary to 
the Ministry of Agriculture, in moving the resolution 
recalled the circumstances of crisis in which the 
original Act was passed in 1934. He said that the 
milk marketing scheme then inaugurated was 
particularly welcome to the Board of Education 
because that Department had for some time been 
contemplating an intensive drive in the direction of 
more extended physical education and training for 
children, which would also necessitate greater attention 
to the health of the children so trained. It was 
obvious that they could not neglect the provision of 
better facilities for diet and nourishment for those to 
be trained. For that reason, the action taken under 
the Milk Act of 1934 to provide cheap milk for 
children was one of the best actions ever taken by 
any Government. The scheme was still in its experi- 
mental stage and there was need in many directions 
for further investigation. Even if it were possible 
at the moment to embark on a long-term policy it 
would still be advisable to operate the milk-in- 
schools scheme on an experimental basis to remove 
various difficulties before placing it on the permanent 
basis on which he trusted it would one day be placed. 
By the spring of 1935 the number of children in 
public elementary schools taking milk had increased 
to about 2,500,000. If they added the children in 
grant-aided schools the number to-day was in the 
neighbourhood of 2,750,000 and the consumption 
was just on 23,000,000 gallons. There were still, 
however, about 2,800,000 scholars who were not 


INTELLIGENCE 


drinking milk in schools, that was more than 60 per 
cent. of the school population. 

The Government to-day were faced with three 
alternatives. First, that the provisions of the Act 
of 1934 should be allowed to lapse. That would be 
deplorable. Secondly, they might retain the milk-in- 
schools scheme and terminate the assistance given 
to manufacturing milk, devoting the amount of 
that assistance to providing further cheap milk for 
children. That would severely shake the price 
structure of the industry, by leaving an immense 
gallonage on the manufacturing market. The Govern- 
ment were therefore left with the third alternative, 
which he recommended to the Committee. It was 
that they should continue their action along the 
lines of the 1934 Milk Act and extend those provisions 
in accordance with this financial resolution. 


CRITICISM OF GOVERNMENT POLICY 


Mr. T. JOHNSTON said he could not understand, 
when Mr. Ramsbotham said there must be a further 
investigation, what there was to investigate. The 
facts were beyond dispute. Men like Sir John Orr 
had committed themselves to the statements that 
we could increase the height of our school-children 
by 3in. and increase their weight by 4 to 61b., and 
the Leighton-McKinlay experiment in Lanarkshire, 
though covering only a period of four months, seemed 
to justify to the full the statements made by Sir John 
Orr and the other experts who had made this subject 
their own. We were facing now, in wintér time, 
27 per cent. of an alleged milk surplus, but the 
Government did not know what to do with it. They 
were providing considerable sums of money to 
convey the surplus into dried milk, condensed milk, 
and other uses. It was a remarkable fact that in a 
land where at least 10 per cent. of our people lived 
below the British Medical Association’s standard 
of nutrition, we raised money to destroy an absolutely 
essential food. 

There was a need for supplying liquid milk to the 
consumers of this country. 

As a result of prolonged study nutrition experts 
had discovered, particularly in the Newcastle area, 
that 47 per cent. of the children of the poor were 
below standard weight, that 23 per cent. were 
anemic, and 36 per cent. were unhealthy and unfit. 
The last report, for 1932, showed that 52 per cent. 
of the recruits applying for admission to the. British 
Army failed on physical grounds, and that of the 
48 per cent. who got through 36-9 per cent. were 
subsequently rejected on medical grounds. A League 
of Nations committee of experts reported on the 
Physiological Bases of Nutrition, and said that there 
should be at least one litre of milk a day for expectant 
and nursing mothers, as well as an abundant supply 
for infant children of all ages and adolescents. The 
practice of providing milk, either free or at a reduced 
price, was highly recommended. The Orr-Lloyd 
investigations showed that 10 per cent. of our people 
were not spending 4s. per head on food, yet the 
British Medical Association’s figure was 5s. 104d. 
per week as a minimum. There were at least another 
20 per cent. just on the borderline of the Association’s 
minimum standard. 

The hospitals, infirmaries, clinics, and poor-law 
institutions were in a terrible plight, and the Govern- 
ment were busily engaged in organising a policy of 
increasing the cost of milk to voluntary hospitals, 
infirmaries, and clinics. At the Royal Hospital for 
Sick Children in Glasgow the Government’s milk 
policy raised the cost of milk to these poor sick 
children by £500 a year. The cost to the Royal 
Infirmary had gone up by £1500. The jump in the 
figure for the hospitals of the Lanarkshire county 
council was £800, and for the Glasgow town council 
hospitals, £12,300. There was something inherently 
wrong in that. He recognised that it was not a 
practicable proposal at the moment to ask that milk 


THE LANCET] 


should be supplied free to the hospitals and institu- 
tions, but surely the Minister could make it imperative 
that the price to be charged for milk should be the 
pre-Milk Order price, that at which they were getting 
milk before the Marketing Boards started to raise 
prices. Then the hospitals and clinics would use 
more milk. 
After further debate, 


REPLY BY THE MINISTER OF AGRICULTURE 


Mr. ELLIOT said that 2,750,000 children were 
getting milk to-day who would not have been getting 
milk if these proposals had been defeated two years 
ago. Not only that, but they were getting milk at 
half the price at which they were getting it then, and 
another great army besides. What was more, the 
cheapening of the milk to the local authorities had 
meant the doubling of those who were getting milk 
entirely free. They had to do two things—to 
maintain the milk industry and the production of 
milk and also to secure so far as they could the health 
and upbuilding of the future generation. No greater 
injury could be done to either than to try to fuse 
the two. If they advanced the cause of health in 
the schools on the ground of merely finding a receptacle 
for the surplus of milk, or anything else, they would 
defeat their own objects. He welcomed the criticism 
which had been made about the defects in the milk- 
in-schools scheme and he was asking the Committee 
for a further extension of time in order to investigate 
them. This period of test—not of experiment— 
of administrative experience would be most valuable 
when they came, as they would within a few months, 
to the framing of the long-term policy in this section 
of agriculture. Refuting the suggestion that milk 
was being destroyed for food purposes the right hon. 
gentleman said that not a penny of Government 
money had been spent on any milk that was going 
to any other process than the processing óf milk 
for food. As to the improvement of the quality 
of the milk-supply steps had been taken by the 
Government and the Milk Marketing Board to 
improve the quality by making a levy on all producers 
and giving a bonus of a penny a gallon on all milk 
which came up to the standard of Grade A; and in 
a relatively short space of time they had brought 
27 per cent. or more of the milk up to Grade A 
standard. That was a far greater improvement in 
the quality and the cleaning up of the milk than had 
been obtained in any comparable time by any other 
administrative measure. When the statement was 
made that the Government should here and now 
adopt some ad hoc method for children, and more 
particularly for adults, in ensuring the consumption of 
milk, he thought that the Committee would be well 
advised to consider well before embarking on that 
step. He had heard suggestions that cards should be 
sold by the Ministry of Labour to the unemployed 
whereby they could buy more milk. That seemed 
to him to be coming terribly close to the issue of 
ration cards. There was a grave danger of segregation 
of the classes in some of these proposals. 

Mr. JOHNSTON: Will the right hon. gentleman 
say a word or two about the position of the hospitals 
and infirmaries and the increase that they have been 
compelled to pay 

Mr. ELLIOT said that while he had the utmost 
sympathy with the desire of those institutions to 
get their milk-supplies at a lower rate, he was afraid 
that he could not concede the main point that if they 
got them at a lower rate they would purchase more. 
As far as the hospitals were concerned it was exactly 
that case that he had tried to make again and again 
and he had been defeated by the obvious answer 
that the hospitals would buy as much as was 
necessary for the needs of their patients, but that 
no amount of cheap milk would alter the figures. 
Certainly if any scheme could be worked out he would 
support it forthwith. If not, then he was afraid 
they could not solve the question under this method ; 
they must wait for the long-term measure. 


The resolution was carried by 213 votes to 140. 


PARLIAMENTARY INTELLIGENCE 


as p - Te ee ee ee ea L 


[FEB. 22, 1936 455 


Committee on Child Adoption 


In answer to a question put to him in the House 
of Commons on Feb. 13th, whether he had considered 
the representations made to him in regard to the 
alleged existence of abuse in connexion with the 
adoption of children, Sir JOHN SIMON said he had 
appointed a committee to inquire into the matter’ 
consisting of Miss Florence Horsbrugh, M.P. (chair- 
man), Mr. Benjamin Edward Astbury, Mr. John 
Henry Harris, Mr. J. J. Mallon, LL.D., J.P., Mr. 
Brian Manning, F.C.A., J.P., Mrs. Montagu Norman, 
and Mr. Geoffrey W. Russell, with Mr. J. A. R. 
Pimlott of the Home Office (secretary). The com- 
mittee would inquire into the methods pursued by 
adoption societies or other agencies engaged in 
arranging for the adoption of children and report 
whether any, and, if so, what measures should be 
taken in the public interest to supervise or control 
their activities. 


-HOUSE OF COMMONS 
WEDNESDAY, FEB. 12TH 
British Red Cross Units in Abyssinia 


Mr. MANDER asked the Secretary of State for Foreign 
Affairs if he had information as to how many British 
subjects were serving Red Cross units in Abyssinia ; what 
attacks had been made on these units by the Italian air 
force; and whether any undertaking had been asked for 
or obtained from the Italian Government that no further 
attacks would be made on Red Cross units.—Mr. EDEN 
replied: According to such information as is available, 
I understand that 19 British subjects are serving in the 
British Red Cross hospital and other ambulance units, 
foreign and national, in Ethiopia. This figure does not 
include native dressers, transport drivers, and other junior 
non-European personnel recruited in Kenya or British 
Somaliland, for service with these units. As regards the 
second part of the question, I would refer the hon. 
Member to the reply I gave on Feb. 10th. As regards the 
last part, the Italian Government have been officially 
notified, through H.M. Embassy in Rome, of the sphere 
of action of the British Red Cross unit now operating 
with the Ethiopian forces on the northern front. 


Interpretation of Poisons Rules 

Sir ERNEST GRAHAM-LITTLE asked the Home Secretary 
whether he would, in view of the variety of interpretations 
given to it, state what was the precise meaning to be 
attached to the word manufacture as used in Rule 29 
of the Poisons Board Rules issued in December, 1935 ; 
and whether that word covered the processes of com- 
pounding and dispensing medicines containing poisons and 
used for the treatment of internal human ailments.— 
Mr. GEoFrrREY LuLoyp, Under-Secretary, Home Office, 
replied : Rule 29 of the Poisons Rules has been made under 
Section 23 (1) (i) of the Pharmacy and Poisons Act, 1933, 
which gives power for rules to be made “for requiring 
persons in control of the manufacture of pharmaceutical 
preparations containing poisons to be registered pharma- 
cists or persons possessing the prescribed qualifications in 
chemistry.” It seems to me clear that the word *‘ manu- 
facture,” both in the Act and in the Rule, denotes only 
the operations carried on in factories by manutacturers, 
and does not cover such operations as the compounding 
and dispensing of their own medicines by medical 
practitioners. 
THURSDAY, FEB. 13TH 


Writing of Medical Prescriptions 


Lieut.-Colonel Moore asked the Home Secretary 
whether, in view of the recent disclosures at coroners’ 
proceedings that doctors wrote prescriptions so illegibly 
that in many cases the address and signature were 
indecipherable and of the serious developments to which 
such practices were giving rise, especially in the issue of 
drugs, he would consider taking action to ensure that 
prescriptions should not be dispensed unless easily legible. 
—Sir Joun SmoN replied: I have no information that 
would lead me to suppose that the practice referred to is 
prevalent or has been productive of any harm to the 


456 THE LANCET] 


PARLIAMENTARY INTELLIGENCE 


[FEB. 22, 1936 


public. There are, as the hon. Member will be aware, 
various legal requirements in regard to the dispensing of 
poisons and dangerous drugs which seem to provide such 
safeguards as may be necessary. 


Amidopyrin Scheduled as a Poison 

Mr. HaLL-Camer asked the Home Secretary whether 
his attention had been called to the increase of deaths by 
poisoning due to pyramidon; and whether steps were to 
be taken to ensure that this would be classed as a poison 
at the earliest opportunity.—Sir Joun Simon replied: 
Yes, Sir. Under the new Poisons List and Rules which 
are to come into operation on May Ist next, this drug 
(which is more correctly described as amidopyrin) will 
be scheduled as a poison and its sale to the public will be 
unlawful except on medical prescription. 


Tuberculosis (Attested Herds) Scheme 

Mr. WILFRID RoBERTs asked the Minister of Agriculture 
how many herds in England and Wales have now been 
attested under the Tuberculosis (Attested Herds) Scheme ; 
how many of these herds were previously licensed as 
Grade A (T.T.) or certified herds; and what the total 
costs had been to date in administration and in the 
payment of the premium of ld. per gallon.—Mr. ELLIOT 
replied : Sixty-five herds have been attested in England 
and Wales under the Tuberculosis (Attested Herds) 
Scheme. Of these, 22 are herds licensed to produce 
Grade A (T.T.) and Certified milk. The total cost of 
administering the scheme to date, including £1485 in 
respect of the expenses incurred in a course of training 
of the Ministry’s inspectors in the uniform application of 
the tuberculin test and £1430 in experimental investi- 
gations for improving and perfecting the technique and 
material used in the application of the test, is £9600. 
A further sum of £715 has been paid in respect of the 
premium of ld. a gallon for milk sold from attested herds 
through the Milk Marketing Scheme. 


Anesthetics in Municipal and Voluntary Hospitals 

Mr. IEkpwarp Dunn asked the Minister of Health if 
there were any statistics available which showed the 
difference in the mortality-rate where gas-and-oxygen 
was used as the anesthetic as against the use of chloro- 
form and ether in municipal and voluntary hospitals.— 
Sir Kincstey Woop replied: I am not aware that any 
statistics of this character are available. Certain informa- 
tion in regard to deaths during or connected with the 
administration of anesthetics of all kinds is contained in 
the Text Volume of the Registrar-General’s Statistical 
Review for the year 1933. 


Ambulance Service at Enfield 

Mr. Buu asked the Minister of Health under what 
circumstances the ambulances of local authorities were 
permitted to be used for the conveyance of sick persons 
not suffering from any infectious disease, as well as for 
cases of acute surgical and medical emergency ; whether 
his attention had been called to the absence of such 
permission in the case of the Enfield ambulance service ; 
and whether this matter could be reviewed.—Sir KINGSLEY 
Woop replied: A local authority which has provided an 
ambulance for the conveyance of persons suffering from 
infectious disease has power to use it for the conveyance 
of other sick persons with suitable precautions. In Enfield 
the power of providing ambulances for infectious disease 
vests in the joint hospital board and not in the urban 
district council, and I understand that the council are 
actively considering means of getting over this difliculty. 
The Departmental Committee on the Consolidation of the 
Law. relating to Local Government and Public Health 
have considered the question of the provision of ambulances 
by local authorities and have recommended a simplification 
of the law. 

Vaccine Lymph from Rabbits 

Mr. Leaca asked the Minister of Health whether rabbits 
were still used in the Government lymph establishment in 
connexion with the production of calf lymph, notwith- 
standing the opinion of certain vaccination experts that 
the use of rabbits was probably the cause of the cases 
of post-vaccinal encephalitis which had followed the use of 
such lymph in recent years.—_Sir KINGSLEY Woop replied : 
Yes, Sir. I am advised that there is no valid evidence 
to suggest that the use of rabbits in the preparation of 


lymph has any influence on the occurrence of post- 
vaccinal encephalitis. 

Mr. Groves asked the Minister of Health whether 
rabbits were still used in the Government lymph establish- 
ment in connexion with the production of the supplies of 
calf lymph issued to public vaccinators; and what 
measures were adopted to secure that the rabbits so used 
were not suffering from spontaneous encephalitis.—Sir 
KINGSLEY Woop replied: The answer to the first part of 
the question is in the affirmative. As regards the second 
part, the rabbits are born and reared on the premises and 
are used at the age of three to four months. There is, 
therefore, ample opportunity for observing their con- 
dition. Further, as I am advised, there is no affinity 
between the encephalitis of rabbits and post-vaccinal 
encephalitis, 


Clothing and Footwear for Necessitous Children 

Mr. Evuis SmitH asked the President of the Board of 
Education if it was the intention of the Government 
to institute legislation which would enable education 
authorities to provide clothing and footwear for necessitous 
school-children.—Mr. OLIVER STANLEY replied: The 
whole question of the provision of clothing and footwear 
for necessitous children was raised by a deputation from 
the Association of Education Committees which I received 
on Jan. 16th, and I am at present considering it. 


' MONDAY, FEB. 17TH 
Disabled Soldiers and Hospital Allowances 


Mr. Davip Davies asked the Minister of Pensions 
(1) the amount of allowances at present paid to disabled 
soldiers attending hospitals for treatment due to disabilities 
caused by the Great War, distinguishing the cases of men 
who were forced to leave their employment and the cases 
of men who were unemployed, and (2) the number of 
ex-Service men who attended hospitals under the Ministry 
during -1936 for treatment, who had not received any 
treatment allowances, and whose wives and dependants, 
in consequence of the failure of the Ministry to provide 
allowances, had been compelled to seek poor-law relief.— 
Mr. R. S. Hupson replied: In the case of men who are 
normally in employment before admission and who 
suffer loss of wages or profits on account of admission 
to hospital, allowances are payable in accordance with the 
terms of the Royal Warrant. In the case of men who were 
unemployed before admission but were in receipt of either 
unemployment benefit or allowances from the Unemploy- 
ment Assistance Board before admission to hospital, supple- 
mentary grants are payable in accordance with the 
announcement which I made in the House on Oct. 22nd 
last, which substantially meet the loss of income suffered 
by their families. The object of this, as I stated at the 
time, was to obviate the necessity of their families having 
to have recourse to the poor-law solely on account of the 
man’s admission to a Ministry Hospital. Although I 
have no statistics which would enable me to answer the 
hon. member’s second question, I am satisfied that in 
general my object has been achieved. 


Milk Production and Consumption 


Sir Francis ACLAND asked the Minister of Agriculture 
the total milk production for England and Wales for each 
of the last four calendar years ; and the estimated amounts 
consumed as liquid milk and used in factories for milk 
products. 

Mr. Tuomas WILLIAMS asked the Minister of Agriculture 
the quantities of milk sold for liquid consumption by the 
Milk Marketing Board and producer retailers; and the 
quantities sold for manufacturing purposes during the 
years 1934 and 1935.—Mr. ELLIOT replied: The estimated 
total production of milk in England and Wales in the four 
years 1931/32-1934/35 is as follows :— 


Years (June to May) Million gallons 


1931/32 1:303 
1932/33 ©aa L349 
1933/34 .. .. .. 1879 
1934/35 1°399 


The foregoing figures represent the total amount of 
liquid milk estimated to have been available for all purposes 


THE LANCET] 


other than for feeding to stock, and are based on the 
information obtained through the voluntary census of 
1930/31, assuming that the average lactation yield has 
not changed since that date. The information at my 
disposal is not sufficient to enable me to say how much 
of the total production was consumed as liquid milk and 
how much was used in factories for milk products. The 
following particulars of milk sold for liquid consumption 
and for manufacture by the Milk Marketing Board have 
been supplied by the Board. 


Year ended. 
Sept. 30th, | Sept. 30th, 
1934. 1935. 
Sold for liquid consumption— Gals. Gals. 
(3) Under wholesale contracts .. | 523,813,326 | 554,174,376 
b) By producer-retailers 109,970,885 | 104,932,128 
— l 633,784,211 | 659,106,504 


Sold for manufacture 192,623,561 301,829,328 


Milk Prices and Public Demand 


Mr. AcLAND asked the Minister of Agriculture whether 
any experiments analogous to the Bishop Auckland 
potato experiment had been made to ascertain the effect 
of differential milk prices on the public demand for milk ; 
ìf so, what were the results; and, if not, whether any 
such experiments were in contemplation.—Mr. ELLIOT 
replied: No experiment to ascertain the effect of 
differential prices on the public demand for milk has, so 
far as I am aware, been made on the lines of that conducted 
by the Potato Marketing Board at Bishop Auckland. 
The Milk Marketing Board for England and Wales prepared 
a scheme for the supply of milk at special prices to 
unemployed in the Merthyr Tydfil district, one object 
of which was to ascertain the effect of reduced prices on 
demand, but it was not found possible to introduce the 
scheme. 
but I cannot at present say whether it will be possible to 
proceed with them. 


Supply of Milk in Schools 


_ Miss RATHBONE asked the Minister of Agriculture what 

had been the amount of the Exchequer grant actually 
paid during the last 12 months, or other ascertainable 
period, towards the supply of milk in schools and, secondly, 
towards the cost of milk supplied to manufacturers for 
milk products; and what had been the average price 
per gallon received by the farmers in both cases.— 
Mr. Error replied: During the first 12 months (Oct. Ist, 
1934, to Sept. 30th, 1935) of the operation of the Milk- 
in-Schools Scheme in England and Wales, 22} million 
gallons of milk were consumed in respect of which the 
Milk Marketing Board received £401,000 in grants from 
the Exchequer, an average rate of 4°23d. per gallon. 
During the same 12 months (Oct. Ist, 1934, to Sept. 30th, 
1935) (for which information is not yet complete) 200 
million gallons of milk were processed in England and 
Wales in respect of which the Milk Marketing Board 
received £1,061,000 by way of Exchequer advances, an 
average rate of 1°27d. per gallon. Individual producers 
actually received in respect of both supplies the Pool 
Price which has averaged throughout the 12 months in 
question 11°99d. per gallon. 

Mr. WILFRID ROBERTS asked the Minister of Agriculture 
the average number of children that had. obtained milk 
daily under the Milk-in-School Scheme in each quarter 
since the passing of the Milk Act, 1934, and what the cost 
had been to the Exchequer.—Mr. ELLIOT replied: Precise 


figures showing the average number of children that have - 


obtained milk daily under the Milk-in-Schools Scheme in 
each quarter since the passing of the Milk Act, 1934, 
are not available, but at the end of March, 1935, the 
mumber of children receiving milk under the scheme, free 
or for payment, in grant-earning schools in England and 
Wales was about 2? million. At the beginning of October, 
1935, the corresponding figure was about 24 million. 
Exchequer grants amounting to £447,495 have so far been 
paid to the Milk Marketing Board for England and Wales 


PARLIAMENTARY INTELLIGENCE 


Other schemes are still under consideration, . 


(FEB. 22, 1936 457 


in respect of milk supplied during the period Oct. Ist, 
1934, to Oct. 31st, 1935. For similar information relating 
to Scotland, I would refer my hon. friend to my right. hon. 
friend the Secretary of State for Scotland. 

Mr. Tuomas Wi1114Ms asked the President of the Board 
of Education if he would give the figures for the latest 
dates available of the number of school-children who 
received a free supply of milk and the number who 
received milk at schools at the reduced price, and the total 
annual consumption of each category.—Mr. OLIVER 
STANLEY replied : The number of school-children receiving 
free milk in all types of grant-earning schools in England 
and Wales was about 300,000 on Oct. lst, 1935, the latest 
date for which figures are available. The number who 
received milk at school at that date at the reduced price 
under the Milk-in-Schools Scheme was about 2} millions. 
The annual consumption by the children who pay for 
milk is about 22,500,000 gallons. The annual consumption 
by the children who receive free milk cannot be accurately 
estimated, as these children receive varying amounts of 
milk, but it is probably about 4 million gallons. 

Miss RATHBONE asked the President of the Board of 
Education what would be the cost of supplying a free 
ration of one-third of a pint of milk every school day to 
every child in elementary schools, and upon what number 
of children and price of milk was the estimate based; and 
what would be the additional cost if the provision were 
extended to week days when schools did not meet.— 
Mr. OLIVER STANLEY replied: There are about 5,300,000 
children attending public elementary schools in England 
and Wales. To supply this number with one-third of a 
pint of milk daily for 200 school days about 44 million 
gallons of milk would be required. Including week- 
days when the schools do not meet about 69 million gallons 
would be required. I am not in a position to give an 
estimate of the cost to public funds which would be 
involved if this quantity of milk were supplied free, as 
the price per gallon could only be determined after 
negotiations with the milk industry. 


The Attested Herds Scheme 


Mr. AcLAND asked the Minister of Agriculture whether 
he could give, to the most recent convenient date, figures 
showing the number of producers of milk entitled to 
receive the bonus for pure milk provided by the Milk 
Act of 1934; what was the output of such producers ; 
and what improvement the figures showed over the 
corresponding figures at any earlier date.—Mr. ELLIOT 
replied: The number of producers of milk from herds 
certified by the Ministry under the Attested Herds Scheme 
to date is 59, who own a total of 65 herds, comprising 
2558 animals which have been attested at various dates 
since Feb. lst, 1935. Twenty-two of the herds are licensed 
to produce Certified or Grade A (T.T.) milk, and in cases 
in which the owners have claimed exemption in respect 
of such milk from the Milk Marketing Scheme, they are not 
entitled to receive the bonus under the Attested Herds 
Scheme. The only figures indicating output are contained 
in the claims for the ld. per gallon bonus payable in respect 
of milk sold through the Marketing Scheme. Claims have 
been received in respect of 40 herds only, covering an 
average of about five months each, and a total production 
of 237,076 gallons. There are no corresponding figures 
in respect of any previous period. 


Elimination of Bovine Tuberculosis 


Mr. AcLAND asked the Minister of Agriculture what sums 
the Government had spent since 1934 on experiments to 
discover means of eliminating bovine tuberculosis; and 
whether any results had been achieved.—Mr. ELLIOT 
replied: Research on bovine tuberculosis has been in 
progress for some years at the Institute of Animal Patho- 
logy, Cambridge, and, to some extent, at the Ministry’s 
Veterinary Laboratory, and the National Institute for 
Research in Dairying at Reading. It is not possible to 
give a precise figure of the sums expended, which form 
part of the general expenditure of the institutions named. 
Since 1934, however, in consultation with the Agricultural 
Research Council, special grants have been made to extend 
the work at Cambridge, amounting to £375 in the year 
ended March 3lst, 1935, and £5320 in the year ending 
March 3lst next. The subjects of the investigation are 


458 THE LANCET] 


the use of BCG vaccine and of tuberculin and the work 
is still in progress. 


Scarlet Fever and Destruction of School Books 


Mr. ANDERSON asked the President of the Board of 
Education if his attention had been called to the burning 
of school books in the Pinxton district of North Derbyshire 
owing to an epidemic of scarlet fever; and if the method 
stated was universal; and, if so, what was the cost during 
the past 12 months in renewal of books and the depart- 
ment or authority responsible for the cost.—Mr. OLIVER 
STANLEY replied: I have no information regarding the 
burning of school books in the Pinxton district, but I am 
making inquiries. I understand that it is not the universal 
practice to destroy school books after an epidemic, but 
the question in a particular case is one to be decided by 
the local education authority on the advice of the Medical 
Officer of Health. I have no information as to the cost 
involved in the renewal of books destroyed in this way 
during the past 12 months, but any such expenditure 
by a local education authority would receive grant from 
the Board. 


TUESDAY, FEB. 18TH 
Stone-dusting Regulations in Mines 


Mr. Davip Davies asked the Secretary for Mines the 
number of samples of coal dust taken by the inspector 
of mines, under the stone-dusting regulations, in 1935; 
giving the number that did not comply with the require- 
ments provided in the regulations and stating the volatile 
content of the coal seams in the cases where the samples 


MEDICAL NEWS 


[FEB. 22, 1936 


taken were not in accordance -with the stone-dusting 
regulations.—Captain CROOKSHANK replied: The number 
of mine road dust samples taken by inspectors of mines 
in 1935, under the regulations relating to precautions 
against coal dust, was about 6500, of which 520 did not 
comply with the requirements of the regulations. I 
regret that the information asked for in the last part of 
the question is not available. 


Research on Diseases of Animals 


Sir ARNOLD WItson asked the Lord President of the 
Council whether, in view of the fact that apart from 
members of the veterinary profession serving on the com- 
mittees dealing with diseases of animals there was no 
representative of the profession on the Agricultural 
Research Council, he would consider strengthening the 
Agricultural Research Council by the addition of repre- 
sentatives of the veterinary professionMr. Ramsay 
MacDOonaLp replied: It is not considered desirable that 
professions as such should' be represented on the Agri- 
cultural Research Council. The Committee of the Privy 
Council for the Organisation and Development of Agri- 
cultural Research decided, however, at a recent meeting 
that the representation on the Agricultural Research 
Council of the sciences underlying the study of animal! 
health should be strengthened. They therefore approved 
the appointment of Mr. John Smith, O.B.E., M.R.C.V.S., 
D.V.H., formerly Director of Animal Health in Northern 
Rhodesia, and since 1933 a member of the Colonial Advi- 
sory Council of Agriculture and Animal Health, as a 
member of the Agricultural Research Council. 


MEDICAL 


NEWS 


University of Cambridge 

At recent examinations the following candidates were 
successful :— 

D.M.R.E. 

*R. E. Alderson, Sylvia D. Bray, G. Q. Chance, W. J. Craig, 
I. T. Dickson, Isaac Eban, N. G. Gadekar, V. R. Ginde, Mary C. 
Leishman, R. B. Mehta, A. N. Nanda, L. D. Pringle, A. M. 
Rackow, A. I. Silverman, A. C. Sinclair, Edith H. Smith, 
Florence L. Telfer, *Wiliam Tennent, and D. A. Wilson. 


* Distinction. 


Royal College of Surgeons of England 

A meeting of the council of the College was held on 
Feb. 13th with Sir Cuthbert Wallace, the president, in 
the chair. It was decided that the Hunterian dinner 
which could not be held this year should take place on 
Feb. 15th, 1937. The Hallett prize for December, 1935, 
was presented to Robert Sutherland Lawson of the 
University of Melbourne. 

The offer by the British Journal of Surgery of 1000 
guineas to be expended in research work in surgery was 
accepted, and the council gave permission for the erection 
in the College of a tablet to record the services of Lord 
Moynihan to surgery and the journal. It was reported 
that Prof. Einar Key, of Stockholm, had accepted the 
honorary fellowship of the College, and that he would 
attend the meeting of the council on June llth to be 
admitted. Mr. R. E. Kelly was reappointed as the repre- 
sentative of the College on the court of the University 
of Liverpool for three years, and Sir Holburt Waring 
was appointed representative of the College at the con- 
gress of the Universities of the Empire to be held in 
Cambridge in July. 

The council passed a vote of condolence on the death 
of Sir Charles Ballance, a past vice-president of the 
College. 

The posts of resident surgical officer and first house 
surgeon at the Croydon General Hospital were approved 
for recognition for the six months’ surgical practice required 
of candidates for the final fellowship examination. 

Diplomas of fellowship were granted to Theodor 
Anton Green and Josephus Corbus Luke, and diplomas of 
membership to S. Alankaram and to the candidates 
given in our issue of Feb. 8th (p. 339). Diplomas in 
public health, medical radiology, and anesthetics were 
granted jointly with the Royal College of Physicians to 
the candidates mentioned in the same issue (p. 340). 


University of Wales 


Three research scholarships in the University of Wales 
will be awarded in the session 1936-37. Particulars will 
be found in our advertisement columns. 


University of Sheffield 


Prof. J. H. Dible has been appointed external examiner 
in pathology and bacteriology, Prof. E. J. Wayne repre- 
sentative of the university on the National Council for 
Domestic Studies, and Prof. G. L. Roberts on the Dental 
Education Advisory Committee. 


British College of Obstetricians and Gynæcolo gists 
At a recent meeting of the council the folowing were 
promoted to the fellowship of the college :— 


Jack Roland Stanley Grose Beard (Adelaide), Alexander 
Ernest Chisholm (Dundee), John Francis Cunningham (Dublin). 
Constance Elizabeth D’Arcy (Sydney), Ernest Chalmers Fabmy 
(Edinburgh), Margaret Fairlie (Dundee), John Gardner _(Glas- 
gow), Robert Lance Impey (Cape Town), Robert Aim Lennie 
(Glasgow), Hilda Nora Lloyd (Birmingham), Rupert Eric 
Magarey (Adelaide), John Chassar Moir (London), and William 
Foster Rawson (Bradford). 


Royal College of Surgeons in Ireland 


The Charter Day dinner was held last Saturday in the 
hall of the college, with Mr. Seton Pringle, the president, 
in the chair. There was an attendance of nearly 120, the 
guests including the Lord Mayor of Dublin (Mr. Alfred 
Byrne), the American Minister to the Irish Free State 
(the Honourable Alvin Owsley), and the Vice-Chancellor 
of Queen’s University, Belfast (Mr. F. W. Ogilvie). In 
his speech the president spoke of the danger of too many 
students seeking admission to the medical profession 
with the resulting possibility of overcrowding. He sug- 
gested that the medical schools should raise the standard 
of general education required for entrance, and he quoted 
examples of the low degree of education exhibited bw 
some candidates. Prof. T. G. Moorhead, who replied for 
the guests, spoke of the union recently effected between 
the Irish Medical Association and the Irish Free State 
branches of the British Medical Association, and askect 
for support of the union from all members of the profes- 
sion. He also spoke of the prospects of establishing a 
Medical Research Council, to be financed from sweepstake 
funds. Ho said that the profession would not bring into 
being any council that had not full control over the moneys 
that were granted for medical research, nor any council 
with merely advisory functions. 


THE LANCET, 


MEDICAL NEWS 


[FEB. 22, 1986 459 


Dr. C. P. Martin, professor of anatomy at Trinity 
College, Dublin, has been appointed to the chair of anatomy 
at McGill University, Montreal. 


Dr. Douglas Lee, late Sharpey scholar in the physio- 
logy department at University College, London, has been 
appointed to the chair of physiology at the Singapore 
Medical College. 


Royal Sanitary Institute 

At a meeting on housing to be held at this institute 
(90, Buckingham Palace-road, London, S.W.), on Tuesday, 
March 10th, at 5.30 P.M., Sir Raymond Unwin will open 
@ discussion on planned distribution as a means of pre- 
venting crowding. Lord Balfour of Burleigh, the president, 
will take the chair. 


Bilton Poilard Fellowship 
An award of this fellowship, which has an annual 
value of £650, will shortly be made to a man student who 
has held a resident appointment at University College 
Hospital where the fellowship is tenable. Candidates 
must be members of the Royal College of Physicians of 
London or fellows of the Royal College of Surgeons of 
England, and must intend to practise in medicine or 
surgery. Full particulars may be had from the secretary 
_ of the hospital, Gower-street, London, W.C.1, and appli- 
cations for the fellowship must be made before March 2nd. 


London Inter-Collegiate Scholarships Board 

This board announces that an examination for twelve 
medical scholarships and exhibitions, of an aggregate total 
value of £1418, will begin on May llth. They are tenable 
at University College and University College Hospital 
medical school, King’s College and King’s College Hospital 
medical school, the London (Royal Free Hospital) School 
of Medicine for Women, the London Hospital medical 
college, and St. George’s Hospital medical school. Full 
particulars and entry forms may be obtained from the 
secretary of the board at King’s College Hospital medical 
school, Denmark Hill, S.E. 5. 


Course on Mental Deficiency 

A course of lectures on mental deficiency and allied 
conditions has been arranged for medical practitioners 
by the extension and tutorial classes council of the Uni- 
versity of London in coöperation with the Central Asso- 
ciation for Mental Welfare. The course, which will be 
supplemented by clinical instruction, is divided into two 
parts (mental deficiency, April 20th to 25th; retarded 
and difficult children, April 27th to May 2nd), and these 
may be taken separately. Applications should reach 
Miss Evelyn Fox, University Extension Department, 
University of London, South Kensington, S.W.7, by 
March 30th. 


The Food Education Society 

Three lectures will be given by Maj. Gal Sir Robert 
McCarrison at the London School of Hygiene and Tropical 
Medicine, Keppel-street, W.C., on consecutive Thursdays 
at 5 P.M. on nutrition and health (March 12th); food in 
relation to the structure and functions of the body 
(March 19th); and nutrition and national health 
(March 26th). 

A lecture on winter salads will be given by Mrs. Jenny 
Fliess at the Soho School of Cookery, 20, Soho-square, 
London, on Thursday, March 5th, at 3.30 r.M. Tickets 
may be obtained from the Food Education Society, 
29, Gordon-square, W.C.1. 


Tuberculosis Conference 

The tenth conference of the International Union against 
Tuberculosis will meet in Lisbon from Sept. 7th to 10th 
under the chairmanship of Prof. Lopo de Carvalho, who 
will open the discussion on radiological aspects of the 
hilum of the lung and their interpretation. Dr. Olaf 
Scheel (Norway) is speaking on primary tuberculous 
infection in the adolescent and the adult, and Dr. C. J. 
Hatfield (United States) and Dr. D. A. Powell (Great 
Britain) on the open case of tuberculosis in relation to 
family and domestic associates. Other speakers will include 
Dr. W. T. Munro and Dr. L. S. T. Burrell. Further 
nformation may be had from the National Association 
or the Prevention of Tuberculosis, Tavistock House 
North, Tavistock-square, London, W.C.1. 


THE untimely death at the age of 37 of Dr. Erroll 
Williams, of Southport, aroused general sympathy in the 
neighbourhood, for he had only been married a short 
time and had made a good impression on the public 
and his colleagues during his residence in the town. He 
served in the Royal Flying Corps during the war and gained 
the Distinguished Flying Cross. 


The Minister of Pensions has appointed Dr. Michael 
Abdy Collins, O.B.E., to the post of Mental Inspector to 
the Ministry. 


Taunton and Somerset Hospital 
An appeal for £35,000 is being made to build additional 
wards and modernise this hospital. 


New Casual Wards at Enfield House 

The Middlesex county council have provisionally agreed 
to erect new casual wards at Enfield House to take the 
place of those in use at Edmonton House and also to 
build at Chase Farm, Enfield, two additional blocks for 
able-bodied inmates from Enfield House and Edmonton 
House. 


Ramsbottom Cottage Hospital 
Lieut.-Colonel Porritt and his wife have offered to pay 
the building costs of extensions at this hospital which 


. include a new children’s ward and a new operating theatre. 


Bovey Tracey Hospital 
A new children’s ward was opened at this hospital on 
Feb. 5th to commemorate King George’s jubilee. 


Salford Royal Hospital 

The out-patient department at this hospital, which was 
opened in 1911, is to be completely transformed as it is 
inadequate for present-day needs. The massage depart- 
ment, at present housed in a hut in the hospital yard, 
is to have a new building and the provision of a nurses’ 
recreation room is under consideration. 


Maternity and Child Welfare Conference 

A national conference on maternity and child welfare 
will be held at the Picton Hall, Liverpool, on July Ist, 
2nd, and 3rd under the presidency of Mr. Geoffrey Shake- 
speare, parliamentary secretary to the Ministry of Health. 
The subjects for discussion will include maternal welfare 
and the public; antenatal nutrition; the education of 
parents through day nurseries and nursery schools; 
parents and substitute parents; the importance of 
coöperation between maternity and child welfare services 
and the specialist health services; and rest and con- 
valescence as factors in maternal welfare. The conference 
is being organised by the National Council for Maternity 
and Child Welfare and by the National Association for - 
the Prevention of Infant Mortality. The maternity and 
child welfare group of the Society of Medical Officers of 
Health is also codperating in the conference, and will 
afterwards hold a clinical meeting for medical practi- 
tioners on July 4th. The secretary of the conference is 
Miss Halford, Carnegie House, 117, Piccadilly, London, 
W.1. 
Fellowship of Medicine and Post-Graduate Medical 

Association 

An advanced course in thoracic surgery will be given 
at the Brompton Hospital from Feb. 24th to 29th, and 
M.R.C.P. evening courses will be held as follows: chest 
and heart diseases at the Royal Chest Hospital (March 16th 
to April 4th); chest diseases at the Brompton Hospital 
(March 8th to April 4th); clinical and pathological 
demonstrations at the National Temperance Hospital 
(Feb. 25th to March 12th). An all-day course in ortho- 
pædics has been arranged at the Royal National Ortho- 
pedic Hospital (March 9th to 2lst),, and an afternoon 
course in neurology and psychopathology at the West 
End Hospital for Nervous Diseases (March 2nd to 27th). 
Week-end courses are to be held as follows : chest diseases 
at the Brompton Hospital (March 7th and 8th); clinical 
surgery at the Royal Albert Dock Hospital (March 14th 
and: 15th); medicine at the Miller General Hospital 
(March 2lst and 22nd); and urology at the All Saints 
Hospital (March 28th and 29th). Detailed syllabuses of 
all courses may be had from the secretary of the fellow- 
ship, 1, Wimpole-street, W.1. 


460 THE LANCET] 


Medical Diary 


Information to be included in this column should reach us 
tn proper form on Tuesday, and cannot appear if it reaches 
us later than the first post on Wednesday morning. 


SOCIETIES 


ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W. 
MONDaY, Feb. 24th. 
Odontology. 8 P.M. Mr. A. W. Wellings: Three Dental 
Abnormalities. Dr. C. F. Cosin: Aberrations of 
Calcium Metabolism in relation to Dental Disease. 


TUESDAY. 

Medicine. 5 P.M. Dr. G. W. Pickering: Obliterative 
Arterial Disease as it affects the Limbs. Prof. J. 
aeons Ross and Prof. H. M. Turnbull will also 
speak. 

Pathology. 8.15 P.M. for 8.30 P.M. Prof. J. W. McLeod : 
Data Bearing on Significance of B. diphtherie Types 
accumulated in the last four years. 

WEDNESDAY. 

Comparative Medicine. 5 P.M. Prof. J. G. Wright: 
The Use of the Non-volatile Narcotics. Dr. Douglas 
Belfrage, Mr. B. Balfour-Jones, and Mr. Basil Hughes 
will also speak. 

THURSDAY. i 

United Services: Psychiatry. 4.30 P.M. 
Heatly-Spencer and Dr. E. Mapother: 
Nervous Disease in the Fighting Services. 

Urology. 8.30 P.M. Mr. R. H. O. B. Robinson: Horse- 
shoe Kidney. Mr. T. J. Millin: Impotence and its 

Surgical Treatment, with reference to New Operative 
Procedure. Mr. A. Elliot-Smith: Steinach II. Opera- 
tion for Enlarged Prostate. 


FRIDAY. 
Disease in Children. 4.30 P.M. (Cases at 4 P.M.) Dr. 
Bernard Myers: 1. Essential Purpura Hemorrhagica. 
2. Osteochondro- 


Dr. M. Price (for Mr. D. Levi): 
Dr. R. C. Jewesbury : 


dystrophy of Morquio Type. 
? Hepatic Cirrhosis. 4. Bilateral 


3. Jaundice and 
Foramina of the Parietal Bones. Dr. A. G. Maitland- 


Colonel J. 
Functional 


Jones: ő. Tay-Sachs Disease. Dr. David Nabarro: 
6 and 7. Congenital Syphilis showing Cutaneous 
Gummatous Lesions. Dr. W H. Sheldon: 8. 


Anemia with Bone Changes. 
(for Dr. D. Paterson): 9-11. Epiphyseal Dysplasia 
Puncticularis. 
Epidemiology and State Medicine. 8.30 P.M. Sir William 
Hamer: The Endemic Influenza Prevalence of 1933-35. 
Physical Medicine. 8.30 P.M. Mr. Francis Talbot and 
Mr. H. Mandiwall: The Amelioration of Dental Sepsis 
by Physical Methods including Ultra-violet Irradiation 
and Jonisation. 
MEDICAL SOCIETY OF LONDON, 11, Chandos-street, W. 

MONDAY, Feb. 24th.—8.30 P.M., Lord Horder: Ktiology 
and Treatment of Bacillus coli Infections of the 
Urinary Tract. 

WEDNESDAY.—Y P.M., Dr. P. H. Manson-Bahr: The 
Diffcrential Diagnosis of Discases of the Colon (Dysen- 
tery and Colitis) and their Complications. (Second 
Lettsomian lecture.) 

HUNTERIAN SOCIETY. 

MONDAY, Feb. 24th.—9 P.M. (Mansion House, E.C.), Sir 
Lenthal Cheatle: John Hunter’s Time and Ours. 
(Hunterian oration.) 

MEDICO-LEGAL SOCIETY. 

THURSDAY, Feb. 27th.—8.30 P.M. (Manson House, 26, 
Portland-place, W.), Mr. H. N. Linstead: Statutory 
Safeguards against Poisoning—the Work of the Poisons 
Board. 

BRITISH PSYCHOLOGICAL SOCIETY. 

WEDNESDAY, Feb. 26th.—8.30 P.M. (Institute of Medical 
Psychology, Malet-place, W.C.). Miss Margaret Ash- 
down: Tho Rôle of the Psychiatric Social Worker. 
Dr. W.J. T. Kimber and Dr, William Moodie will also 
speak. (Medical section.) 

ROYAL MEDICO-PSYCHOLOGICAL ASSOCIATION. 

WEDNESDAY, Feb. 26th.—2.30 P.M. (11, Chandos-strect, 
W.), Dr. E. Guttmann: Experimental Psychoses 
induced by Mescaline. 


ST. JOHN’S HOSPITAL DERMATOLOGICAL SOCIETY, 
Lisle-street, W.C. 
WEDNESDAY, Feb. 26th.—4.15 P.M., Clinical Mecting. 
5 P.M., Dr. F. A. E. Silcock : The Lady with the Green 
Hair and other Interesting Skin Cases. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 


ROYAL COLLEGE OF PHYSICIANS OF LONDON, Pall 
Mall East, S.W. . 
THURSDAY, Feb. 27th.—5 P.M., Dr. E. L. Middicton : 
Industrial Pulmonary Disease due to the Inbalation 
of Dust, with Special Reference to Silicosis. (First 
Milroy lecture.) 
UNIVERSITY COLLEGE HOSPITAL MEDICAL SCHOOL, 
W.C 


FRIDAY, Feb. 28th.—5 P.M., Dr. Cecil Price-Jones: The 
Sizes of Red Blood Cells. (Sydney Ringer lecture.) 
NATIONAL HOSPITAL FOR DISEASES OF THE HEART, 
Westmorcland-street, W. 
TUESDAY, Feb. 25th.—5.30 P.M., Dr. D. Evan Bedford: 
Bag io ele. Examination of the Heart and Great 
essels. 


Dr. Donald Bateman 


MEDICAL DIARY 


- 


[FEB. 22, 1936 


HAMPSTEAD GENERAL AND NORTH-WEST LONDON 
HOSPITAL, N.W. 
WEDNESDAY, Feb. 26th.—4 P.M., Dr. C. Rickword Lane: 
Clinical Pathology in General Practice. 

BOSE ay FOR EPILEPSY AND PARALYSIS, Maida 
ale, W. 
THURSDAY, Feb. 27th.—3 P.M., Dr. Anthony Feiling: 

Demonstration. 

NATIONAL HOSPITAL, Queen-square. 

MONDAY, Feb. 24th.—z P.M., Dr. Riddoch: 


Out-patient 
Clinic. 


i 3.30 P.M., Dr. Critchley: Cerebral Vascular 
Disease. 


TUESDAY.—2 P.M., Dr. Walshe: Out-patient Clinic. 
3.30 P.M., Dr. Critchley : Cerebral Vascular Disease. 

WEDNESDAY.—2 P.M., Dr. tin: Out-patient Clinic. 
3.30 P.M., Dr. Kinnier Wilson : Clinical Demonstration. 

THURSDAY.—2 P.M., Dr. Symonds: Out-patient Clinic. 
3.30 P.M., Mr. Leslie Paton : Optic Neuritis. ; 

FRIDAY.—2 P.M., Dr. Critchley: Out-patient Clinic. 
3.30 P.M., Dr. Purdon Martin: Other Infectious 
Diseases of Nervous System. 

HOSPITAL FOR SICK CHILDREN, Great Ormond-st., W.C. 

WEDNESDAY, Feb. 26th.—2 P.M., Dr Donald Paterson: 
Bronchitis and Asthma. 3 P.M., Dr. Donald Bateman : 
Tests for Allergen Sensitivity. 

Out-patient Clinics daily at 10 A.M. and ward visits at 2 P.M. 

LONDON SCHOOL OF DERMATOLOGY, 5, Lisle-street, W.C. 

TUESDAY, Feb. 25th.—5 P.M., Dr. W. N. Goldsmith: 
Pigmentary Disorders. f 

TEUR DAT S P.M., Dr. A. Burrows : Malignant Conditions 
o e Skin. 

FELLOWSHIP OF MEDICINE AND POST-GRADUATE 
MEDICAL ASSOCIATION, 1, Wimpole-street, W. 

MONDAY, Feb. 24th, to SATURDAY, Feb. 29th.— INFANTS 
HosPITAL, Vincent-square, S.W. Mon., Wed., and 
Fri., 8 P.M., F.R.C.S. primary course.— BROMPTON 
HOSPITAL, S.W., All-day course in thoracic surgery.— 
NATIONAL TEMPERANCE HOSPITAL, Hampstead-road, 
N.W., Tues. and Thurs., 8 P.M., M.R.C.P. course.— 
NATIONAL TEMPERANCE HOSPITAL, Hampstead-road, 
N.W., Tues., 8.30 P.M., Mr. A. E. Porritt: Infection 
of Bones, and Thurs., Mr. R. Coyte: Large Intestine 
and Rectum.—ST. JOHN’S HOSPITAL, 5, Lisle-street, 
W.C. Afternoon course in dermatology (open to non- 
mambar) = courees are open only to members of the 

ellowship. 
SOUTH-WEST LONDON POST-GRADUATE ASSOCIATION. 

WEDNESDAY, Feb. 26th.—4 P.M. (St. James’ Hospital, 
Ouseley-road, S.W.12), Dr. R. F. L. Hewlett: Tho 
Value of Blood Examinations. 

WEST LONDON HOSPITAL POST-GRADUATE COLLEGE, 
Hammersmith, W.6. f 

MoNDAY, Feb. 24th.—10 A.M., Skin Clinic. 11 A.M., Surgical 
Wards. 2 P.M., Gynæcological and Surgical Wards, 
Eye and Gynæcological Clinics. 4.15 P.M., Mr. Green- 
Armytage : Abdominal Pain in Pregnancy. 

TUESDAY.—10 A.M., Medical Wards. 11 A.M., Surgical 
Wards. 2 p.M., Throat Clinic. 

WEDNESDAY.—10 A.M., Children’s Clinic and Wards. 
11 A.M., Medical Wards. 2 P.M., Eye Clinic. 4.15 PAL, 
Dr. R. W. Ironside: Anresthesia. : 

THURSDAYS.—10 A.M., Neurological and Gynecological 
Clinics. Noon, Fracture Clinic. 2 P.M.. Eye and 
Genito-urinary Clinics. 

FRIDAY.—10 A.M., Skin Clinic, Medical Wards. 12 noon, 
Lecture on Treatment. 2 P.M., Throat Clinic. 4.15 P.M, 
Mr. Vlasto: Pyogenic Infections of the Ear. 

SaTURDAY.—10 A.M., Children’s and Surgical Clinics, 
Medical Wards. ¢ <r 

Daily.—2 P.M., Operations, Medical and Surgical Clinics. 

The lectures at 4.15 P.M. are open to all medical practitioners 
without fee. 

LEEDS GENERAL INFIRMARY. 

TUESDAY, Feb. 25th.—3.30 P.M., Dr. Tattersall: Tuber- 

culosis Demonstration. 
LEEDS PUBLIC DISPENSARY. 

WEDNESDAY, Feb. 26th.—4 P.M., Mr. L. N. Pyrah: The 
Treatment of Burns and Surgical Cutaneous Septic 
Conditions. 

ANCOATS HOSPITAL, Manchester. ; 

THURSDAY, Feb. 27th.—4.15 P.M., Dr. W. J. S. Reid: 
Polycythrmia. 

UNIVERSITY OF DURHAM. 

SUNDAY, March Ist.—10.30 A.M. (Newcastle General 

Hospital), Prof. T. Beattie : Medical Ward Visit. 
GLASGOW POST-GRADUATE MEDICAL ASSOCIATION. 

WEDNESDAY, Feb. 26th.—4.15 P.M. (Ear, Nose, and Throat 

Hospital), Dr. R. J. Watson: The Accessory Sinuses. 


COMMITTEE ON NvutTRITION.—At its first meet- 
ing on Feb. 15th the League of Nations committee 
on nutrition agreed on the general lines of the 
report to be prepared, took steps to obtain further 
information from governments and national authorities, 
and appointed a drafting committee which is to meet on 
Mav 4th, before a second session of the full committee 
to be held early in June. The committee unanimously 
adopted the report of the Technical Commission (which 
appeared in THE Lancet of Dec. 21st, 1935, p. 1434) which 
lays down the principles for a scientifically balanced diet 
for different ages and categories of human beings. This 
report is to serve as the basis for a big programme of 
research work in different countries. 


tl 


eee 


A 


THE LANCET] 


[FEB. 22, 1936 461 


NOTES, COMMENTS, AND ABSTRACTS 


THE CINEMA IN MEDICINE 


THE catalogue published? this week, of British 
medical films ‘‘of technical interest to medical 
practitioners and students,” is a first attempt to 
collect under one cover British made films which 
are likely to be of value, not only in medical teaching 
but in medical practice. The British Film Institute, 
formed in 1933 on the recommendation of the Com- 
mission on Educational and Cultural Films, has an 
advisory committee on which are represented various 
Government departments, including the Ministry 
of Health and the Board of Education, and from this 
committee is set apart a panel of medical men 
interested in the use of films for instructional pur- 
poses. This medical panel undertook to collect 
information on existing medical films in this country, 
for this purpose addressing a questionnaire to all 
the medical schools and universities in Great Britain. 
The present catalogue is the result of this inquiry. 

The films catalogued are classified under 9 sections 
and 42 subsections, which include most of the sub- 
jects taught in the medical curriculum. Against 
each is given title, date, author, width, silent or 
sound, length, name and address of owner, and 
(with excellent intent) whether suitable for under- 
graduate or post-graduate students, for nurses, or 
for public health propaganda. Supplements to the 
catalogue will be issued as need arises. There may 
be in existence medical films made by individuals 
or associations primarily for their own use but which 
may be of more general interest ; the panel is anxious 
to secure full particulars of such films. In too many 
of the films viewed the medical panel noted with 
regret that the producers seemed to have had no 
clear idea of what it was they wished to demonstrate 
or at least of the best methods of demonstrating 
the points they wished to drive home., Sometimes 
an otherwise good film lost much of its teaching value 
for lack of appropriate captions and/or moving 
diagrams. The medical panel offers technical advice 
to those embarking on the production of medical 
films, in order to ensure the best use of the material 
available. 

The use of films in all parts of the medical curri- 
culum is increasing. Lecturers in such subjects as 
pharmacology, physiology, anatomy and biology, 
for example, frequently make films to illustrate their 
lectures, seeking in this way to save time and to 

retain the attention of large classes. While ‘‘ speech ” 
films may have their use in illustrating the operative 
technique of a distinguished surgeon, the panel 
considers that the field for such films in medical 
education is limited, and they have the disadvantage 
of thrusting into the background the personality 
of the teacher on the spot. A film, however good, 
is not intended to replace the lecturer but only to 
supplement his teaching. Slow-motion photography 
gets a good word from the panel. It provides a 
simple method of illustrating complicated technique 
and a means of studying movements which are 
ordinarily performed too quickly for the student to 
follow. In any case the lecturer should be able to 
stop a film when he wants in order to demonstrate 
details of a picture. There are projectors on the 
market in which it is possible to hold the picture 
without damage to the film or serious loss of light. 

Most of the silent films are narrow ones. The 
16 mm. film is non-inflammable and can be shown 
without danger in lecture hall or private house. 
For demonstration to a class of students at a moment’s 
notice this type of film will probably be found the 
most useful for some time to come. The keen medical 
student will welcome the opportunity of supple- 
menting his reading by looking at a film of the sub- 
ject which he is studying. There are on the market 
at the present time projectors for 16 mm. silent 


' British Film Institute, 4, Great Russell-street, London’ 
eU.l, 8. 


films, varying in price from £30 to as little as £6 15s., 
the latter being suitable for two or three persons in 
an ordinary room. The larger projectors can be 
hired for £1 a night. Even so the moving picture 
will often be beyond the student’s purse, and com- 
mercial firms which produce films of medical or 
scientific interest might well arrange to show for a 
modest fee at their own theatres films of interest 
to the medical student. The British Film Institute 
would assist the student if willing to show in a theatre 
for a nominal fee a film which a student may have 
borrowed or have made himself. It is of real import- 
ance for medical education that the student should 
be able, outside of official lecture hours, to see films 
which will help him in that part of the medical 
curriculum which he happens to be studying. 


GOTHIC WOMEN 


THE nineteenth century woman was a mystifying: 
creature. After a childhood of suppression and 
a girlhood in which vapidness was at a premium, 
she reached a maturity of wifely subseryience and 
excessive reproduction. But if she survived the 
childbearing period with spirit unimpaired she 
usually came into her own as the tyrant grandmother 
—no fiction, but a valiant unscrupulous personage 
found surviving in many families in the early years 
of this century. How did she manage it? How 
could a youth of tight-lacing equip her for such 
heroic physical achievement; and when, during a 
much-occupied middle age, did she find opportunity 
to develop the qualities of a dictator? Can she be 
explained, like the older type of hospital matron, 
by saying: ‘‘ If you trample on a person hard enough 
you have taught her all there is to know about 
trampling when her turn comes”? Perhaps she 
cannot be summed up in a formula at all, but at any 
rate much can be learnt about her from Dr. C. 
Willett Cunnington’s ‘‘ Feminine Attitudes of the 
Nineteenth Century ” ! 

Dr. Cunnington has an agreeable formula of his 
own, ‘Gothic Art,” he says, ‘‘ has been defined 
by an eminent authority, as ‘ the Art of constructing 
buttressed buildings.’’”’ For him the nineteenth 
century woman is essentially Gothic. ‘“‘ How ingeni- 
ously her human qualities were buttressed by romantic 
ideals helping to sustain the great illusion! How 
carefully the fundamentals, on which her charms 
were based, were hidden! . . . Somewhere within 
that monolith was hidden a creature of flesh and 
blood.” Nevertheless he remains baffled. He 
pursues her attitudes through the century rather 
like a terrier digging out a strange quarry’ but 
when she is at last exhumed we find on his face the 
puzzled look of the terrier, wondering what this 
thing can be. What did she think of it all? Was 
she conscious of the pose or was she playing the game 
blindfold ? Most disquieting of all, what was her 
real opinion of the Victorian man ? 

With illustration and quotation Dr. Cunnington 
traces the development of the Gothic attitude from 
the “cool, curious, and informed young woman ” 
of the early years of the century, through the increas- 
ing romanticism of the ’thirties, the sentimental 
forties (when women were assured that ‘“ the 
opposite sex love, respect, and adore them and ever 
will, so long as they retain that inestimable jewel 
Virtue ’’) to the Perfect Lady of the ’fifties. Thence 
Victorian woman declined through the revolting 
’sixties (in a rebellious sense) the ornamental 
’seventies, the symbolic ’eighties—illustrated by 
drawings of Girton girls in bustles and an academic 
aura—to the prude’s progress in the ’nineties. 
And a charming history it all makes. Perhaps the 
reader will feel that not much has been proved, and 
that the light thrown on the scene has made the 
shadows look more impenetrable than ever, but he 
is bound to enjoy the extracts from novels and from 


128. 6d. 


*London: William Heinemann Ltd. Pp. 314. 


462 


THE LANCET] 


APPOINTMENTS.—VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS 


[FEB. 22, 1936 


magazines for young ladies, the advertisements of 
“ beauty animated and vision preserved,’’ of ‘‘ the 
pneumatic tube coil... to all appearance an ordinary 
switch of hair,” and one addressed to the Nobility 
and Gentry by Tiffin and Son, Bug-Destroyers 
to the Royal Family, who ‘‘ beg to suggest the 
propriety of having this nuisance removed.” 


Appointments 


BAILEY, K. C., M.B. Camb., has been appointed Assistant 
Medical Otlicer at Croy don Mental Hospital. 

BONNELL, JANE, M.R.C.S. Eng., Assistant Medical Officer at 
the Royal Eastern Counties Institution, Colchester. 

Bowes, R. K., M.D., M.S. Lond.. F.R.C.S. Eng., Obstetric 
Physician in Charge of Out-patients at St. Thomas’s 
Hospital, London. 

Brown, A. I. P., M.B. Lond., Anesthetist for the borough of 
W ilesden. 

EBBAGE, G. B., M.R.C.S. Eng., Resident Surgical Officer at the 
ETA and Midland Eye Hospital. 

GILBERT, BARTON, M.D. Lond., F.R.C.S. Eng., Gynecological 
Pathologist to the Chelsea Hospital for Women. 

LIVINGSTONE, G. H., M.B. Lond., F.R.C.S. Eng., Ear, Nose, and 
Throat Surgeon for the borough of W illesden. 

MaAacDONALD, DONALD, M.B., D.P.H., Resident Medical Officer 
at the Halifax Isolation Hospital. 

MAXWELL, JAMES, M.D., F.R.C.P. Lond., Assistant Physician to 
St. Bartholomew’ 8 Hospital, London. 

MELVILLE, A. G. G., M.B., D.R., F.R.C.S. Edin., Assistant 
Radiologist at the Victoria Intir mary, Glasgow. 

MILLER, A. C., B.Sc., L.M.S.S.A., D.O. M. S., Hon. Assistant 
Surgeon to the Sussex Eye Hospital. 
MONK, H. E., B.Sc., F.I.C., County Analyst and Bacteriologist 
for W orcestershire. 
Porteous, M. I., M.B. Edin., D.P.IT., Assistant Medical Officer 
of Health for the county borough of Warrington. 

Suawcross, E. W. H., M.R.C.S. Eng., D.M.R.E., Radiologist 
at the Samaritan Free Hospital for W omen, London. 

SPENCE, A. W., M.D., M.R.C.P. Lond., Assistant Physician, and 
Assistant Director of the Medical Professorial Unit, st. 
Bartholomew’s Hospital, London. 

TYRRELL, T. M., M.B. Camb., E.R.C.S. Eng., Assistant Hon. 
Surgeon to the Royal Eyo Hospital, London. 

WRIGLEY, A. J., M.D. Lond., F.R.C.S. Eng., Obstetric Physician 
to St. Thomas’s Hospital, London. 

YEO, K. J., M.B. Camb., D. M.R. E., Hon. Radiologist to the 
Royal Northern Hospital, London. 


V acancies 


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Benenden Kent, National Sanatorium.—Jun. H.P. At rato 

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Bristol University.—Asst. Clin. Path. £375. 

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Cambridge, Addenbrooke’s Hospital.—li.S. At rate of £130. 

Cancer Hospital, Fulham-road, S.JV.—Kes. M.O. for Radium 
Dept. At rate of £100. 

Cardiff, Welsh National School of Aledicine.—\Lord Merthyr 
Research Scholarship. £200. Alo Mrs. John Nixon and 
Ewen Maclean Research Studentships. Each £150. 

Central London Ophthalmic Hospital, Judd-street, 1V.C.—Sen. 
and Jun. H.S. £120 and £100 respectively. 

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road, IV.C.—T wo Assts. in Out-patient Dept. 

Charing Cross Ilospital, W.C.—Surg. Reg. £150. Also Obstet. 

£350. 


Reg. and Registrar. Each £100. 
Chester, County Mental IHosnilal.—Jun. Asst. M.O. 

City of London Hospital for Diseases of the Heart and Lungs, 
Victoria Park, #.—Physician to In-patients, 


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Dreadnought Hospital, Greenwich, S.d¢.—H.P. and H S. Each 


at rate of £10. 

Edinburgh, National Association for the Prevention of Tubercu- 
losis.—Secretary-General, £600, 

Elizabeth Garrett Anderson Hospital, Euslton-road, N.W.—Clin. 
Assts. to Medical Dept. 

Exeter, Royal Devon and Exeter Tfospital.—tl1.S. to Ear, Nose, 

and Throat Dept. At rate of £150, 

Guildford, Royal Surrey County Hospital. —H.S. Also H.P. and 
Cas. Each at rate of £150. 

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Also H.S. Each at rate of £150. 

Herefordshire General Hospital.—H.P. Also H.S. and Cas. O. 
Each at rate of £100, 

Hospital for Tropical Diseases, Gordon-street, W.C.—II.P. At 
rate of £120, 

Hospital of St. John and St. Elizabeth, 60, Grove Iend-road, N.W. 
Sure. Reg. £100. Also Clin. Asst. to Ear, Nose, and 
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DONALDSON.—On_ Feb. 


Huddersfield Royal Infirmary.—Cas 0. £200. 
rate of £150 

Kesteven County “Council. —M.O.H. £1000. 

Leicester County Sanatorium and Isolation Hospital, Markfield.— 
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Leicester Royal Infirmary. —Res. Anesthetist. At rate of £150. 
Cas. O., H.S., and H.P.’s. Each at rate of £125. Also 
Jun. Cas. O. at rate of £100. 

Paver DOEI. eels General Hospital.—H.P. and H.S. Each at rate 
o ( 

Liverpool, Hospital for Consumption and Diseases of the Chest, 
Mount Pleasant.—Res. M.O. £150. 

Liverpool, Royal Babies Hospital.—Res. M. O. At rate of £90. 

Liverpool, koyal Children’s Hospital.—Res. Surg. O. for Heswall 
Branch. At rate of £120. 

London Homeopathic Hospital, Great Ormond-street, W.C.—Hon. 
Surgeon. Also Hon. Asst. Surgeon. 

Maidenhead Hospital.—Hon. Physician. 

Maidstone, West Kent General Hospital.—H.P. £175. 

“Manchester, Duchess of York Hospital for Babies.—Sen. and Jun. 
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Manchester Jtoyal Children’s Hospital, Gartside-street.—Two 
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Mane tee Infirmary.—Jun. Asst. M.O. for Radiological 

ept. £350. 


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Manor House Hospital, Golders Green, N.W.—Jun. M.O. £200. 

Melton, Suffolk, St. Audry's Hospital.—Jun. Asst. M.O. £350. 

Middlesbrough County Borough.—M.O.H. for Maternity and 
Child Welfare. £350. 

Middlesex County Council.—Tuberculosis Sanatorium, South 


Mimms. Deputy Med. Supt.,Xc. £450. 
Mount Vernon Hospital, Northwood.—H.S. At rate of £150. 
Norwich, Norfolk and Norwich Hospital.—Res. M.O. £250. 


Also Res. Orthopmdic O. £200. 
for Fracture and Ortho- 


Nottingham General Hospital.—H.S. 
predic Depts. £300. Also H.S, to Ear, Nose, and Throat 
Dept. At rate of £15v. 

Piymouth City General Hospital.—Jun. Asst. M.O. £250. 

Plymouth, Prince of Wales's Hospital, Greenbank-road.—H.S. 
and H.P. Each at rate of £120. 

Preston, Biddulph Grange Orthopedic Hospital.—Jun. H.S. At 
rate of £200. 

Preston Royal Infirmary.—H.S. for Obstet., Eye, 
Wards. £150. 

Preston. Sharoe Green Hospital.—Sen. and Jun. Asst. Res. 
M.O.’s. At rate of £200 and £100 respectively. 

Prince of Wales’s General Hospital, N.—Res. Jun. H.P. and 
H.S.’s. Each at rate of £90. Also Hon. Med. and Surg. 
Regs. Each £100. i 

Princess Louise Kensington Hospital for Children, St. Quintin- 
avenue, }V.—H.s. At rate of £100. 

Queen's Hospital for Children, diackney: road, E.—H.P. and 
Cas. O. Each at rate of £101 

Rhondda Urban District Council. eh: M.O. £500. 

Rochdale, Birch ITill Hospital.—Jun. Res. M.O. At rate of £200. 

Rochdale Infirmarn and Dispensary.—Second H.S. £150. 

Rotherham Hospital,—sSen. H.S. or P. £200. Also Cas. H.S. £150. 

Royal Army Medical Corps.—Commissions. 

Royal College of Surgeons of England.—Election to Court of 
Examiners. 

Royal Eve Hospital, St. George’s-circus, S.E.—Part-time Patho- 
logist and part-time Bactcriologist. Each £160. Also 
Sen. H.S. and two Asst. H.S.’s. At rate of £150 and £100 
respectively. 

Royal Masonic Hospital, Ravenscourt Park, 1.—Res. Surg. O. 
At rate of £250. 

St. Bartholomew’s Hospilal Medical College.—Sen. Demonstrator 
in Dept. of Pathology. £400. 

St. George's Hospital, S.W.—Asst. Bactcriologist. £500. 

St. Leonards-on-Sea, Buchanan Hospital.—Jun. H.S. £125. 

St. Peter’s Hospital for Stone, d-c., Henrictta-street, W.C.— H.S. 
At rate of £75. 

Shorcham-by-Sea, Southlands Tosp.—Second Asst. Res. M.O. £300. 

South Shields, Ingham Injirmary.—Jun. H.S. £150. 

Stockport Infirmary.—H.P. £100. 

Stoke-on-Trent, Stanfield Sanatorium.—Res. M.O. £250. 

Swansea County Borough.—Asst. M.O. £500. 

Warringlon Counlu Mental Hospital, Winwick.—Asst. M.O. e 

West London Hospital, Hammersmith-road, W.—H.P. and H.S 
to Spec. Depts. Each at rate of £100. 

Whitechapel Venereal Diseases Clinic, E.— 
Director. £1250. 


The Chief Inspector of Factories announces a vacancy for a 
Certifying Factory Surgeon at Wrexham (Denbigh). 


Births, Marriages, and Deaths 


BIRTHS 


GRATRIX.—On Feb. 8th, at Redcliffe-gardens, South Kensington, 
S.W.. the wife of Dr. William H. Gratrix, of a daughter. 

ORME.—On Feb. 6th, at Bidston, Matlock, the wife of Dr. C 
L’Estrange Orme, of a son. 

SMITH.—On Feb, sth, at Topsham, Devon, the wife of Dr. E. H. 
pr Oehorae Smith, of a daughter. 

`eb. 10th, at Belvidere, Weymouth, the wife 

of William Rayner Thrower, M.D., M.R.C.P. Lond. ., of 


a son, 
DEATHS 


lith, at a Coventry nursing-home, 
James Smith Donaldson, M.B. Glasg., of Balsall Common, 
aged 37 years. 

GuBB.—On Feb, 3rd, suddenly, at Mustapha Supérieur, Algiers, 
Alfred S. Gubb, M.D. Paris, M.R.C.S. Eng., D.P.H. 


N.B.—A fee of 78. 6d. is charged for the inserlion of Notices of 
Births, Marriages, and Deaths. 


and Ear 


Turner-street, 


THE LANOET] l n 


[FEB. 29, 1936 


ADDRESSES AND ORIGINAL ARTICLES 


ON THE PROPHYLACTIC ACTION OF 
‘BAYER 205” AGAINST THE 
TRYPANOSOMES OF MAN 
CONCLUDING OBSERVATIONS 


By H. LynpHURST DUKE, O.B.E., M.D., Sc.D. Camb. 


DIRECTOR OF THE HUMAN TRYPANOSOMIASIS RESEARCH 
INSTITUTE, ENTEBBE, UGANDA 


THE preliminary paper of this research was pub- 
lished in this journal in June, 1934. In that paper 
a brief summary was given of the work already done 
on Bayer 205 as a prophylactic against the try- 
panosomes of man, but no reference was made to 
the work of Fourche and Haveaux (1931), of which 
at the time I was not aware. These investigators 
concluded that preventive treatment should be 
restricted to the healthy while the infected are 
undergoing cure, doubtful cases being rigorously 
excluded; that at least two doses of Bayer 205 
should be employed ; and that the preventive effect 
can be relied upon for from six to seven months at 
most. 

In December, 1934, there appeared a paper by 
Corson on the action of Bayer 205 on Trypanosoma 
rhodesiense in white rats infected by tsetse flies 
(Corson b). The author, to use his own method of 
presenting his results, found that a dose of 0:015 g. 
per kg. body-weight did not protect these animals 
for 21 days, and that a dose of 0-03 g. failed to protect 
for 40 days. He concluded that the drug has a 
strong prophylactic action in animals and may be 
presumed to have the same in man; also that the 
action varies somewhat in degree in individual 
animals of the same species, and it may be expected 
that this will also occur in man. He also remarked, 
“The chief difficulty seems to be the question whether 
the drug might cause such alteration of the virulence 
of the trypanosomes as to make diagnosis difficult.” 


THE PRELIMINARY INVESTIGATIONS 


The following is a summary of the investigations 
already described in Tur LANCET (1934, 1., 1336). 


Two groups of native volunteers were taken. The 
first consisted of 4 men, A., B., C., E., who had recently 
been experimentally infected with T. rhodestense and then 
treated with Bayer 205 immediately trypanosomes were 
seen in their blood (i.e., 8-11 days after the act of infection). 
Each man had received six doses of Bayer 205 in 1-0g. 
doses intravenously at intervals of a few days. The 
second group comprised 3 virgin volunteers, I., M., and Q., 
each of whom received a single intravenous injection of 
1-0 g. Bayer 205. In every instance exposure to infection 
was by the bite of tsetse known to be infective to man, 
7 clean volunteers being used as controls. The results 
of the investigation were as follows: The men A., B., C., 
and E. resisted T. rhodesiense for at least 190, 180, 182, and 
105 days respectively, these figures relating to their 
last exposure to infection. Volunteer B., who was still 
protected at the 180th day against T. rhodesiense, was 
infected by T. gambiense between the 208th and 212th 
days after the last dose of Bayer 205. Volunteers I., M., 
and Q., who received a single dose, were protected against 
T. rhodesiense for at least 111, 113, and 108 days. Volun- 
teer M., when exposed to T. gambiense on the 145th day, 
became infected. Those who escaped infection—namely, 
A., C., I., and Q., remained under observation in perfect 
health for more than 18 months, after which all of them 
were employed again. 

In the discussion that followed it was suggested that the 
degree of protection conferred might be to some extent 

5870 


proportional to the quantity of Bayer 205 administered, 
a@ conclusion also reached by Browning and Gulbransen 
(1934) in their work on T. brucet in mice. It appeared 
possible also that the protection conferred by Bayer 205 
was greater against T. rhodesiense than T. gambiense ; 
either because the greater biological adaptation of 
T. gambiense to man rendered that trypanosome in some 
way less susceptible to the drug in man, or because of the 
greater susceptibility of 7’. rhodestense to the drug. Findlay 
(1930) records that Moranyl is less efficient against 
T, gambiense than T. rhodesiense. ` 

Two experiments perfọrmed with monkeys suggested 
that the greater the susceptibility of the vertebrate to the 
trypanosome the less efficient the protection conferred 
by the drug; in other words, that an animal’s natural 
resistance helps the Bayer 205 to stave off the trypanosome. 


The use for the first time of native volunteers on 
a large scale involved difficulties that have since 
been largely overcome, and explained the inclusion 
of the men of Group I. These were the first volun- 
teers to come forward and were willing to serve again. 
It was realised that there were objections to their 
employment—i.e., the large amount of Bayer 205 
administered. and the possible immunising effect of 
the liberation of antigen following the destruction 
of the trypanosomes by the first dose. But time 
and opportunity were pressing and no one else was 
available. 

The Inquiry Continued 


The full extent of the protection conferred by the 
drug against T. rhodesiense was not determined as 
no protected volunteer succumbed to that try- 
panosome, the only 2 men who were infected falling 
to T. gambiense. In the course of the present inves- 
tigations, several of the volunteers after having been 
infected and treated were later on again exposed to 
infection. Table I. gives brief details of their exposure 
to reinfection :— | 

l TABLE I 
Re-exposure of Experimentally Infected Volunteers to 
Infection, at 6-16 Months after Cessation of Treatment 


_|Trypanosome and Trypanosome and 
ee date o t pt nar f date of subse- 
. infection. quent infection. 
A. rhodesiense 29.1x.33 rhodesiense 
(30.viii.33) (15.vii.35) 
B. (1) rhodesiense 30.ix.33 — 
(23.viii.33) 
B. (2) gambiense 29.vi.34 gambiense 
(28.iv.34) (try parsamide) (22.vi.35) 
D. rhodesiense 26.iv.34 rhodesiense 
(S.iii.3-4) (7.v.35) 
E.. rhodesiense 13.xii.33 rhodesiense 
(G.ix.33) (1.iii.35) 
M. — 1-0 g. Bayer 205 — 
propbylactic, 
13.xii.33 
gambiense 6.vi.34 rhodesiense 
(tryparsamide) - (2.vii.35) 
' K. rhodesiense 23.iv.34 rhodesiense 
(16.iii.34) (28.vi.35) 
Z.A. gambiense l 9.v.34 rhodesiense 
(12.iv.34) (tryparsamide) (10.vi.35) 
A.A. gauibiense 3.iV.35 rhodesiense 
(18.11.35) (tryparsamide) (15.x.35) 
E. E. gambiense 5.iv.35 _ gambiense 
(21.ii.35) (tryparsamide) (18.x.35) 


The evidence presented in the two Tables of this 
paper suggests that the maximum immunity is 
obtained from the frequently repeated destruction 
of living trypanosomes in an organism initially pro- 
tected by Bayer 205. 

The great majority of the volunteers infected 
with T. rhodesiense and treated with Bayer 205 
experienced, immediately after their first injection, 
a rise of temperature to 104-106°F., falling in 
36-48 hours to normal where it continued. From a 


464 THE LANOET] 


study of the charts of all the men employed, it would 
appear that the patient’s reaction when T. gambiense 
is treated with tryparsamide is less severe than that 
following treatment of T. rhodesiense with Bayer 205. 
A striking exception to the usual response to 
treatment was shown by one of the volunteers. 


He was ‘admitted with a temperature of 103° F., and 
received his first dose of Bayer 205 when his temperature 
was 100° F., after which for 48 hours it fluctuated between 
99%F. and 101°F. Then, following a second Bayer 205 
injection, the temperature rose to 105° F. and remained 
remittent around that Ievel for nine days, during which 
another injection of Bayer 205 and two of quinine were 
given, malaria having been found in his blood. The fourth 
dose of Bayer 205 was followed by yet another rise to 
105° F., and 36 hours later the temperature fell to normal 
and remained there. 


This extraordinary course cannot, I think, be attri- 
buted to the coincident malaria, for a number of 
the volunteers had this parasite simultaneously with 
trypanosomes. It is, rather, an example of an 
idiosyncrasy either for the products of the destruction 
of the trypanosomes or for the drug itself. 

In none of the men of Table I. was the incubation 
period prolonged. These reinfections show that any 
immunity conferred by a brief (10-15 days) infection 
with T. rhodesiense or T. gambiense followed by a 
course of six injections with Bayer 205 or tryparsa- 
mide, does not persist for as long as 6-16 months. 


CONTROL MEASURES DURING THE INVESTIGATION 


It is of course necessary to prove the infectivity of the 
tsetse before they bite man ; and similarly when the syringe 
is used, the inoculum must be proved to be infective to 
animals when it is introduced into the volunteer. The 
former process takes up time and so increases the likelihood 
of infective flies dying before they have bitten man. 
But in addition to ordinary routine precautions against 
the casual infection of experimental animals (described 
elsewhere, Duke, 1934), the employment of man intro- 
duces new complications. Natives differ individually 
„in their natural resistance to trypanosomes, and strains 
of human trypanosomes, particularly T. rhodesiense, 
may alter from time to time in their pathogenicity to man. 
It is impossible to present all experimental details, and 
the reader must accept the assurance that the strains 
used in these experiments were indeed infective to man, 
as proved by control experiments on man at frequent 
intervals. 

Another difficulty has been the provision of an adequate 
number of gland-infected flies with which to ensure 
exposure of the volunteers to infection. In the experi- 
ments recorded in this paper over 16,000 flies were dis- 
sected of which 120 had gland infections, more than half 
of these last dying before they were ever fed on man. 

It was hoped during these experiments to secure 
decisive evidence whether there is any essential difference 
between the results obtained by fly-bite and by syringe 
infection, but this proved impracticable. The former 
method is to be regarded as the more reliable in assessing 
the value of the prophylactic, as it is the method 
encountered in nature. I have discussed elsewhere 
(Duke, 1935) the two modes of infection and, in opposition 
to certain investigators, still believe that subcutaneous 
inoculation of infected blood may give misleading results, 
especially when the pathogenicity of a trypanosome to 
man is under investigation. In these experiments the 
syringe method has been used mainly under constraint, 
in default of a sufficient number of gland-infected flies. 


And now a word to the impatient. The investi- 
gation, from whatever angle, of the behaviour of 
human trypanosomes in man involves contact with 
a number of different factors. In the present inquiry, 
for example, the following have to be borne in mind : 
differences in man’s individual resistance to try- 
panosomes; the characters of different strains of 
trypanosomes ; the immunising effect (so far quite 


DB. LYNDHURST DUKE: ‘f BAYER 205"? AND TRYPANOSOMES OF MAN 


[FEB. 29, 1936 


unknown) of repeated small inoculations of living 
metacyclic or blood trypanosomes into an individual 
still under the protection of Bayer 205; and the 
rate and extent of absorption and elimination of the 
drug in the individual. All these are variables, and 
we must therefore be content for the time being with 
rough indications rather than accurate scientific 
conclusions, Indeed the more one studies the try- 
panosomes of the brucei group in relation to man 
himself the more apparent becomes our ignorance of 
his true place in their economy in nature, 


EXPLANATION OF TABLE II 


Table II. sets forth the details of the exposure and 
response of the volunteers to infection. | 


Of the 53 gland-infected flies actually used in these 
experiments, 34 came from different boxes—i.e., one 
infective fly per box ; the other seven boxes each contained 
2—4 infective flies. Each single box of flies, before being 
placed on a volunteer had infected at least one clean 
animal and often more. Fly No. 15, for example, in the 
course of its career of 86 days, infected in turn a guinea-pig, 
2 unprotected volunteers, 3 antelopes, and a monkey. 
Each infective fly is distinguished in the Table by a 
number, and where more than one occurred in the same 
box a letter is added. For obvious reasons it was 
impossible to test every fly on a separate clean volunteer, 
but the following were actually proved able to infect man : 
Nos. 1, 2a, b, c, and d, 3a and b, 5, 8, 10, 14, 17, and 
18a, b, c, and d, 33a and b, and 41. The untested majority 
all carried strains known to be readily infective to man. 

In the course of investigations at this laboratory and 
particularly during the last six months, flies infective with 
certain lines of T. rhodesiense have been found to be non- 
infective to unprotected volunteers. Such trypanosomes 
have therefore been excluded from the Table. Only two 
strains of T. rhodesiense have been used in these experi- 
ments and great care has been taken throughout only to 
use lines of these two strains that have given recent 
evidence of pathogenicity to man. More exact control 
than this was not possible. Ideally, each individual 
fly should be tested independently on several volunteers— 
obviously an unattainable ambition. Work of this kind 
is full of surprises, and there have been incidents here and 
there in the course of these and other kindred investigations 
which do indeed suggest that with “ borderline ” strains 
individual flies may differ in their ability to infect man. 
The evidence for this is admittedly slight, but the 
possibility cannot be dismissed merely because it appears 
to be improbable. 

The volunteers were exposed to infection by one of 
two methods; either by allowing infective flies to bite 
them, or by subcutaneous inoculation of blood containing 
living trypanosomes. The method used is shown in the 
columns under “exposure to infection.” Every inocula- 
tion recorded in the Table was accompanied by controls, 
all of which were promptly infected. All the inoculations 
of salivary glands of infective flies were likewise controlled, 
and none is recorded unless the control rat or guinea-pig 
became infected with the opposite gland of the same fly. 
The inoculation of salivary glands was always additional 
to the exposure by fly-bite recorded in column 4. 

The incubation period (in days) is calculated to the 
day when trypanosomes were first found in stained thick 
films of the blood. The dose of Bayer 205 received by 
each volunteer is shown under his designation in column 1: 
Thus, 1-0 g. = a single intravenous injection of 1-0 g. of 
Bayer 205, irrespective of body-weight; 2:0 g.=a 
single dose of 2-0g.; 1:0 + 1-0 g. = two doses of 1-0 g. 
each, separated by 21 days. No attempt was made to 
standardise the amount of Bayer 205 administered accord- 
ing to the weight of the volunteer, and in practice it is 
unlikely that this would be done. The net weight of 
each man in kilos is shown in column 1 of the Table; 
it will be noted that only two touch 10 st. (63-6 kg.). 

Every fly before being placed on the volunteer was 
either starved for 72 hours and then given one opportunity 
of feeding, or starved for 48 hours and then put on him 
on the two succeeding days. All flies that refused to feed 
were at once killed and dissected. 


THE LANCET] 


. DRE. LYNDHURST DUKE: “ BAYER 205” AND TRYPANOSOMES OF MAN [FEB. 29, 1936 465 


ee ea e S ss 


TABLE I].—SHOWING THE MODE OF INFECTION. OF THE VOLUNTEERS AND THE DIAGNOSIS 


aq TR Exposure to infection. Be fai Exposure to infection. 
AT Su e. | w r= aS ap Su e | wo =] i 
2 g BOD | o Oo go | GOS |o oo 
Aata j pea |f pa Inoculation of | a%Xq | 2a | £ Gp Inoculation of 
n D S K: 8 w | 8 By tsets 433 volunteer’s OT S 8 m | 8 By tset. B rd volunteer’s 
goa woe | M 9 re 329 Result blood into gua woe |S y tse re 2° sul blood into 
of | S88 | J| (serial | Su 9 sult. | clean monkey.J=5%| S23 | J| (serial | 5=,9; Result. | clean monkey. 
gs S san È numbers). | 482 g2 S| 3a z numbers). | 9.4.4 
63 = =a 9 ~ a 
© P © © þh © 
SS | A 2 £2 Se | 7 2 A 
i C.C. C.c 
E. E. | 92-94 |G.|2a,b,c,d| .. |+, ine. 17 si ‘| P. P. |128-136| R. | 10, 11, 15 fe Nil. r 
1-0 g. 1:0+ 143 R. 11 3 Nil. i 
48:5 1:0 g. 1160-161] R. 5 is Nil. l is 
51:5 170-171 R. 5, 16 oe Nil. ee 
K. K. |119-120| G. | 2a, b, ©, dj .. Nil. su 203-204| R. 38 om } +. ine. ? es 
10g. 59 |G.| 3a, b, .. | +, ine. 5 i 223 |R. a 1 » inc., ae 

51 G. G. | 98-99 | G. | 2a, b,c, d] .. Nil. z 

1:0 -+ |122-124| G. | 2a, b, c,d Nil. R 
F. F. 96 |G.]2a,b,œo d| .. Nil. z% 1-0 g. |156-159| G. |3a, b, 4,7,8 Nil. ss 
1-0 g. |110-111| G. | 2a, b, c, d $ Nil. Ss 70 166 G. we = Nil. es 

47 122-123 R. 5 ee e ee 187 G. ee ee Nil. ee 

138-140 G. 3a, b, 6a, 7 ee +, inc. 14 ee 222 : R. ee 1 +, inc, 10 . o 
I. I. 105-107 G. 1 ee +, inc. 19 ee H. H. 104-106 G. 2a, b, C, d oe Nil. oe 
1-0 g. i 1:0 + 115 G. a, b, C, d . Nil. ee 
57:5 1-0 g. er ae a , 25 ‘ ND: Si 
Z.E.| 92 ÍR. s 1 |+, inc. 12 Oe ry lR ll. i n NIL 
1-0 g. . 224-226| R.|18a, b, c, a| .. | +, inc. 2 
a O. O. 118-119] R.| 10,11 EN i 
. e 11 x e f 9 ee . ee 
Be ee = i ai = 1-0+ 1130-136} R. | 10,41,15| |: | NE | O0 X 
54:5 10g. 148 IR. 10 me Nil. ae 
57:5 |163-164| R. 5 Nil. 
Z.M. 73 ÍR. zs 1 Nil. Si 233 R. |18b, c, d, 19 +, inc. 10 
1-0 g. 97 G. ee 1 Nil. ee , 

52 127 NEN zi : å 5 o.c. : nil. Z. H. 97 R. : 1- Nil. — za 
135-141; R.| 20, 23a, b \ + es 20g. 131 R. . 1 Nil. i 
146-148) R. |22b,c,28,30 ee 63-5 150 es ats ¿ s 5 o.c. : nil. 

174 Si si es 506.0.: +,inc. 7 151 R. 29 : Nil. os 

181 hi zi R 50.c.: +,inc. 7 162-163) R. 20,21 sa Nil. ' ae 
Z. F. 103-104 R. 10 e Nil. ee 200 . œ e ee ee 5 C.C. : pil. 
1-0 g. 121-122 R. 11 . Nil. ee 203 R. e 1 +, inc. 10 oe 

53 135-136 R. 11 Nil. ee Z. K. 103 R. e 1 Nil. ', ,ee 
141-142 R. 10 . Nil. ° 2-0 g 155 . R. ee 1 Nil. oe 
150-151 R. 5 Nil. ee 64 179 . ee ee oe 5 C.C. e nil. a 
167-168 R. 12 Nil. . 103 R. eve 1 Nil. ee 

171 R. ee es Nil. ee 155 G. ees 1 . o 
198 R. 14 . Nil. ee 179 ee ee ee 5 6.¢c. 7+, inc. 22 
212 R. 17 Nil. ia 179 R. es 1 +,inc. ? 
237-238 R. 18c, d, 19 Nil. . 203 ee ee . 5 C.C. : +, inc. 18° 
252—253 R. 28 . Nil. . * 209 R. ee 1 ee 
262-263) R. |22a,b,c,23b) .. Nil. ‘ Z. L. 104 R. A 1 Nil. l 
286-289| R.| 33a, b, sa Nil. ‘ 20g. 128 G. ; 1 Nil. ay 
301 oe en a 5 c.c. : nil. 47°5 152 sa i Ss ae 5 c.c. : nil, 
306 ae ee ee 5 c.c nil. 152 R. e 1 à Nil. ee 
307 R. 37 as Nil. ‘ 174 a% . A sa 5 c.c. : nil. 
320 ia ou ee 5 c.c. : nil. 175 R. ia 1 |+,inc. 14 48 
320-323) R. 38, 39 are Nil. ae Z.N. 130 R. a 1 Nil. ae 
327 R. ate Nil. oe 2:0 g. 1153-156) R. 27,29 AR Nil. ‘ 
344 za i ae is 5 c.c. : nil. 54:5 160 R. 21 ; Nil. ié 
347 is a : 5 c.c. : nil. 180 R. 22b, © Nil. š 
350 R. F 1 |+, ince. 16 ‘ 200 aa es icy ae 5 c.c. : nil, 
365 sa a. a ‘ 201-204] R. |32,33a,b,34; .. +, oe 
Z.G. 93 R. a 1 Nil. “s inc, 11-13 
1-0 g. 120-121 R. 18c, d, 27 ee Nil. . 213 ee ° ee ee Cc C. e +, inc. 8 
64 149-150) R. 30 ox Nil. Z. I. 97 R. oe 1 Nil. ae 
165-166) R. 32, 36 Nil. è 2-0 g. 131 R. we 1 Nil. è 
180 s aa ss va 5 c.c. : nil 59 153 G. se 1 Nil. i 
182 Da A a ne 5 c.c. : nil 178 Si ; as s 5 c.c. : nil. 
190 R. T 1 Nil. š 179 R. s 1 Nil. i 
209 es s Res as 5 o.c.: nil 200 R. ‘ 1 +, inc. ? ; 
211 RR iie si 5 c.c. : nil 219 a ‘ oe p c.c.: +, inc. 13 
211 R 1 +, inc. 10 ‘ 221 R. 1 T s 
Trypanosomes: R.=rhodesiense ; G.=gambiense. inc. =incubation. c.c.=cubic centimetres. 
REMARKS 


K. K.—tThe short incubation period suggests that the previous 
infection was established and dormant. 

Z. M.—135th—-141st and 146th-148th day: inoculated with 
gland of 28 and 22a respectively. Trypanosomes first seen in 
Z. M.’s blood on 188th day; no symptoms from 148th—-179th 
days; sce text, “‘ cryptic infections.” 

Z. F.—171st day: inoculated with gland of 13. 252nd—-253rd 
day: Ditto 21. 262nd-263rd day: Ditto 24. 320th-323rd 
day: Ditto 38 and 40. 365thday: Lumbar puncture ; cells 
4:5 per cm. 

Z. G.—120th-121st day: inoculated with gland of 18b. 
149th—-150th day: Ditto 22b. 

P. P.—223rd day: Acute general and local symptoms and 
trypanosomes 6 days after the blood inoculation. Probably 
also cryptic infection due to last fly-bite (see text). 


SUMMARY OF THE INFORMATION CONVEYED BY 
TABLE I 
(1) Nine volunteers received a single dose of 
1-0 g. Bayer 205; five others a single dose of 2-0 g. ; 
and four others two doses of 1:0 g. each, separated 


G. G.—166th day: inoculated with gland of 8 and 9. 187th 
day: Ditto 3b. 


H. H.—224th-226th day : inoculated with gland of 18a and 26. 


Z. K.—Symptoms and trypanosomes on 219th day. See text 
discussion cryptic infections. 


Z. L.—152nd day : control clean volunteer also inoculated and. 
infected after 12 days’ incubation. 


Z. N.—153rd-156th day: inoculated with gland 18d, 19. 
180th day: Ditto 22e. 201st-204th day: inoculated with 
gland 31. Small painful swelling on area of fly-bites. 


Z. I.—Trypanosomes first found in Z. I.’s blood on 233rd day ; 
see text, discussion on cryptic infections, . 


by an interval of 21 days. Al injections were given 


intravenously, 

(2) Of those receiving 1-0 g., four were infected 
at their first exposure, 92, 105, 92, and 73 -days 
after the administration of the drug, two falling to 


466 THE LANCET] 


T. gambiense and two to T. rhodesiense. The remain- 
ing five were protected for 120, 123, 97, 190, and 
327 days respectively. Against T. gambiense the 
minimal periods of protection were 120, 111, and 
97 days, and against T. rhodesiense 123, 73, 327, and 
190 days. It must however be realised that as 
most of the later exposures were carried out with 
T. rhodesiense, the majority of the figures for 
T. gambiense are very conservative estimates. 


(3) Of those receiving 1:0+1:0 g. none were 
infected at their first exposure. Protection against 
T. gambiense lasted 169 and 187 days, and against 
T. rhodesiense 171, 206, and 164 days. 


(4) Of those receiving 2:0 g. none were infected 
at their first exposure. Protection against T. gam- 
biense lasted 128 and 153 days, and against T. rho- 
desiense 163, 103, 152, 180 and 179 days. 


(5) No more evidence has been secured about the 
relative effect of Bayer 205 on each of the two human 
trypanosomes, because, owing to lack of flies carrying 
T. gambiense, most of the later exposures were made 
with T. rhodesiense. 


(6) As a general rule when infection did ensue it 
developed normally. There were however certainly 
three and possibly five examples of delayed or 
“cryptic ” infection (volunteers Z. K., Z. I., Z.M.,P.P., 
and K. K.) which are discussed below. 


(7) The Table affords some support of the belief 
that 2:0 g. of Bayer 205 confers greater protection 
than 1-0 g. 

(8) The most arresting result is the protection 
conferred upon volunteer Z. F., who was exposed to 
a long succession of gland-infected flies carrying 
T. rhodesiense, several of which had actually been 
proved to be infective to man, and all carrying 
strains known to be strongly pathogenic. 


The single fly (41 of Table II.) which bit this man on 
the 327th day, had infected a clean volunteer a few days 
previously. The fly was dissected a few hours after 
biting Z. F. and was full of his blood; its glands were 
swarming with trypanosomes. On the day before trypano- 
somes appeared in Z.F.’s blood, lumbar puncture was 
performed. A perfectly clear fluid emerged under very 
slightly increased pressure. Hxamined by the Ross- 
Jones test the fluid contained no excess of globulin; and 
the lymphocyte count was 4:5 perc.mm. On the following 
day, the 16th after his last exposure, Z. F. complained 
of headache, his temperature was 99:5° F. and trypano- 
somes were found in his blood. This was the first occasion 
in his long experimental service that Z.F. complained 
of any symptoms. The condition of the cerebro-spinal 
fluid and the subinoculations of his blood into monkeys 
show that he had in truth escaped infection until the last 
subcutaneous inoculation. 


An experiment was carried out to determine 
whether Z. F.’s blood possessed any action against 
T. rhodesiense. 


Eight white rats were inoculated on Sept. 6th, 1935, 
with 0:25 c.cm. citrated blood of a monkey infected with 
T. rhodesiense. Trypanosomes appeared in the peri- 
pheral blood of all the rats on Sept. 10th. On the 12th 
three of the rats (weighing respectively 184, 217, and 
207 g.) received a subcutaneous inoculation of 0:5 c.cm. 
serum of a normal European; three others (weighing 
184, 190, and 169g.) received 0-5c.cm. serum of Z.F., 
321 days after his injection of Bayer 205; and the remain- 
ing two (weighing 167 and 165 g.) were kept as controls. 
No apparent effect was produced by either serum on the 
number of trypanosomes appearing daily in the peripheral 
blood or on the duration of the disease. The European 
serum rats died on Oct. 7th, llth, and 17th ; those receiv- 
ing Z. F.’s serum on Oct. 2nd, 7th, and 14th; andthe two 
controls on Oct. 8th. As the untreated disease lasted for 
32 days in rats, it is considered these limited observations 


DR. LYNDHURST DUKE: ‘“‘ BAYER 205” AND TRYPANOSOMES OF MAN 


[FEB. 29, 1936 


reveal no difference in the protective power of the two 
human sera tested. 


General Discussion 
MODE OF INFECTION AND STRENGTH OF INOCULUM 


It has not been possible during this research to 
learn anything definite about the significance of the 
number of trypanosomes introduced or to contrast 
the two methods of infection. We know now that 
a single fly can infect man with either T. gambiense 
or T. rhodesiense, and it is highly probable that this 


“is the way he ordinarily becomes infected in nature. 


Certainly it is extremely unlikely that anyone will 
be so unfortunate as to be bitten simultaneously 
by three or four gland-infected flies as were several 
of the volunteers on several occasions during these 
experiments. 

‘ Various observers have examined this question 
using the blood forms of the trypanosome, the most 
recent being Corson, who decided that the number 
of trypanosomes in the inoculum makes very little if 
any difference to the result (Corson (c)). The opinion 
of the volunteers themselves is that the syringe is 
the more deadly of the two modes of infection, but 
they are no doubt biased by the greater local dis- 
comfort it causes. Some of the “arms” that fol- 
lowed subcutaneous injection were really impressive, 
as also was the rapidity with which the local inflam- 
mation disappeared with trypanocidal treatment. 

Unfortunately, it is impossible to compare the 
two methods of infection in the same subject, and 
I can only reiterate my belief that the inoculation 
of 1 c.cm. of citrated blood containing say from 
1-3 trypanosomes per microscopic field (4 obj. X 2 oc.) 
is a more severe test than the bite of a single fiy 
infective with the same strain. 


CRYPTIC INFECTIONS 


In Table II. there are four instances of what may be 
described as cryptic infections among these volun- 
teers—i.e., P. P., Z. I., Z. K.,and Z. M.—and K.K. is 
possibly another example. With volunteer P. P. it is 
true the evidence is not absolutely conclusive. This 
man developed typical symptoms of infection 6 days 
after an injection into his forearm of blood infected 
with T. rhodesiense. On the third day after this 
inoculation, the arm being then considerably swollen, 
a small tender swelling appeared on his leg, on the 
area of skin where the last batch of infective flies had 
bitten him 21 days before. 

Now a small tender swelling at the bite of an 
infective fly is not an uncommon symptom in volun- 
teers infected by this method. The appearance of 
this swelling, therefore, together with the short 
period (6 days) elapsing between the injection of 
the blood and onset of symptoms, suggest that there 
was an undetected focus of living trypanosomes 
persisting at the site of the fly-bite and that this 
focus lit up during the general disturbance caused 
by the subsequent injection of infected blood. In 
support of this conclusion is the fact that in a control 
untreated volunteer who was inoculated simul- 
taneously from the same inoculum as P. P., the first 
symptoms did not develop until the 15th day after 
inoculation. Volunteer K. K. is possibly another 
instance of the same kind. Volunteer P. P. when 
treated with Bayer 205 reacted in a typical manner, 
the temperature rising to 106° F. after the first injec- 
tion and falling to normal within 36 hours. K. K., 
infected with T. gambiense and treated with try- 
parsamide, exhibited a very mild febrile reaction 


THE LANCET] 
during his treatment, 101°F. being the highest 
recorded. 

' Trypanosomes were first found in Z.I.’s blood 
33 days after his infection with blood containing 
T. rhodesiense ; he denied feeling indisposed at any 
time and his temperature when the “ positive” 
slides were taken was normal. His blood infected 
a monkey 19 days after his own infection. In this 
case, also, a second inoculation of T. rhodesiense was 
made before the original infection was diagnosed— 
i.e., 21 days later. When admitted to hospital this 
man’s temperature remained for 48 hours between 
subnormal and 99°F. before treatment. After the 
first two injections of Bayer 205 (which produced 
no rise) the temperature remained normal for 7 days, 
rising for a few hours to 101°F. after the third 
injection, after which no further rise occurred. 


The other two cases were more definite. 


Volunteer Z. K. was inoculated with blood containing 
T. rhodesiense on two occasions after his actual infection 
with T. gambiense and before that infection had been 
-diagnosed, the dates of the three inoculations being: 
T. gambiense on July 19th, 1935, and T. rhodesiense on 
August 12th (afternoon) and Sept. 9th. He first showed 
the characteristic early symptoms of trypanosomiasis 
‘on Sept. 20th, 11 days after the last inoculation of 
'T'. rhodesiense and two months after his inoculation with 
'T'. gambiense. His blood infected a clean monkey on 
August 12th (morning) and again on Sept. 3rd, on both 
-occasions with T. gambiense; but until Sept. 20th he 
-denied feeling any discomfort whatever. On admission 
into hospital his temperature was 102°F., and 12 hours 
after the first injection of Bayer 205 reached 105°F., 
dropping to normal 12 hours later. On the fifth and sixth 
days it rose to 99° F., tryparsamide was administered, 
and no further rise occurred. 

Volunteer Z.M. was bitten by several ghand-infected 
flies carrying T. rhodesiense between August lst and 14th. 
He remained apparently in perfect health until Sept. 21st, 
-when on close questioning he admitted a slight headache 
-overnight. Trypanosomes were found in stained thick 
films of his blood on Sept 23rd, and his temperature 
.(taken four-hourly) during the ensuing 48 hours twice rose 
‘from normal to 99°F. On Sept. 9th and 16th his blood 
infected clean monkeys with T. rhodesiense. During 
‘his first two days in hospital his temperature reached 
-99° F. twice; the first two doses of Bayer 205 produced 
mo further rise, but on the seventh day 101°F. was 
recorded for a few hours. 

The trypanosomes isolated from both Z.K. and Z.M. 
‘were found to be readily transmissible by G. palpulis. 


To balance the impression made by these cases, 
‘in all of which Bayer 205 may possibly have played 
‘in part, an example must be cited from another 
‘investigation. A similar kind of infection occurred 
-in a volunteer (O.) who had been experimentally 
‘infected some 20 months previously with T. rhode- 
stense and treated in the usual way with Bayer 205, the 
_last dose being given on Dec. 6th, 1933. 


His temperature reaction on that occasion showed the 
‘typical rise to 105° F. after the first dose and then a rapid 
-drop to normal. On August 7th, 1935, 610 days after the 
last dose of his course of Bayer 205, this man was inoculated 
with the blood of a guinea-pig infected with a strain of 
P. rhodesiense known to be of uncertain pathogenicity to 
Two other adequately controlled injections of this 
.strain into normal and untreated volunteers had failed, 
-and in this man an entirely symptomless infection was 
revealed by an inoculation of his blood into a clean monkey 
on August 29th, 22 days after his exposure. 

In the course of daily examinations of stained thick 


-filrms of the blood of this monkey, trypanosomes were found | 


first on Sept. 19th, 1935, and were subsequently diagnosed 
-as T. rhodesiense. On Sept. 9th, still claiming to be in 
jperfect health and his infection still undetected, the man 


DR. LYNDHURST DUKE: ‘“ BAYER 205” AND TRYPANOSOMES OF MAN [FEB. 29, 1936 467 


received another inoculation of same strain, this time from 
a monkey. On the 18th his blood again infected a clean 
monkey with T. rhodesiense, the incubation period in the 
monkey being nine days. Thick stained films of the man’s 
blood were taken and examined on Sept. 23rd, 24th, 25th, 
26th, and on the 27th very scarce trypanosomes were 
seen for the first time, and again on succeeding days 
until treatment was started. His temperature, taken 
twice daily, first rose above normal on Oct. 3rd, and his 
health according to his repeated asseverations remained 
excellent until that date, when he was taken into hospital. 
On admission he registered 99° F., and after the first 
injection of Bayer 205 the temperature was 99-6° F. and 
thenceforward normal. 

The fact that the strain of trypanosomes responsible 
for this man’s infection had already completely failed to 
infect 2 virgin volunteers shows that his previous infection 
and its treatment with Bayer 205 had left no trace of 
protection against his subsequent infection twenty months 
later. 


This case shows that cryptic infection of man is 
not solely dependent on Bayer 205, but that it may 
arise also from the interaction between the natural 
resistance of the individual and the invading 
trypanosome. Cryptic infection must in fact be 
recognised as one of the forms assumed by human 
trypanosomiasis, and may occur with both of man’s 
trypanosomes. 

It was deemed unjustifiable to postpone treatment 
of these 3 men in order to watch the course of events. 
All 6 (Z. K., Z.M., P. P., K. K., Z. I, and O.) 
responded readily to treatment, there being no 
suspicion of drug-resistance in the trypanosomes in 
their blood. 


CONDITIONS FOR DEVELOPMENT OF CRYPTIC 
INFECTIONS 


The employment of volunteers on a large scale has 
thrown new light on certain phases of the early 
stages of trypanosome infections in man. The possi- 
bility of the occurrence of cryptic infections in man 
has long been debated, and Duren and Van den 
Branden (1934) have recently described two cases 
of T. gambiense of this nature in Europeans, one of 
which is peculiarly significant. The patient, who 
had quitted Africa 18 months previously, consulted 
the authors, complaining of mild lassitude and tachy- 
cardia—nothing more. Trypanosomes were found in 
his lymph and blood, and he responded immediately 
to ordinary treatment. This case is of course still 
more striking than those described above, although 
details of the original infection were not available. 


The evidence afforded by the host’s subjective 
sensations in cases of this kind can of course only 
be obtained from man, and should be useful in 
studying trypanosome infections in resistant animals 
generally. All the volunteers were on full duty 
during the whole period of the development of their 
infections, and their repeated denial of any sign of 
discomfort was at first a- very puzzling feature. 


Strangeways (1935) has noted that in mice T. gam- 
biense, after a brief period when trypanosomes are 
discernible in the peripheral blood, may remain 
latent in the region of the choroid plexus for many 
months without producing any apparent effect on 
the animal’s well-being. Corson (a) has described 
a somewhat similar infection produced by a feebly 
pathogenic strain of 7. brucei in a white rat. It is 
of course possible that some of the cryptic cases 
described above would if left alone have remained 
without obvious symptoms for months, during which 
time serious involvement of the central nervous 
system might take place. 


468 ‘THE LANCET] DR. LYNDHURST DUKE: 


“ BAYER 205” AND TRYPANOSOMES OF MAN 


[FEB. 29, 1936 


In 4 of the 5 cases cited in the present paper the 
progress of the disease was obscured by later infec- 
tions superimposed before a diagnosis had been 
made. On the other hand, in most of the protected 
volunteers infection, when it did ensue, speedily 
manifested itself. In the case of Z. F., the incuba- 
tion period was 16 days and the onset typical. 

Whether a cryptic infection develops or not will 
depend partly on the trypanosome and partly on 
the resistance of the individual. A virulent strain 
will doubtless soon declare itself ; an avirulent may 
not. Typical virulent T. rhodesiense is unlikely to 
remain hidden for long; T. gambiense is often mild 
in man in many parts of Africa, and so is more 
likely to be overlooked. But this gap between the 
two organisms is lessened by the knowledge that 
T. rhodesiense is prone to lose its full virulence for 
man. Volunteer O. was infected by just such a 
strain. 

The age, condition, and natural resistance of the 
individual will also play a part, and so will the fre- 
quency of exposure to reinfection ; for it is highly 
probable that persons protected by Bayer 205 owe 
some and possibly a great deal of their immunity 
to the repeated inoculation and destruction of living 
trypanosomes within their tissues. This same 
process of repeated inoculation will take place in 
natives undergoing prophylaxis in an infected area ; 
indeed, the more unhealthy the environment the 
greater presumably will be the immunisation of 
tbose protected. 

There is good reason to believe that the resistance 
of both ruminants and man to trypanosomes depends 
to a considerable extent on. the general well-being 
of the host. Years ago Roubaud (1921) drew atten- 
tion to this factor in connexion with protozoal infec- 
tions of man, and of late years it is becoming more 
and more widely recognised as of very great practical 
importance. Dumont (1935) has assembled the 
opinions of experienced observers in sleeping-sickness 
territories in the French African possessions, all of 
which emphasise the importance of the standard of 
living in determining the spread of the disease. At 
the Conference on Sleeping Sickness held at Entebbe 
in 1933 the improvement of the conditions of living 
among the native tribes in Eastern Africa was unani- 
mously recommended as an essential part of any 
campaign against sleeping sickness. Any scheme of 
drug prophylaxis against infection should therefore 
be accompanied by a serious attempt to raise the 
standards of living of the exposed population, whose 
normal dietary is as a rule far from balanced according 
to modern ideas. 

How these cryptic infections arise it is difficult to 
explain. They may be due to the trypanosome itself 
being in some way weakened by the drug (we have 
seen that this will not cover all such cases) or to the 
host’s resistance being increased to a point where 
the trypanosome is restrained from exerting its 
normal action. The fact that most of the protected 
volunteers eventually developed ordinary symptoms 
shows that the virulence of the trypanosome under- 
goes no permanent change. On the other hand, the 
prolonged resistance shown by volunteer Z.F. can 
scarcely be due alone to the direct effects of the 
original 1-0 g. of Bayer 205 on each fresh consignment 
of metacyclic trypanosomes introduced at intervals 
over a period of some eleven months. His behaviour 
suggests rather that immunity is acquired from 
repeated “vaccinations” with living antigen, the 
immunisation beginning while the drug is still actively 
trypanocidal in the patient’s tissues. Kligler and 
Weitzman (1926) found that repeated inoculation 


of rabbits with dead trypanosomes induced hyper- 
sensitisation, whereas if the animals were inoculated 
with trypansomes suspended in Bayer 205 definite 
resistance was produced. The same might occur in 
the protected subject during the first few weeks after 
the administration of the prophylactic. 

It is almost certain that this obscure kind of 
infection will be overlooked in any ordinary examina- 
tion of a native population for trypanosomiasis. 
For without gland enlargement or fever or malaise 
of some kind, and with a “negative” blood slide, 
there is little chance of a diagnosis being made. 
Cases of this nature could do much harm in spreading 
the disease. 


APPLICATION OF BAYER 205 


Does the prospect of cryptic cases constitute a 
vital objection to the use of Bayer 205 as a prophy- 
lactic? My own opinion is that it does not. Two 
seemingly good reasons are first that these cases are 
readily amenable to treatment, and secondly that 
they occur where no Bayer 205 has been used. The 
knowledge that they may occur will help, too, in 
their detection. When protection is needed for per- 
sons entering an infected area for some definite and 
limited undertaking, Bayer 205 should certainly be 
employed, the dose being repeated at intervals, say, 
of three months. 

A more difficult problem is the protection of the 
indigenous population of a sleeping sickness area. 
I believe that here too Bayer 205, if employed under 
careful supervision and with the intelligent codpera- 
tion of the population itself, will be of great value. 
It should be borne in mind that T. gambiense is more 
likely to evade detection than T. rhodesiense. 

Where the conditions in an infected area are such 
that the disease persists unchecked by clearing and 
other local control measures, then Bayer 205 should 
prove a valuable aid, if applied at regular intervals 
and to a population adequately supervised. To every 
inoculated individual protection will be conferred for 
two months at least, and in some for much longer. 
Of those whose period of protection is allowed to 
lapse, only a minority will develop cryptic infections ; 
the majority, according to the experiments of this 
paper, will show the ordinary symptoms of the 
disease. Moreover, cryptic infections will be encoun- 
tered apart from any system of prophylaxis. . 

There is little doubt that 7. gambiense in many 
infected areas is spread by a comparatively small 
number of infective flies, any one of which may 
however be responsible for 30-40 cases during its 
life-time. Under these conditions the protection of 
the exposed population for a period of two or three 
months—during which time infected flies are dying 
out—will surely help enormously in checking the 
spread of the trypanosome. 

In T. rhodesiense areas, where game animals can 
maintain for considerable periods strains pathogenic 
to man, this indirect effect of Bayer 205 will be less 
noticeable. But here also man is in the long run the 
main reservoir for human strains, and anything that 
reduces his susceptibility will be of ultimate yas 
in controlling the disease. 

To the medical man in Africa there is still some- 
thing mysterious about the action of Bayer 205 and 
its curious potency against man’s trypanosomes, 
and this may explain to some extent the rather vague 
fears entertained in certain quarters about its use 
as a prophylactic on a large scale. Dr. Van Hoof, 
however, informs me by letter that the results 
obtained with Bayer 205 and T. gambiense in the 
vast infected areas of the Belgian Congo suggest the 


THE LANCET] 


need for circumspection in the employment of the 
drug, and his figures will be awaited with great 
interest. 

. With increasing confidence, inspired by the know- 
ledge that for three months at least the majority 
of those inoculated are safe, both the administrator 
and the native himself will find a way to that genuine 
coöperation which is so essential to success in this 
particular problem. Once freed from the dreaded 
old-time consequences of detection as a sufferer— 
removal to a distant hospital, wholesale evacuation 
of the homeland, and all the well-remembered restric- 
tions and dislocations imposed in the days of our 
comparative ignorance and inexperience—the native 
will willingly come to the help of the authorities by 
searching out and reporting early cases of the disease, 
and coéperating to the full in any local measures 
that may be prescribed. | 


Conclusions 


(1) A dose of 2:0 g. of Bayer 205 administered to 
an adult may be expected to confer protection against 
T. gambiense and T. rhodesiense for at least three 
months. The protection may last much longer. 

(2) One volunteer (Z.F.) resisted infection by 
tsetse for 327 days after he had received 1:0 g. of 
Bayer 205. 

(3) In a proportion of those protected by Bayer 205 
and exposed to infection with human trypanosomes, 
infection when it does at length occur may be of a 
cryptic type, the patient showing no apparent 
symptoms for two months and possibly longer. An 
infection of this kind may gradually generate typical 
symptoms or it may become merged into a subse- 
quent infection superimposed upon it and running a 
normal course. Cryptic infection can however arise 
independently in nature, apart ene from the 
administration of any drug. 

(4) A consideration of the bohavious of the volun- 
teer Z. F. suggests that frequently repeated inocula- 
tions of living trypanosomes during the three or 
four months immediately following the administra- 
tion of Bayer 205 lead to the establishment of a 
‘more prolonged immunity than that conferred by 
the drug alone without such frequent exposures to 
infection. If this is true, then the more intense the 
exposure in nature to infective tsetse the greater 
the benefit derived from the prophylactic. 


4 


Dr. W. H. Kauntze, director of medical services, Uganda 
Protectorate, has helped in a variety of ways by placing 
at my disposal his advice and the resources of his depart- 
ment. To Dr. J. Black and his colleague, Mr. Barkat 
Singh, of the Medical Department, Entebbe, I am indebted 
for continuous help throughout this research. All 
preliminary examinations and all treatment of the 
volunteers were carried out by these two officers. That 
no mishap of any kind has occurred is a tribute to their 
care and skill. 


REFERENCES 


Browning, C. H., and Gulbransen, R.: Jour. Path. and Bact., 
934, ee 75. 


Corson, J. F : (a) Jour. Trop. Med. and Hyg., 1934, xxxvii., 11. 
(b) Ann. Trop. ed. and Parasit., 1934, xxviii., 535. 

(c) Ibid., 1934, xxviii., 525 

Duke, H L, : Parasitology, 1934, xxvi., 3153; 1935, xxvil., 68. 

Dumont, R.: Rev. de mód., et d'hyg. trop., 1935, xxvii., 36. 

Duren, A., and Van den Branden, F.: Ann, de. Soc. Belge de 

trop., 1934, xiv., 437. 
Findlay, 6 M.: Recent Advances in Chemotherapy, London, 


Fourche, J. A., and Haveaux, G.: Bull. Soc. path. exot., 
1931, xxiv., 557. 

Kligler, I. J., and Weitzman, I.: Ann. Trop. Med. and Parasit., 
1926, XX., 147. 

Roubaud, E.: Poh Pon path. exot., 1921, xiv., 664. 

Strangeways, W. I Ann. Trop. Med. and Parasit., 1935, 


‘ LADY BRISCOE: ANTAGONISM BETWEEN CURARINE AND PROSTIGMIN 


[FEB. 29,1936 469 


THE 
ANTAGONISM BETWEEN CURARINE . 
AND PROSTIGMIN 
AND ITS RELATION TO THE MYASTHENIA 
PROBLEM 
By GRACE BRISCOE, M.B. Lond. 


(From the Physiological Laboratory, London (R.F.H.) 
School of Medicine for Women) 


THE beneficialeffect obtained in cases of myasthenia 
gravis by injection of prostigmin, reported by 
Dr. Mary Walker? and confirmed by other workers, 
has centred attention on the pharmacological mode 
of action of this drug, an analogue of eserine.* The 
reasons which led to this important observation 
were the resemblance between myasthenia and 
mild curare poisoning and the well-known antagonism 
between eserine and curare. Blake Pritchard ? ? 
has made advances by showing (1) that the form of 
the myogram in myasthenics differs markedly from 
the normal, showing quick fatigue with high rates 
of stimulation, and (2) that prostigmin restores the 
myogram to the normal form while simultaneously 
restoring the patient’s strength. 

The object of the present paper is to show that 
a parallel observation can be made experimentally. 
The myogram of the cat’s quadriceps, showing 
quick fatigue under mild curarisation, can be restored 
to normal by a large dose of prostigmin such as would 
cause acute depression in fresh unpoisoned muscle. 
Some observations on the peripheral effects of 
(1) prostigmin alone, and (2) varying doses of curarine 
and prostigmin together will be given which suggest 
an explanation of this paradoxical effect. Details 
of technique have been given in other publications.‘ 
The nerve-muscle preparation has been the quadriceps 
of the cat with circulation intact, and the movement 
of extension of the knee has been recorded. The 
cut nerve has been stimulated by neon lamp dis- 
charges which can be readily altered, both in strength 
and frequency.’ 

Control myograms are first taken, showing the responses 
to short spells (1-2 secs.) of different rates and strengths 
of stimuli. A small dose of curarine chloride is then 
injected intravenously. In a few minutes the contraction 
caused by the fast rate is not maintained as in the control 
but rapidly gives way. The myogram closely resembles 
that seen in myasthenics in response to fast rates. At 
this point a large dose of prostigmin (1 c.cm. for a 3-kilo. 
cat, preceded by atropine) is given intramuscularly. 
In a few minutes the myogram improves and returns 
to the normal (Fig. 1). Control experiments show that 
recovery due to gradual elimination of curarine would 
take an hour or more. 

An indication of the mode of action of this 
antagonism is found by studying the peripheral 
actions of prostigmin and curarine separately in 
fresh unpoisoned muscle. The two factors in the 
myogram affected by these drugs are (1) height of 
contraction, (2) maintenance of the same. 


THE ACTION OF PROSTIGMIN ALONE 


Prostigmin in the large dose indicated progr _ 
marked and characteristic effect. 


Five rates of stimulation (30, 50, 75, 105, anc 
sec.) at submaximal and supramaximal strer 


* Prostigmin was used in these ag rmente bec 
been extensively employed clinically. Eserine has gi 
experimental results. There is no reason to su 
prostigmin has any particular advantage over the be 
substance eserine, 


470 THE LANCET] 


LADY BRISCOE : ANTAGONISM BETWEEN CURARINE AND PROSTIGMIN 


[FEB. 29, 1936 


A B C 


FIG. 1.—Cat, 2°9 kg.; quadriceps. 
traction is downwards in all tracings. 
150 per sec. Strength, just under maximal. (A) Control 
curve of normal muscle. (B) Same stimulus. Mild curarisa- 
tion, 0°25 mg. per kg. intravenously. Tension not main- 
tained. Arrow indicates cessation of stimulus. (C) Fourteen 
minutes after injection of 1 c.cm. prostigmin intramuscularly 
preceded by atropine 2 mg. Tension maintained. Improve- 

~ ment in contraction was noticed four minutes after injection. 


Time in seconds. Con- 
Rate of stimulation, 


tested. Controls show that fast rates produce larger 
contractions than slow ones. Sometimes rates 105 and 
150 per sec. produce contractions of equal size. 

A few minutes after the intramuscular injection of 
prostigmin a progressive change is seen in both the size 
and shape of the myograms. The response to the fastest 
rate with strong stimuli is most affected, being both 
diminished in size and less well maintained, until 
eventually at the end of 10 to 20 minutes it is smaller than 
the response to the slowest rate and is twitch-like in 
character (Fig. 2). At the height of the depression, 
rate 75 per sec. usually produces the largest contraction 
and rate 150 the smallest. 7? This alteration in relative 
size of contraction is seen both with submaximal and 
supramaximal stimulation. 


A third characteristic change is seen in prostigmin 
and eserine poisoning, but not with curarine. It 
is a modification of the initial curve of contraction 
which affects all responses. Normally the leg rises 
to full extension in one movement. After prostigmin 
with slow rate stimulation the movement is interrupted 
by a temporary falling back, after which the move- 
ment of extension is resumed. In cases of mild 
poisoning this jerk may not be more than an accentua- 
tion of the backswing which is often seen when a 
heavy limb is thrown suddenly into full extension 
by. a supramaximal stimulus. In deep poisoning 
with fast rates of stimulation there is no recovery 
from this early depression and the response therefore 
becomes twitch-like. The myograms show that 
with all rates of stimuli the first movement of 
extension is alike, but the recovery from “ inhibition ” 
is swift in the slow rate responses. Extension there- 
fore can still be maintained. These changes are 
more pronounced with a greater degree of poisoning. 
With weak submaximal stimuli similar changes may 
be seen, but the interruption occurs earlier in the 
curve of contraction (Fig. 3). During elimination 
of the drug the notch gradually disappears, until 

ventually the myograms show as smooth a curve 
`n the controls. To sum up, there is in prostigmin 
ning a progressive deterioration affecting both 
and maintenance of contraction which is 
‘ked in the responses to the faster rates 
maximal stimulation. 

‘ens of recovery from prostigmin poison- 
\pear within an hour of administration. 
ry gradual and the effect of the drug 
d for several hours. Recovery is 
lete when the fastest rate produces the 
‘ion, which holds for a period of at 

is without loss of tension. 


THE ACTION OF CURARINE ALONE 


The peripheral action of non-paralytic doses of 
curare is well known. Bremer and Titeca® have 
shown that contraction is not maintained whatever 
the rate of stimulation—i.e., 10 or 70 per sec. Thiese 
observations have been confirmed. d 

The point to be noted in responses to different 
rates after moderate doses of curarine (0-3 mg. per 
kilo) is that there is no fundamental change in the 
sizes of the contractions relative to each other. -As 
in the control series the faster rates produce the larger 
contractions; that is, normal order is retained, 
though all the contractions are reduced in size and 
are twitch-like in character (Fig. 2c). This is in 
direct contrast to the condition following prostigmin 
poisoning. 


THE ANTAGONISM OF PROSTIGMIN TO CURARINE 


If curarine be given in doses which cause temporary 
paralysis a large dose of prostigmin will halve 
(approximately) the time of recovery. For instance, 
a moderate dose of curarine produced in 12 minutes 
a paralysis which lasted for 4 minutes, after which 
small twitches reappeared. In 40 minutes recovery 


IS ETS. 
NORMAL 


CURARINE 


FIG. 2.—Quadriceps. All stimuli supramaximal (double just 
maximal strength). (A) Controls. Five responses to different 
rates of stimuli. Rate 30 per see. produces smallest contrac- 
tion and rates 105 and 150 the largest. Controls were also 


taken in reverse and random order. (B) Saine stimuli, after 
prostigmin. Rate 75 produces largest contraction and 
rato 150 the smallest with rapid loss of tension. Response 
to rate 30 shows brief relaxation followed by recovery. 


(C) Another preparation. Twitch-like responses to all rates 
after curarine., Stimulation continued for at least one second. 
Arrow shows cessation of stimulus. Contractions larger with 
increases of rate. 


THE LANCET] 


FIG. 3.—Quadriceps. Submaximal stimulation. Control con- 
tractions showed smooth curves and increase of sizo with 
increase of rate. Time, one second. Upperrow: Submaximal 
responses during recovery from deep prostigmin poisoning, 
injection 25 minutes earlier. Slower rates produce larger 
contractions. Well-marked notch in all tracings and coarse 
tremor. Lower row: Same stimuli. Ten minutes later, 
notch less well marked. Slowest rate produces smallest 
contraction. Two hours after injection curves were as smooth 
as in controls and rates 30 and 50 gave smaller contractions 
than the three fasterrates. Supramaximalfast rate responses 
still showed some depression. 


was still incomplete—i.e., a slow rate of 30 per sec. 
could just maintain a contraction for 5 seconds 
without sign of failure. At this point a second 
similar dose of curarine was given which caused 
paralysis in 1 minute. Atropine and prostigmin 
were now injected and a similar stage of recovery 
was reached in 23 minutes—i.e., a stimulus of slow 
rate maintained a contraction for 5 seconds. 

It has already been shown (Fig. 1) that the quick 
fatigue produced by mild curarisation can be 
restored to normal by an injection of prostigmin. 
It is remarkable that this antidotal action which 
restores responses to all five rates is secured by giving 
poisonous doses of prostigmin such as would cause, 
in normal muscle, the marked depressant effects 
illustrated in Fig. 2B. There may be no sign of 
characteristic prostigmin depression. Contractions 
have been recorded, showing normal curves, for a 
period of over four hours after injection of the drug. 
When the initial dose of curarine was smaller, slight 
signs of prostigmin effect could be detected about 
an hour after injection of the antidotal large dose 
in that response to rate 150 was smaller than response 
to rate 105. 


ANTAGONISM OF CURARINE TO PROSTIGMIN 


When an animal deeply affected by prostigmin 
receives a dose of curarine (0:3 mg. per kilo) capable 


B C 
FIG. 4.—Quadriceps. Stimuli supramaximal in strength. 
(A) Nonmnal responses to rates, 30 and 150 per sec. 12°8 P.M. 


Prostigmin, 1 c.cm. (B) 12.39 P.M. Slow rate response shows 
temporary relaxation and recovery. Fast rate response is 
twitch-like and smaller. 12.40 P.M. Curarine, 0°3 mg. per kg. 
(C) 12.41 P.M. Both responses nearly normal. 


LADY BRISCOE: ANTAGONISM BETWEEN CURARINE AND PROSTIGMIN 


- 


[FEB. 29, 1936 471 


of producing in the normal animal twitch-like 
responses to all rates a striking antagonistic effect 
is seen. The small twitch-like responses to the fast 
rate (150 per sec.) are suddenly improved, they show 
less depression and become larger than responses 
produced by the slow rate stimuli (30 per sec.). 
This result occurs in less than a minute (Figs. 4 and 5). 

If the doses are fortunately balanced there may be 
an almost complete restoration to the normal and the 
notch disappears from submaximal contractions. 
Usually the restoration is incomplete and does not 
last long. In a few minutes the characteristic 
curarine effect becomes predominant. All the 
myograms show depression but normal grading is 
resumed in that the faster rates produce larger 
contractions. The presence of prostigmin, however, 
diminishes the degree of depression produced by the 
curarine. KS T Moss 

If a smaller dose of curarine (0-15 mg. per kilo) 
be given, the antagonistic effect may show itself only 


A 


B 


FIG. 5.—Records taken on slow rate of drum. Two-second 
spells of supramaximal stimuli every ten seconds. Rate 
raised between each spell (30, 50, 75, 105, 150 per sec.). All 
taken in same sequence. (A) Before prostigmin. Rate 30, 
smallest contraction. (B) After prostigmin. Rate 150, 
smallest contraction and twitch-like. (C) Two minutes after 
intravenous injection of curarine, 0'3 mg. per kg. Curves 
nearly restored to normal. Little curarine cifect developed, 
so U'3 mg. per kg. curarine was given one and a half hours 
later. (D) Eight minutes after second dose. Typical curarine 
effect. All contractions are twitch-like and faster rates give 
larger contractions. 


by reducing the time of recovery from prostigmin 
poisoning from several hours to one hour—i.e., there 
is a complete absence of curarine depression. 


Discussion 


The work of Loewi, Dale, and many others has 
brought great support to the theory of a chemical 
transmitter of excitation between nerve-ending and 
effector organ.!® It is known that eserine delays 
the normal swift destruction of this transmitter by 
the esterase in the blood, thus causing accumulations. 
The present experiments indicate that such accumula- 
tions are capable of causing depressant effects in 
normal muscle contractions. Can the paradoxical 
effect of prostigmin—depressing function in 
unpoisoned muscle restoring function in curarised 
muscle—be explained on this theory ? 

Two different solutions can be offered. The first 
supposes that the fault in curare poisoning and in 
myasthenia gravis lies in the too rapid destruction 
(or insufficient production) of transmitter. This fault 
in both cases would be rectified by the delaying action 
of prostigmin on the destruction of the transmitter 
and normal contractions would follow. Conversely, in 
muscle poisoned by prostigmin the delay in destruc- 
tion of transmitter would be counterbalanced by the 

12 


492 THE LANCET 


PROF. A. H. ROFFO: ULTRA-VIOLET RAYS AND CANCER 


[FEB. 29, 1936 


speeding-up action of curarine. The second explana- 
tion, suggested to me by Sir Henry Dale, is that 
curarine counteracts the depressant effects of prostig- 
min not by affecting the output or stability of the 
transmitter but by raising the threshold for its 
depressant action when excess is present. On the 
other hand, if curarine raises the threshold for 
stimulation, prostigmin would counteract the 
depressant effect of curarine by increasing the amount 
of transmitter which would enable the obstacle of 
raised threshold to be overcome. An observation 
has been made by Dale and his associates which 
is in favour of the latter suggestion. They have 
shown that there is no obvious fall in the amount 
of transmitter, identified by them as acetylcholine, 
in the venous effluent of an eserinised muscle whose 
contraction has been blocked by curarine. It is not 
possible at present to decide between the alternative 
theories. 

That the depressant effects in prostigmin and 
curarine poisoning respectively are not identical in 
origin is suggested by a comparison of the myograms 
resulting from different rates of stimulation. Although 
twitch-like responses are obtained with both drugs 
in myograms from the fast rate, a marked difference 
occurs with the slower rates. Under curarine each 
contraction, whether with slow or fast stimulation, 
starts normally and then fails at once. With deficiency 
of transmitter or rise of threshold there is no reason 
why the relative sizes of the contractions should be 
disturbed. Under prostigmin the fast rates produce 
contractions which are deficient in size and power 
of maintenance, but the slow rate myograms are 
less affected. It is difficult to explain this result 
unless it be accepted that excess of transmitter can 
“ blanket” contractions when high rates and strong 
stimuli are accentuating such excess. The notching 
in the initial curve of contraction is also difficult 
to explain. It may be due to a kind of “ adaptation ” 
to excess of transmitter, which in the fast rate 
myograms does not have time to show itself. 

It is clear from these experimental findings that some 
balance, in relation either to the rate of destruction 
or to the threshold, has to be preserved if the nerve- 


muscle unit is to function efliciently. This balance. 


can be readily upset or restored by either of the drugs 
studied. Recent work by Cowan?! indicates that 
neither nerve trunk nor muscle-fibre is affected by 
prostigmin, so that by exclusion the site of its action 
must be the neuromuscular junction. This has 
long been recognised in the case of curare. 

To apply these results to the problem of myasthenia : 
if this condition is really akin to curare poisoning 
either of the two solutions offered would explain 
the temporary alleviation procured by prostigmin. 
Stedman 2 has estimated the choline esterase of 
blood in (a) myasthenics, (b) normals. He found no 
excess of esterase in the first group. If it be accepted 
that the esterase content of the blood is a measure 
of its concentration in the tissues this piece of evidence 
is against the theory that the condition of myasthenia 
gravis is due to the excessive destruction of 
acetylcholine by the enzyme in the blood. 


Summary 


The peripheral actions of prostigmin and curarine 
have been studied separately showing that either 
is capable of producing acute depressant effects, which, 
however, are not identical. Their mutual antagonism 
is such that normal muscular action can be preserved 
when poisonous doses of the drugs are exhibited 
together. These results can be explained on the 


theory of chemical transmission of excitation. Their 
application to the myasthenia problem is discussed. 


REFERENCES 


. Walker, M. B.: THE LANCET, 1934, i., 1200. 

. Pritchard, E. A. Blake: Jour. of Physiol., 1933, lxxviii., 3P. 
. Same author: THE LANCET, 1935, i., 432. 

. Briscoe, G.: Jour. of Physiol., 1934, Ixxxii., 88. 

. Briscoe, G., and Leyshon, W. A.: Proc. Roy. Soc. B., 1929, 


cv., 259. 
. Briscoe, G.: Jour. of Physiol., 1936, Ixxxvi., 1 P. 
. Same author: Ibid., 1936, Ixxxvi. (in press). 

Compt. rend, Soc. de Biol, 


. Bremer, F., and Titeca, J.: 
1931, evii., 253. 
. Briscoe, G.: Jour. of Physiol., 1935, Ixxxiv., 43 P. 
10. Dale, H. H.: Brit. Med. Jour., 1934, i., 835. 
Jour, of Physiol., 1936, Ixxxvi. (in press). 
lbid., 1935, Ixxxiv., 56 P. 


Dm NO Queu We 


11. Cowan, S. L.: 
12. Stedman, E.: 


ROLE OF ULTRA-VIOLET RAYS IN THE 
DEVELOPMENT OF CANCER 
PROVOKED BY THE SUN 
By Pror. A. II. Rorro 


DIRECTOR OF THE INSTITUTE OF EXPERIMENTAL MEDICINE AND 
CANCER RESEARCH, BUENOS AIRES 


In 1932, in a paper! on the part played by the sun's 
rays in the causation of skin epitheliomata, I pointed 
out that though this suggested etiology has produced 
some very interesting communications, none of their 
authors (Dubreuilh, Gougerot, Larabi, &c.) has 
adequately explained the process by which the 
transformation to malignancy takes place. 

My own first observations on this process were 
published in 1928,2 when I drew attention to the 
high incidence in the Argentine Republic of cutaneous 
epitheliomata, localised exclusively on the face and 
on the back of the hands. Among 65000 cancer 
patients attending the Cancer Institute of Buenos 
Aires none showed cancer of any part of the skin 
covered by clothing (except in two or three cases 
where tumours developed on nevi or burn scars). 
The predilection of cutaneous cancer for regions 
exposed to the sun is shown by the following rates 
obtained at the Institute :— 


EPITHELIOMA OF SKIN (1500 CASES) 


(a) Regions exposed to 
the s 


(b) Regions protected by 
sun. % thi 


clothing. 


70 
Skin, face... oe 95°51 Hairy skin é «> 1°02 
Skin, back part of the Foot... ice e.. 0°52 
hands aie oe 3°07 


In the face the parts most often affected are those 
most prominent and exposed; for example, the nose 
bears 61 per cent. of the facial epitheliomata, com- 
pared with 18 per cent. on the cheek and hardly any 
on the forehead. It is also found that men are more 
receptive (70-9 per cent.) than women (29-1 per cent.), 
the lower incidence in women being related to the 
care they take of their skin, protecting it with powder. 
The few: epithecliiomata seen in females have been 
only in countrywomen and those of very humble 
standing who do not bother to protect their skin. 
The lesions develop both in workmen and in those 
of the higher social classes who have to expose 
themselves to the sun all day—e.g., farmers and 
planters. Suficrers from epithelioma are generally 
found to have very white (photosensitive) skins, and 
I have not seen a single case in natives, negroes or 
mulattoes. The patients have a peculiar aspect: 
the face up to the brim of the hat, and the hands 
up to the sleeves of the coat or shirt, present at first a 
diffuse erythema, and later numerous pigmented zones, 
which contrast with the white skin of the forehead 
and the forearm. These pigmented zones get more 
pronounced and hyperkeratotic; then they ulcerate 


THE LANCET] 
and become cancerous. These changes are asso- 
ciated with hypercholesterol of the tissues exposed 
to the sun, known as “cholesterol mask” and 
“ cholesterol gloves.” 

The hyperkeratosis which leads on to the epithelioma 
is dominated by a photodynamic mechanism, and 
for fulfilment of the process the following factors are 
necessary : the living cell, a sensitising photodynamic 
substance, the presence of oxygen, and the rays of 
the sun. Consequently I ascribe great importance 
to a substance, cholesterol, which is always present 
in the living protoplasm, and plays an active part 
in cell development. Experiment has shown that 
it is present in excess in cancerous tissues, that it is 
heliotropic, and that it has photo-activity.2 Moreover 
we find that the parts of the face most exposed to 
the sun (nose) which develop the highest percentage 
of epitheliomata have also the highest content of 
cholesterol. This is seen from the following per- 
centages based on 302 cases of facial skin cancer 
examined at the Institute :— 

Incidence of epithelioma. Cholesterol content of dried 


70 skin. of, 
Nose .. oe .. 61-40 Nose .. ws -. 074 
Cheek .. ee .. 18-00 Cheek ks .. 0-50 
(Abdomen) .. .. 0-06 (Abdomen) .. .. 0-20 


As a result of these observations, experiments 
have been undertaken which confirm the view I 
have outlined. 
tumours of different histopathogenesis (epitheliomas 
and spindle-cell sarcomas) in unprotected parts of the 
skin (ears and ocular conjunctiva). These tumours 
have developed under the influence of the total sun 
rays or under ultra-violet rays with a wave-length 


of 1800-3400 A. In animals, as in human beings, 
the skin is found to have an abnormally high choles- 
terol content before the development of the tumours. 
A summary of the experiments made on a series 
of 10 rats, with ultra-violet rays from a Hanau 
apparatus, is given below. 


Three of the rats died from insolation, the experiments 
having been carried out in summer. When the temperature 
was very high, a ventilator was placed over the animals, 

The period of exposure was gradually increased, the 
doses of ultra-violet rays being equal to the, average of 
the sun units, measured with the dosimeter S.V. At 
first irradiation lasted 5 minutes; it was then increased 
and after fourteen days it had reached 1200 minutes daily. 
The longest test lasted nine months and five days. The 
rats were fed in the same way as the non-irradiated 
control animals, none of which developed cancer. 


—— — -——- s- SS Se 


FIG. 2 (Rat 3).—Ear tumour. 
down to the cartilage. 


PROF. A. H., ROFFO : ULTRA-VIOLET RAYS AND CANCER 


In white rats I have obtained . 


Highly anaplasic pavement carcinoma reaching 


(FEB. 29, 1936 473 


MEG gat 


>< 


AE” ? ae nd ther : 
’ 1 i 4 i. y 
Pr. ph Fo the PAN tty 
PRS eee, oC uses 
VSS, A | ne Sa 
ig ee 4 J Fa s 


FIG. 1 (Rat 1).—Spindle-cell sarcoma of the conjunctiva of 
the eye, partly covered by Malpighian conjunctival epithelium. 


The following Table summarises the results 


obtained. 
Results of Ultra-violet Irradiation of Rats 


Duration of 

Rat | the process in 

No. | months and 
days. 


1 8in. 13d. 


Lesions provoked. 


Enormous sarcoma of eye. Multiple 
lesions, papillomatosis, and hyperkera- 
tosis of the ears, 


Large cancroid of left ear. Multiple 
lesions, papillomatosis, and hyperkera- 
tosis. Spindle-cell sarcoma of right ear. 


2 8m. 28d. 


Enormous spindle-cell sarcoma of neck, 
previonsiy shaved. Multiple hyper- 
eratotic lesions; papillomatosis of 
Voluminous cancroid of left 


3 8m. 20d. 


the ears, 
ear. 


Large tumour of eye (spindle-cell sar- 
coma). Multiple formations on ears ; 
hyperkeratosis, papillomatosis, and 
epitheliomata, 


Large tumour of eye (spindle-cell sar- 
coma). Multiple formations on ears; 
hyperkeratosis and papillomatosis. 


4 8m. 12d. 


IO OH 


Enormous epithelioma formed on ear; 
multiple hyperkeratotic lesions an 
papillomatosis. 


In looking for records of similar experiments I 
have found two papers by Findlay ¢ who has induced 
papillomata and epitheliomata 
in mice by exposing them to 
ultra-violet rays. But these 
animals had been artificially 
depilated with sodium sulphide. 
In a third paper Putschar and 
Holtz é report having obtained 
epitheliomata of the ear, but 
they do not mention spindle- 
cell sarcoma. 


The second part of my 
experiments was intended to 
elucidate the process by which 
the rays cause the cells to 
become cancerous. I regard 
this process as a vital pheno- 
menon which can only take 
place in the presence of certain 
sensitising substances, which 
are activated by the sun’s 
rays. My observations ê on 
cholesterol show it is increased 
in amount in the skin of 


474 THE LANCET] 


animals irradiated in certain regions, and they 
have been confirmed by Kawaguchi.’ 

In naturally hairless regions (ears) I have been 
able to demonstrate any excess of cholesterol in 
the skin before any of the histological changes of 
cancer could be detected. The increase in cholesterol 
of the irradiated ear in relation to the non-irradiated 
ear reaches a very high figure (1-5 g. %). 


SUMMARY 


It is clear that the rays of the sun and of the actinic 
spectrum will produce malignant tumours without the 
intervention of other agents. In rats the tumours 
are of epithelial type—epitheliomata with conspicuous 
anaplasia, and large sarcomata of the spindle-cell 
type—and they attain their largest size after seven to 
nine months. They grow in the regions naturally 
free from hair (ears and conjunctiva) or artificially 
depilated. The process begins with hyperplasia, 
hyperkeratosis, papillomatosis. The action of the 
rays is not specific for particular kinds of cells, for 
the epithelial cells and the conjunctiva respond in 
the same manner to the rays. The proportion of 
animals developing tumours is very high (all of 
7 surviving rats), and in the same animal both 
sarcoma and epithecliioma may be observed. The 
irradiation produces a local excess of cholesterol 
which can be detected before there are any histo- 
logical changes. In view of the heliotropism and 
photo-activity of cholesterol I look upon its increase 
as highly significant. 


ADDENDUM 


Since this paper was written 1 have made further 
observations and I would like to add the following 
conclusions, 

Exposure to the sun’s rays is in itself sufficient 
to produce malignant tumours in 70 per cent. of rats 
and mice. The process takes 7-10 months passing 
through hyperplasia and papillomatosis, and the 
carcinomatous and sarcomatous animals alike die 
in a state of cachexia with metastases in lymph- 
glands. In the development of cancer in this way 
cholesterol plays an important part as a photo- 
active, heliotropic, and energising substance. I’xperi- 
ments performed with different sorts of rays (total 
sun, filtered sun, ultraviolet rays, Juminous rays, 
neon gas, and short Hertzian waves) show that the 
power of the rays to produce tumours depends on 
their actinic and not on their luminous intensity. 
Histologically the lesions obtained closely resemble 
those observed in persons with photosensitive skins 
which have been much exposed to the sun, and 
these observations emphasise the danger of such 
exposure, 

REFERENCES | 
Bull. Inst. Exp. 1930, 


1. Koor H. Med. Buenos Aires, 


2. RotYo: Ibid., 1928, p. 907. 
3. Rotfo: THE "LANCET, 1931, ii., 1187. 
4, Findlay, G.M.: lbid., 1928, ii., 1071 ; 1930, i., 1229. 


5. Putschar, W., and Holtz, F.: Zeits. f. Krebsforsch., 1930, 


xxxiii., 219. 
6. Boor and Pilar, Fr.: 


oie Prensa méd. argentina, 1930, xvi., 
7. Kawaguchi, S.: Biochem. Zcits., 1930, cexxi., 


232. 


RoyYyaLr DEVON AND ExETER l OsPITAL.—There 
is a loss at this hospital of over £4000 on the 
year’s working and the financial position is less satis- 
factory than for many years past. The cost of road 
accidents is large, while various internal improvements 
and a greater numbor of patients have also increased 
expenses. About 30 beds will shortly be added and it is 
essential that the number of annual subscribors should 
also grow, | 


DR. V. E. LLOYD : GONADOTROPIC HORMONES 


following the 


[FEB. 29, 1936 


GONADOTROPIC HORMONES IN THE 
TREATMENT OF STERILITY IN MAN 


By V. E. Luoyp, M.B. Lond. 


DIRECTOR OF THE VENEREAL DISEASES DEPARTMENT, 
GUY'S HOSPITAL, LONDON 


Ir seems to have been clearly established that 
the normal descent of the testes into the scrotum 
is closely associated with the action of gonadotropic 
hormones. The recent clinical trial of such hormones 
in the treatment of delayed descent of the testes in 
man has resulted in an encouraging proportion of 
successes. The initiation and degree of spermato- 
genesis in animals also appears to be under hormonal 
control, Excision of the anterior lobe of the 
pituitary gland is known to be followed by cessation 
of spermatogenesis as well as atrophy of the accessory 
reproductive glands, and the return of spermatogenesis 
after implantation of anterior pituitary tissue has 
also been reported. 

Schockhaert! has successfully used gonadotropic 
hormones to induce precocious spermatogenesis 
in birds, but the many attempts to influence the 
immature mammalian testis in the same way have 
given uncertain results, and clinical improvement 
administration of these hormones 
in the treatment of azoéspermia or oligospermia 
in man has rarely been described. Brosius and 
Schaffer? record one case of azodspermia following 
mumps orchitis in which therapy with urinary 
gonadotropic hormones was followed by the produc- 
tion of motile spermatozoa; Brosius® has also 
reported pregnancy after the use of these hormones 
in one case of deficient spermatogenesis in man. 
There are so few reports of this kind, however, that 
the following cases are likely to be of interest. 


Case 1.—Man aged 27. Married three years without 
children ; no contraceptives had been used. On examina- 
tion in November, 1932, his general condition was good, 
and his secondary sex characters normal except for lack 
of full development of adult male voice. He had suffered 
from mumps after puberty, but there had been no known 
orchitis. Both testes were smaller and softer than normal ; 
the epididymes were thin and flaccid; the prostate gland 
was small; and the seminal vesicles could not be 
palpated. After detailed inquiry, sexual desire, potency, 
ejaculation, and orgasm were considered to be normal. 
The patients wife had been seen by Mr. Frank Cook 
who had found no evidence of any disease or abnormality 
of the pelvic viscera. 

A first specimen of semen was examined in December, 
1932, 23 hours after coitus; the volume was 3'5c.cm. 
and it contained 2 million spermatozoa per c.cm., none 
being motile. Films stained with iron hematoxylin and 
eosin showed 24 per cent. of abnormal spermatozoa. 
As only two days had elapsed since the previous coitus 
a further specimon, obtained after a longer interval, 
was examined in February, 1933. This specimen, which 
showed no motility 12 hours after production, contained 
14 million spermatozoa per c.cm. Advice was given as 
regards soxual rest, open-air exercise, and increase of the 
protein and vitamin content of the diet. A third examina- 
tion of the semen in May, 1933, gave a spermatozoa count 
of 22 millions per c.cm. and showed about 50 per cent. 
motile spermatozoa 14 hours after production. 

Following this response a course of injections of a urinary 
gonadotropic hormone (Parke Davis and Co.’s Antuitrin S) 
was given at approximately weekly intervals, in doses 
equivalent to 100 rat units, for a period of four months. 
Tho last of these injections was given in December, 1933, 
and pregnancy of the wife was diagnosed in March, 1934. 
A final examination of the semen a few weeks later showed 
a high degree of motility 11 hours after production and 
the maintenance of motility of some spermatozoa up to 


THE LANCET] 


MR. H. I. DEITCH :: ARTERIAL BMBOLECTOMY 


[FEB. 29; 1936 475 


nN er 


22 hours. The spermatozoa content of this specimen, 
which was 6c.cm. in volume, was 69 million per c.cm. 
A differential count revealed abnormality of 8 per cent. 
A normal full-term child was born in October, 1934. 


The main features of this case are set out in Table I. :— 


TABLE I.—EHxaminations of Semen in Case 1 


Total 


Hours Motile Abnormal 
Date. oa before | sperma- (mill, per sperm. 
ume" 1 exam. tozoa. c.cm.). (per cent.). 
Dec., 1932 3-5 23 Nil. 2 24 
Feb., 1933 ? 12 al 14 ? 
, TREATMENT DIRECTED TO EXERCISE AND DIET. 
May, 1933 | 4 | . 14 |About 50%| 22-5 | 17-5 
TREATMENT WITH ANTUITRIN 8. SEPT.—DEC., 1933 


Apr., 1934 | 6 | 11 pout 50% 


a as 


CasE 2.—Aged 27. Married five years and childless ; 
no contraceptives had been used. When aged 24 the 
patient had suffered from an attack of mumps with right- 
sided orchitis. There was no history of any venereal 
disease. Two years previously he had had medical 
treatment for a suspected duodenal ulcer. His wife had 
recently been examined by Mr. Cook and considered free 
from any pelvic visceral disease or abnormality. On 
examination in March, 1933, the general condition was good 
and the secondary sex characters well marked. The 
penis, urethral meatus, and left testis were normal, but 
the right testis was of small size, though its sensitivity 
was normal. Both epididymes were apparently empty 
and almost impalpable ; the prostate gland was abnormally 
small; and both seminal vesicles were only partly 
distended. 

The first specimen of semen examined in May, 1933, 
was 2 c.cm. in volume, and less than a dozen feebly motile 


spermatozoa were seen three hours after its production. | 


The spermatozoa count was 7 million per c.cm., and a 
differential count of stained films showed 17 per cent. 
of abnormal spermatozoa. Bi-weekly injections equivalent 
to 100 rat units of antuitrin S were given during June and 
July, 1933. Sexual rest and an increase in vitamin-rich 
foods were advised. At the second examination of 
semen in November, 1933, the volume was 1*5c.cm. 
and only six feebly motile spermatozoa were noted three 
hours after production. The spermatozoa count, however, 
had risen to 52 million per c.cm., and the proportion 


TABLE II.—EHxamination of Semen in Case 2 


Total 
eras Motile. | sperm. ae 
exam, | ®Perm. re (per cent). 
May, 1933 2 3 | Toss 1 Ban 7 17-2 
ANTUITRIN S8 DURING JUNE AND JULY 
Nov., 1933| 15 | 3 | 6 (feebly)| 52 | 12:5 


ANTUITRIN 8 DURING NOVEMBER AND DECEMBER 
May, 1934 3°5 About 10% 75-5 10-5 
(highly 
active) 


ð 


abnormal was reduced to 12°5 per cent. A further series 
of injections of antuitrin S was given once weekly during 
November and December, 1933. A third examination of 
semen followed in May, 1934, when the volume was found 
to be 3°5c.cm. There were about 8 per cent. of motile 
spermatozoa, some highly active, five hours after coitus, and 
the spermatozoa count was now 75°5 million, with 10°5 per 
cent. abnormal. In view of the increase in the numbers 
of spermatozoa no further treatment was given. Pregnancy 
im the patient’s wife was diagnosed in April, 1935, and a 
healthy child, 10 lb. in weight, was born last November. 


Table Il. summarises the various counts made. 


In both these cases the number of spermatozoa 
increased and their quality improved after administra- 
tion of gonadotropic hormones. In both of them, 
moreover, the treatment was followed by pregnancy 
of the wife leading to birth of a normal full-term child, 
although the marriages had previously been sterile 
for periods of three and five years. 


REFERENCES 


1. Schockaert, J. A.: Anat. Rec., 1931, 1., 381. T 

2. Brosius, W. L., and Schatfer, R. L.: Jour. Amer. Med. 
Assoc., 1933, ci., 1227. 

3. Brosius, W. L.: Endocrinology, 1935, xix., 69. 


THREE ARTERIAL EMBOLECTOMIES 
THE SAME PATIENT 
INCLUDING ONE IN EACH FEMORAL ARTERY 


IN 


By H. I. Derrcu, M.S. Lond., F.R.C.S. Eng. 


RESIDENT SURGICAL OFFICER, BRADFORD ROYAL INFIRMARY 


ONLY ten cases of successful arterial embolectomy 
have been recorded in Great Britain. The case here 
reported is the first, so far as I know, in this country 
of successful femoral embolectomy, and it is singular 
in that in this man embolectomy has now been suc- 
cessfully performed upon both his femoral arteries 
at an interval of a year. He has had altogether three 
separate emboli removed from three different sites— 
one in January, 1934, and two others in December, 
1935. The patient illustrates the after-history of 
embolectomies as described in a recent leading article 
in THE LANCET,! and shows that the prognosis of 
successful embolectomy is that of the primary condi- 
tion, and is not, or should not be, affected by the 
operation itself. 

: FIRST ILLNESS 


The patient was a man, aged 44, suffering from auricular 
fibrillation and bedridden on and off for 18 months. 
He was admitted to hospital Jan. 4th, 1934, with a history 
that a week previously he had had an attack of agonising 
colicky pain across the lower part of the abdomen, so 
severe that in spite of being bedridden, he had to get up 
and walk about to relieve the pain. His bowels moved, 
but he passed no blood. At the time, and subsequently 
until his second operation, I assumed that this pain was 
due to a small mesenteric embolus. Iam now convinced 
however that this pain was spasm in the large vessels 
on the posterior abdominal wall, due to the passage of the 
embolus. At 9.45 p.m. on the day of admission there was 
a sudden feeling of numbness in the left knee. This was 
painless at first and gradually spread down his leg to the 
foot. The limb felt cold and dead and when he touched 
it with his other foot it felt ‘‘as though it belonged to 
someone else.” Within 15 minutes the numbness changed 
to a tearing, burning pain; the limb felt as if it were 
bursting, as though the skin was too tight, and the pain 
began to spread up the thigh. It was, he said, worse than 
anything he had suffered in his hfe, and it persisted 
unchanged until operation. He applied compresses 
of scalding water to the leg, but these failed to relieve the 
pain, and it was only slightly alleviated by morphia 
gr.3. Dr. L. L. Hurwich saw him and diagnosed the 
condition immediately as one of embolus of the femoral 
artery and sent him to hospital, where he was admitted 
at 12.30 a.m. on Jan. Sth. 

Examination.—I saw him at 1.30 4a.m.; he was still in 
a condition of extreme shock, pallid and sweating, with 
drawn face and suffering intense pain in spite of the 
morphia. His left lower limb below the middle of the 
thigh was cold, shrunken, marbled, and felt greasy to the 
touch. It was anesthetic and voluntary movements 
were absent. Pulsation could only be felt in the upper few 


1 THE LANCET, a 4th, 1936, p. 33. 
I 


476 ‘THE LANCET] 


MR. H. I. DEITCH: ARTERIAL EMBOLECTOMY 


[FEB. 29, 1936 


inches of the common femoral artery—i.e., in the region 
where one feels it in the normal thigh—but not in the 
vessels about the ankle, l 

The operation was begun at 2.30 A.M., and as the pain 
had commenced above the knee his popliteal artery was 
first explored under local anæsthesia, together with 
. morphia, hyoscine, and atropine. The artery was readily 
exposed and found to be collapsed; it was obvious that 
the block was higher up. The femoral artery was there- 
fore next explored in Scarpa’s triangle, the pulsation being 
traced down to where it ceased, which was just above the 
origin of the deep femoral artery. The upper margin 
of the embolus could be felt as a sharp edge; its lower 
limit passed imperceptibly into a long clot which extended 
several inches down the superficial femoral artery. The 
affected length of the artery was isolated only on its 
superficial aspect, and fine rubber tubes were passed under 
the vessel above and below the affected segment; it was 
occluded by pulling upon the rubber tubing, thus kinking 
it and complete occlusion was obtained by pressing the 
two parts of the rubber tubing together close to the 
artery. The vessel below the clot was gripped between 
the finger and thumb of the left hand, and a longitudinal 
incision was made over the embolus. As the artery was 
opened the embolus, followed by the clot, was milked 
out in one piece by the finger and thumb from below, 
passing upwards along the vessel, Extrusion was 
accompanied by a gush of blood which, from its direction, 
must have come from the deep femoral artery. The 
milking process was repeated, and a probe was passed 
down the vessel; the incision was then sutured. When 
this was completed pulsation had returned to the exposed 
length of the superficial femoral artery and the patient 
declared that his pain had all gone; his general condition 
also begain to improve immediately. By the time the 
wound was closed capillary reaction had returned to the 
foot and sensation was also coming back. Pulsation did 
not return to the posterior tibial artery until that evening. 

The wound healed by first intention, and the man was 
discharged home in about two weeks. In May his doctor 
informed me that he was in good health and that his leg 
had remained normal in all respects. 


During the operation several interesting facts 
were noted ; that, in the region affected the induction 
of anesthesia was unnecessary, as only above the 
level of the embolus in the artery was sensation 
present in the artery itself ; the tissues in the affected 
area were bloodless ; the superficial tissues appeared 
to be insensitive to the ordinary operative manœuvres 
up to the same level, and this level appeared to 
coincide in the limb very accurately with the level of 
the embolus in the artery.. It was difficult to secure 
hemostasis and to appose accurately the edges of 
the incision at the site of the embolus, although it 
was easy above that level; hemostasis at the suture 
line was readily obtained in the uninvolved portion 
of the artery, but was delayed in the affected part, 
probably attendant upon the restoration of the 
circulation in the walls of the artery. After suturing 
the vessel the upper part of the incision was dry 
immediately. The lower part required swab pressure 
for several minutes before it, too, became dry. 


SECOND ILLNESS 


On Dec. 14th the patient was readmitted to the hospital 
as an emergency with a history of having had the previous 
day an attack of abdominal pain, vomiting, and diarrhea ; 
there was no blood in the motions. The pain commenced 
to the right of the umbilicus and stayed there for about an 
hour and then moved clown to the right iliac fossa and 
also to the right loin. Later the pain became worse and 
also radiated down to the right testis ; he vomited every 
time he drank and he could not sleep because of the pain. 
He had no increased frequency or hematuria, and he was 
sent into hospital as a case with possibly renal colic, 
or, from his history, an embolus of the renal artery. 

On admission there were no physical signs obtainable, 
and it was decided to watch him. His urine was normal 


in all respects, and it was thought most probable that he 
had an embolus. Between Dec. 15th and the morning 
of the 18th he was quite well without any pain or other 
symptoms. At 10.20 a.m. on the 18th he suddenly com- 
plained that he was getting pain in the middle of the thigh 
and his right leg was going dead “‘ just as it had done last 
time.” At 10.30 a.m. when I saw him the right leg was 
exactly as the left had been one year previously, and the 
diagnosis of an embolus at the origin of the right deep 
femoral artery was made. While waiting to be taken to 
the theatre he complained that his left leg was also feeling 
numb, and that he had colicky pain across the lower half 
of his abdomen. On re-examination pulsation was still 


- present in the right common femoral, but had disappeared 


from the left. It was therefore thought that in addition 
to the embolus in his right femoral artery he had an 
embolus at the bifurcation of the left common iliac artery. 


Operation was begun at 11.30 a.m., by which time both 
lower limbs were cold, pallid, and anesthetic. He still 
had no great degree of pain, his complaint being only of 
the numbness. Spinal anesthesia was used, and an 
oblique incision was made cutting through muscle to 
expose extraperitoneally the left common and externa? 
iliac arteries, the peritoneum being retracted well to the 
right side. A large embolus was felt in the common 
iliac artery proximal to its bifurcation. The common 
iliac, just below its origin, and the external iliac, well 
below the embolus, were occluded by rubber tubing, and 
the artery was incised Just above the clot. Owing to 
the depth and the difficulties of exposure, it was impossible 
to incise the artery, as one wished, completely above the 
embolus. By incising the artery, however, and by 
milking up the embolus I succeeded in removing it intact ; 
its exit was accompanied by a spout of blood which 
appeared to come from the internal iliac. The wall was 
sutured and with swab pressure for a few moments became 
quite dry. After waiting a few minutes pulsation could 
be felt in the external iliac artery, and even before the 
wound was closed, colour had returned to the foot. The 
right common femoral was exposed and an embolus was 
removed in a way similar to that on the left a year 
previously. Here, however, one was able to incise the 
vessel completely above the embolus, and hzemostasis 
was immediate and complete on suturing the incision. 
By the time this incision was sutured, pulsation had 
returned to both the posterior tibial and dorsalis pedis 
arteries of the right foot. 

Progress.—Healing of the incisions was uneventful, 
and both legs became normal with the single abnormality, 
that even after two weeks, when he was sent home, pulsa- 
tion had not returned to any vessel in the left lower limb, 
in spite of this the superficial circulation, feeling and move- 
ments were quite normal. This is difficult to explain 
as pulsation was seen and felt to return to the external 
iliac at the operation. The vessel appeared in a state 
of spasm when incised ; suturing was difficult and possibly 
the bites taken of the wall were too large. This, in 
association with the previous embolectomy in the left 
common femoral, might account for the persistent absence 
of pulsation. 


COMMENT 


In all three vessels operated upon there was much 
spasm in the affected portions, and it appeared to 
diminish the size of the artery by more than a half. 
In the first operation an ordinary curved intestinal 
needle was used to suture the artery ; in the second, 
a very small hare-lip needle, which is much more 
suitable to use; but the former, in spite of its size, 
was quite satisfactory. Ordinary fine silk soaked in 
liquid paratin for half an hour was used on both 
occasions. 

Recently attention has been drawn to non-opera- 
tive methods of treating the condition of arterial 
embolism, but the operation is so simple and easily 
performed, and can be carried out in the limbs under 
local, or possibly no other anesthetic than morphia, 
&c., that I think no alternative is required. When 
once it has been seen, one does not readily forget the 


a 


THE LANCET] 


DR. E. W. ANDERSON : ALCOHOLIC PSEUDO-PARESIS 


[FEB. 29, 1936 477 


dramatic relief which is given to a patient by remov- 
ing an embolus, and by the immediate improvement 
in his condition. It seems important to relieve the 
obstruction at a point where not only the main 
but the collateral circulation to a part is simul- 
taneously occluded. Even if some clot remains behind, 
one is sure of freeing at least the collateral circula- 
tion, and this, even if it does not prevent gangrene, 
limits it to the more distal parts of the limb. In 
this patient, when an embolus was removed from the 
junction of the superficial and deep femoral arteries, 
a very strong gush of blood came from the deep 
femoral, so that we felt sure that even if only the 
passage between the common and deep femoral were 
freed, a good circulation would be established. 

In all three operations there was no doubt that 
the embolus, from its size, could not have gone 
further; there was so much spasm below and, to 
some extent, above, that the embolus stood out as a 
definite bulge in the line of the artery. Hence mas- 
sage in these instances, where it could have been 
applied, would have been valueless. In the first 
operation, when about five hours had elapsed between 
onset and operation, a clot about 3 in. long was 
present distal to the embolus. In the second and 
-third operations, when only an hour had elapsed, 
there was no clot present at all. This is why success 
follows an early operation more often than one long 
delayed. All three emboli were tough, solid 
masses. | 
~ In the history of this case there were several 
features which are not typical. The site of maximum 
pain was well below that of the embolus, and not, as 
is usually described, directly over the site of impac- 
tion, and the onset which was gradual rather than 
sudden. In his second attack he had no severe pain 
even after an hour. From the history preceding this 
attack I feel sure that his abdominal pain on both 
occasions was due to spasm and to the passage of 
the embolus along the aorta. 


I wish to record my gratitude to Mr. Peter McEwan 
for his kindness in allowing me to treat this case and to 
report it to the Bradford Medico-Chirurgical Society in 
January, 1935, and also for his permission to publish it. 


A CASE OF ALCOHOLIC PSEUDO-PARESIS 


By E. W. ANDERSON, M.D. Edin., 
M.R.C.P. Lond., D.P.M. 


MEDICAL DIRECTOR OF THE CASSEL HOSPITAL FOR FUNCTIONAL 
NERVOUS DISORDERS, PENSHURST, KENT 


THE condition known as alcoholic pseudo-paresis 
-was more familiar to the older psychiatry than it is 
to that of the present-day, and cases are now 
comparatively rare. Bleuler writes: ‘* Probably 
because the concept of paresis has become clearer 
-we have not seen for ten years any disease we could 
designate as alcoholic pseudo-paresis.”»1 As there is 
even a tendency to deny its existence altogether 
X think it desirable to place on record the present 
«case, which is the first in my experience. 

The condition was first described as a clinical 
entity by Magnus Huss? in 1852, but it was recognised 
amperfectly before that time. For example Huss 
quotes Brihl-Cramer’s account of “a condition of 
torpidity of the nervous system associated with the 
<appearances of general muscular weakness and thus 
= particular sluggishness of all functions voluntary 
as well as involuntary.” Since Huss wrote, there 
Jaave been many other reports of cases, including a 


very interesting one recorded by Régis? in 1883 
where the patient had had no fewer than 16 attacks 
of the disorder, in some of which it was diagnosed 
as general paralysis by distinguished psychiatrists 
and in all of which it cleared up completely. Good 
descriptions of the disorder are to be found in all 
text-books of psychiatry and it is unnecessary 
to go into particulars here. Like the Korsakow 
syndrome, of which it is a form, it appears to be rather 
commoner in women. All writers stress the good 


‘prognosis if alcohol be withheld. 


Mrs. A. B., aged 52, was admitted to the Cassel Hospital 
on July 26th, 1935. This hospital does not admit organic 
cases but from the account given by her doctor it seemed 
that she might benefit from admission. 

The family history was essentially negative, but her 
husband was unable to furnish many details of it or of 
her early life. i 

Personal history.—The patient, who had been on the 
stage, was of Scottish birth and extraction and had 
evidently been a difficult child. There was a definite 
history of syphilis, which had been fully treated by a 
distinguished syphilologiss who pronounced her free 
of the disease before marriage; the blood Wassermann 
reaction had been negative 15 to 20 years before admission. 
There was also a history of “a dropsical tendency ”’ 
about 30 years previously—perhaps a syphilitic nephritis. 
More recently she had been operated on for arthritis of the 
knee, but no further details of this were forthcoming. 

The patient had had a child before marriage but no 
other children. She was married in 1908 and her meno- 
pause occurred about 14 to 2 years before admission 
to hospital in 1935. Her married life had been extremely 
unhappy, both because of her husband’s taste for other 
women and her own cyclothymic, paranoid personality, 
quick to see insults and hypersensitive, jealous, and 
exacting. In addition she was prone to violence, assaulting 
servants if they displeased her and flying into uncontroll- 
able rages. All this had been observed before she started 
drinking ; for she had become a teetotaller from marriage 
and there was a history of only a year’s indulgence in 
gin and burgundy up to admission. There was no history 
of drugs. 

Before her menopause there had been no signs of definite 
mental illness; but about this time she became very 
depressed and apathetic, although she had hitherto been 
an active woman with many interests. Finally she made 
a suicidal attempt which her husband thought was chiefly 
histrionic but which led to her commitment. After a 
few weeks in a mental hospital she was. discharged 
recovered and to her husband seemed perfectly normal. 
Soon afterwards however the old quarrels began anew 
and life with her at home was impossible. For a year 
she had been drinking heavily. It is hard to say with 
precision when the symptoms which she presented on 
admission began, for her husband was not living with 
her at the time. That they were of recent origin is almost 
certain—at least in their grosser form—as her private 
doctor could scarcely have overlooked them. It is likely 
that he did not see her immediately before admission. 
There was no history of any other alcoholic psychosis. 

On examination a well-built, rather stout woman of 
florid complexion. On reaching hospital she was unable 
to walk and could hardly stand without assistance. Her 
pupils were equal, circular, and moderately dilated. 
The right reacted very sluggishly to light (direct) but the 
consensual response was brisker. The left pupil was also 
sluggish to light but rather less so. Both reacted quite 
well on convergence. There seemed a slight paresis of 
the right face, but this was difficult to establish. The 
tongue was furred; protruded in the midline; there 
was a medium tremor. There was also tremor of the lips 
and considerable slurring of speech as evidenced by the 
test phrases. This slurring was of the type usually seen 
in general paralysis. Vision in the left eye seemed a 
little defective, but owing to the mental state it was 
impossible to be certain of anything in which much 
coöperation was required. Both discs were somewhat 
pale but within physiological limits. The remaining 
cranial nerves showed nothing abnormal. 


478 THE LANCET] DR. C. A. BIRCH: JAUNDICE DUE TO PHENOBARBITAL [FEB. 29, 1936 


There was no evidence of paresis of the limbs and both 
grips were good and equal. No wasting of muscles. 
The deep reflexes were equal and active. Superficial 
reflexes: abdominals were not elicited (abdomen very 
flabby); both plantars gave a flexor response. There 
was considerable failure of codrdination as evidenced by 
the finger-nose test, some dysdiadokinesis and, as already 
stated, inability to maintain an upright posture without 
assistance. There was a medium tremor of the out- 
stretched fingers. Sensation could not be examined 
owing to the clouding of consciousness; next day, 
when she could coéperate better, no disturbance was found. 

The pulse-rate was 70 and the radial arteries not 
thickened. No enlargement of heart, but sounds muffled 
all areas; no bruits. Blood pressure 156/90. Other 
systems: nothing abnormal found. 

Mental state.—She was dull and lethargic; her face 
was stupid and heavy looking, and her words came slowly. 
There was some degree of agnosia. She was two days 
out in the date and could not furnish the time of day. 
She answered questions irrelevantly. There was no 
evidence of delusions or hallucinations. The immediate 
impression was that of a case of general paralysis or some 
intoxication. 

Progress.—Next day she was slightly clearer and was 
able to give some account of herself. She said she was 
depressed and admitted drinking heavily, speaking bitterly 
of her husband’s behaviour. She complained of memory 
difficulty and said she could not remember next morning 
what happened the, day before. This was objectively 
demonstrable although it was not as gross as might have 
been expected. The disorientation in time persisted in the 
same degree but that for space and identity was intact. 
She could not reproduce a simple story told to her and 
missed its point. Her grasp of general information was 
patchy, though better than might have been expected ; 
but she failed miserably in the simplest calculations and 
could not repeat even four digits backwards. 

Three days after admission her speech was slightly less 
slurred. There was now no evidence of agnosia in any 
field nor apraxia ; though she still spoke a little irrelevantly 
she remembered details of her previous conversation 
with me. Her mood was unstable and she readily broke 
down into tears, bemoaning her position. Four days 
after admission the slurring of speech seemed even less 
manifest but was still present. Both pupils now reacted 
briskly to light and the tremor of the tongue had 
diminished. Her mood was rather hostile and she spoke 
in the dramatically portentous manner of the slightly 
intoxicated. Next day there was little change, but 
memory tests revealed a much grosser defect of recent 
memory than she had previously shown. She was again 
friendly and coéperative. On August 2nd, 1935, it was 
possible to satisfy oneself that there was no disturbance 
of sensation, and the day after this there was a distinct 
improvement all round. The speech difficulty had dis- 
appeared and the tremor of the face also, whilst that of 
the tongue was much less. She was now correctly 
orientated but still failed in simple calculations. For 
the next week she made steady improvement and on 
August 10th she was correctly orientated, her memory 
much improved, her mood much more stable. Five 
days later the only remaining feature was a slight tremor 
of the lips; she was so much improved that she was able 
to go up to town and do a round of shopping accompanied 
by anurse. By August 29th she made a completely normal 
impression, but it was found that she was still shaky in 
signing her name and she could not perform the finer 
movements such as sewing. She left hospital on Sept. 18th, 
as she did not wish to stay longer, completely recovered. 

Serological findings on admission.—Cerebro-spinal fluid : 
clear and colourless apart from a few red corpuscles ; 
cells 3 per e.mm.; 580 red cells per c.mm.; protein 
0-055 per cent.; globulin, Nonne-Apelt and Pandy 
reactions negative; Lange’s goldsol test, no change in 
any tube. The Wassermann reaction was negative 
in blood and cerebro-spinal fluid, and tho latter was held 
to be within normal limits, affording no evidence of 
neurosyphilis. 


The serological findings leave no alternative to 
the diagnosis of alcoholic pseudo-paresis, the rarity 


of which in the last few years must be attributed 
chiefly to (1) a change in the habits of the people, 
with consequent reduction of the alcoholic psychoses 
in general, and (2) an improvement in means of 
precise differential diagnosis—a factor probably 
of equal importance. The present case demonstrates 
the good prognosis of this disorder and the rapid 
recovery following withdrawal of alcohol. The patient 
was seen again on Oct. 22nd and except for her worries 
was perfectly well. 


I am indebted to Dr. J. G. Greenfield, of the National 
Hospital, Queen-square, for kindly carrying out the 
necessary serological examinations. 


REFERENCES 


1. Bleuler, E.: A Zest DOOR of Psychiatry, authorised 
English edition trans. A. Brill. London: 1923. 

2. Huss, Magnus: miss taiemus Chronicus : German 
translation from Swedish by G. van den Busch. Stockholm 
and Leipzig, 1852. 

3. Régis, E.: L’Encephale 1883, iii., 91. 


JAUNDICE DUE TO PHENOBARBITAL 


By C. Arran Bircun, M.D. Liverp., M.R.C.P. Lond., 
D.C.H., D.P.H. 


SENIOR PHYSICIAN, NORTH MIDDLESEX COUNTY HOSPITAL, 
LONDON 


Phenyl-ethyl barbituric acid (now officially 
called phenobarbital) was first introduced in 1913, 
and has been used extensively since that time. 
Huddleston,! who reviewed the literature up to 1928, 
reported toxic effects in 22 out of 1000 patients 
taking phenobarbital, and it is now generally agreed 
that evidence of poisoning may be expected in as 
many as 2 or 3 per cent. 

The toxic manifestations are similar to those of 
barbiturates in general, as described at length by Lundy 
and Osterberg? and by.Gullespie.2 They include mor- 
billiform eruptions, nervous disturbances such as 
vertigo, ocular disorders and coma, and certain general 
effects—fever, albuminuria, nausea, and vomiting. 
Jaundice, however, is almost unknown. Pemberton 
and Pearson 4 claimed that their patient showed all the 
known cutaneous and visceral effects except hamato- 
porphyrinuria, and although the liver was enlarged 
jaundice was absent. Scarlett and Macnab 5 in a 
recent survey of phenobarbital fatalities do not 
mention jaundice. Huddleston! described more or 
less severe and constant epigastric pain, not responding 
to diet and alkalinisation, in 5 per cent. of 1147 
cases in which phenobarbital (in an average dose of 
3 grains daily) had been given over a period of years ; 
but none of these patients had jaundice. 

There is some evidence that barbitone (Veronal or 
diethyl barbituric acid) can cause liver damage. 
Gerlach and Bredmose ë at the Viborg Mental Hos- 
pital confirmed the observation of Ravn? that 
veronal damaged the liver, and found positive uro- 
bilinogen and bile-acid, tests when veronal was 
given continuously and also (less often) when it was 
administered intermittently. Apparently clinical 
jaundice did not occur. 

In 1925 Parkes Weber 8 described the case of a 
choreic girl, aged 13, who developed a morbilliform 
eruption with jaundice and bile-containing bullse 
after taking 0-1 gramme (1} grains) of Luminal* 
daily for 14 days.t The stools were pale and the 


* A proprictary preparation of phenobarbital. 
t Tho dose was incorrectly given in the original paper but 
was corrected by Dr. Parkes Weber subsequently (Brit. your. 
Child. Dis., 1927, xxiv., 328). 


THE LANCET] TUBERCULOSIS ASSOCIATION [FEB. 29, 1936 479 


urine contained bile. The van ‘den Bergh reaction 
was positive, and the icterus index was 40. The 
child was not seriously ill and had no pyrexia; the 
Wassermann reaction was strongly positive. The 
case I wish to record was as follows :— 


A man, aged 50, with well-marked hyperthyroidism 
was admitted to hospital in order to be prepared for 
thyroidectomy. He was given l grain of phenobarbital 
every night, “beginning on August 15th, 1935, while 
preliminary investigations of basal metabolism, &c., 
were being made. On Sept. 2nd a course of liquor iodi 
aquosus B.P.C. (Lugol’s iodine), 5 minims three times a 
day, was begun. All went well until Sept. 4th when the 
patient had some conjunctivitis. On the 6th a diffuse 
macular rash appeared and phenobarbital and iodine 
were discontinued. He became drowsy and was strange 
in manner. The macules coalesced and small vesicles and 
pustules appeared and the mucous membrane of the 
mouth was affected. Itching was considerable. The 
temperature was remittent, 102°-104° F., and the patient 
obviously very ill. On Sept. 10th jaundice appeared 

and increased until it was very deep. The liver was 
enlarged about half-way to the umbilicus. The van den 
Bergh reaction was prompt direct positive (15 units). 
Bile salts and pigment and albumin were present in the 


urine. The stools were pale. The Wassermann reaction 
was negative. The whole picture slowly subsided and by 
Sept. 25th his temperature was normal. Very extensive 
desquamation followed, and he left hospital on Oct. 26th. 


Toxic symptoms appeared in this case after 
l grain of phenobarbital had been given daily for 
22 days. Subsequent administration of Lugol’s 
iodine caused no ill-effect, and hence the illness 
cannot be ascribed to iodine. ‘The skin condition 
was typical of phenobarbital poisoning, and since 


, Jaundice occurred concurrently, in the absence of 


any other cause, my conclusion is that the jaundice 
was produced by phenobarbital. 


REFERENCES 

1. Huddleston, J. H.: Jour. Amer. Med. Assoc., 1929, xciifi., 1637. 

2. Lundy, J. S., and Osterberg, A. E.: Proc. Staff Meet. Mayo 
Clin., 1929, iv., 386. 

3. Gillespie, R. D.: THE LANCET, 1934, i., 337. 

4. Pemberton, H. S., and Pearson, R. W. L.: Ibid., 1931, 
i., 635. 

5. Scarlett, E. P., and Macnab, D. S.: Canad. Med. Assoc, 

our., 1935, xxxiii., 635. 

6. Gerlach, P., and Bredmose, G. V.: Hospitalstidende, 1934, 
lxxvii., 963. 

7. Ravn, J.: Ibid., 1933, Ixxvi., 1103. 

8. Weber, F. P.: Brit. Jour. Dis. Child., 1925, xxii., 280. 


MEDICAL SOCIETIES 


TUBERCULOSIS ASSOCIATION 


AT a meeting of this association held on Feb. 21st 
the first subject discussed was 


Primary Tuberculosis in Children and its 
Relationship to Meningitis l 


Dr. H. H. Scort said that twenty years ago it was 
recognised that tuberculous meningitis was usually 
part of a general tuberculosis, the primary seat being 
often in the bronchial, cervical, or mesenteric glands, 
by the infective material passing to the meninges 
by way of the lymph or blood stream. Had there 
been much advance since then? How did or could 
such a tuberculous gland give rise, by way of the 
lymph stream, to a meningitis? While some of his 
own cases apparently confirmed the prevailing idea 
that in blood invasion the brain or meninges was 
the first to suffer, Dr. Scott believed this idea to be 
a fallacy, in view of the numerous exceptions—e.g., 
cases in which the spleen, liver, and kidneys were 
involved, but the brain and meninges escaped. 
Even with focal lesions in the lungs, however, it was 
difficult to explain tuberculosis affecting no other 
secondary site. He knew of no lymphatic connexion 
between the lungs and the base of the brain, and one 
was driven to conclude provisionally, that the infection 
was conveyed by the blood, although, where there 
was extensive involvement of the meninges, invasion 
of other parts might have been expected. It was 
sometimes impossible to discover any primary 
focus; this might be so even in the presence of 
‘widespread dissemination (the granulie primitive 
of French writers) possibly due to a massive exogenous 
infection, especially in debilitated subjects—for 
example, as a sequel to one of the acute exanthemata. 
Meningeal tuberculosis might occasionally be primary, 
as in the case of a child four years of age in whom 
the meningeal tuberculosis was the only discoverable 
lesion. In his series of 300 autopsies on tuberculous 
subjects, meningeal infection was found in 41 per 
cent. of 225 children under ten years of age, and in 
449 per cent. of 65 adults over twenty years. The 
distribution of the milia gave no support to the 
sstatement, frequently made, that tubercles may 


often be found along the fissures of Sylvius when 
they are not discoverable elsewhere in the meninges. 
In only one case in the whole series—in a man 27 years 
old—a few tubercles were found along the fissures 
without involvement of any viscus other than lungs 
and pleura. Tuberculous tumours of the brain, 
tuberculomata, or conglomerate tubercle might or 
might not be associated with meningitis. They were 
often multiple and had a special predilection for the 
cerebellum, the base of the brain, and the basal 
ganglia. Judging from his own cases (9 in the whole 
series), the association of conglomerate tubercle with 
meningitis was largely fortuitous, and one might 
exist without the other until the tumour reached the 
surface and so came to affect the covering membrane. 


Dr. C. H. C. Toussarnt said that tuberculous 
meningitis and miliary tuberculosis were metastatic 
manifestations of tuberculous disease and not primary 
forms. Usually it was possible to find at autopsy 
the primary site of infection. The two main sources 
of infection were bovine and human tubercle bacilli 
with their carriers. Summarising the investigations 
of a large number of workers in this country and else- 
where into the occurrence of bovine infection in 
tuberculous meningitis, the speaker said 25 per cent. 
had been shown to be due to bovine bacilli and 
75 per cent. to the human type. The fact had thus 
been amply confirmed that in the primary tuberculosis 
of childhood human infection was of far greater 
importance than infection with the bovine type of 
bacillus. In the Lancashire investigation of deaths 
from non-pulmonary tuberculosis in children of 
0-5 years, tuberculous meningitis accounted for 
two-thirds of the deaths. Dr. Toussaint showed 
slides giving particulars of the human contacts of 
80 children aged 0-10 who died from tuberculosis 
in Bermondsey during the years 1928-35. The 
probable human source of infection was found in 
46 out of 54 cases in which complete investigation 
was possible. Early notification was of vital 
importance to enable the tuberculosis officer to 
investigate the source of infection, but it should not 
be forgotten that notification should be made only 
on definite evidence of tuberculous disease. In cases 
of tuberculous meningitis or miliary disease, it was 
often difficult to establish a true diagnosis, but 


480 


increased use of chest radiology in such children 
should be of considerable assistance. In prevention, 
bearing in mind that the major problem was the 
danger of human infection, there were three main 
lines of procedure : immunisation of children exposed 
to risk; boarding-out of contacts; and—perhaps 
most important of all—the segregation in institutions, 
if possible, of patients with tubercle bacilli in the 
sputum. These must be found at as early a stage 
as possible and maintained in hospitals or sanatoria 
for as long as possible. Too often they saw a chronic 
sputum-positive case returned home for no other 
reason than that there was ‘“‘ no further advantage in 
retention.” The use of the local municipal hospital 
for the care of advanced cases was of great service 
in this respect. | 


THE LANCET] 


Tuberculosis of Bones and Joints 


At the second session the subject for discussion 
was the Treatment of Tuberculous Lesions of 
‘Bones and Joints. 


Sir HENRY GAUVAIN said that there was one point 
of fundamental importance to be remembered— 
that a tuberculous bone or joint lesion was an osteitis 
or arthritis occurring in a tuberculous patient, or in 
other words, that it was secondary to a primary focus 
occurring elsewhere which might or (more usually) 
‘might not be discovered. If this was admitted, treat- 
ment logically followed on two lines, local and general. 
Radical treatment of the local lesion, by which he 
meant extirpation of the lesion, became less often 
indicated, although it was still of value in certain 
circumstances such as tuberculous disease of the 
knee-joint in an adult. As a rule conservative 
treatment was called for, and this, in the case of 
tuberculous disease of bones and joints, might be 
defined as the adoption of all measures which tended 
to improve the patient’s health, to increase his 
powers of resistance to tuberculous disease, and to 
preserve or restore the part attacked ; while sometimes 
it might be wise also so to fix the lesion by operative 
treatment that the affected part was immobilised 
and later risk of deformity or disability minimised— 
the treatment still, however, being strictly con- 
servative. In children suffering from advancing 
and progressive spinal caries he would unhesitatingly 
avoid bone-grafting or fusing, since mechanical 
immobilisation alone would almost always result 
in cure. Later on, after successful treatment, 
if the patient had poor dorsal musculature and 
could not have satisfactory after-care supervision, 
a bone-graft was definitely indicated. Even in 
adults, osteosynthesis should only be performed when 
the disease was becoming quiescent. In tuberculous 
disease of the hip, where adequate conservative 


treatment was undertaken and efficient after-care | 
given, operation was not as a rule called for. In, 


any case he did not favour operative treatment in the 
acute stages of hip disease, nor in any case of tuber- 
culous disease of the knee-joint in children. In 
adults with tuberculous knee-joints he usually 
favoured excision. Turning to general and adjuvant 
treatment, Sir Henry said that climatic and seasonal 
changes were of value to the patient, producing 
varying stimuli which were of great assistance. 
Sun-bathing, light treatment, and sea-bathing were 
also helpful in suitable cases and in suitable dosage. 
But though open-air treatment was now advised 
by general consent, many wards designed for the 
purpose were miserable and cheerless structures. 
To make such wards completely open on one side 
was not only unnecessary, but sometimes even cruel, 


SOCIETY OF RADIOTHERAPISTS 


[FEB. 29, 1936 


A folding wall on'the south side which could be 
instantly opened or closed was preferable. 


Mr. G. R. GIRDLESTONE said he fully appreciated 
the fundamental consideration underlying the 
conservative treatment of tuberculous disease of 
bones and joints, in that it was a local manifestation 
of a general disease; and he entirely agreed that a 
long period in hospital such as was rendered necessary 
by the conservative treatment was of immense 
advantage in countering the general disease and ought 
not to be cut short by operative measures which led 
to either the excision of the diseased focus or the 
arrest of the diseased focus by some form of fusion 
operation. This long period in hospital, whether 
or not the treatment was purely conservative, was 
especially advantageous to children, both because 
in childhood lymphatic tuberculosis was far more 
likely to be still active and even widespread, and 
also because they throve under prolonged rest, 
in a well-run open-air hospital. For patients above 
the age of twenty these special considerations no 
longer applied, and the economic factor had also to 
be reckoned with. Those who favoured purely 
conservative treatment had, he thought, been biased 
by statistics based on cases many of which were 
probably not tuberculous at all; or on cases which 
for reasons of distance or age never returned to the 
hospital and were set down on the records as cured. 
The reasons for deciding on an operation were: the 
preservation of life (e.g., amputation in middle life 
for proved and active tuberculosis of hip or knee, 
or wide excision in the presence of persistent sepsis 
added to tuberculosis); the elimination of persistent 
disease (e.g., in proved active tuberculosis of elbow 
or shoulder in or after middle life); and the aim of 
“a permanently safe and useful limb” (Lovett), 
including the spine. The decision here depended 
largely on the extent of destruction and the mechanics 
of the limb or body in relation to the site of disease. 


_A further object of operation was to save time in 


bed (e.g., in adults in whom the joint focus had 
outlasted all signs of lymphatic tuberculosis due to 
mechanical strain). But where the joint disease 
was of comparatively recent origin, indicating there- 
fore active lymphatic tuberculosis, there could be 
no cutting short of general treatment. This reason, 
therefore, could only apply in a strictly limited field. 


SOCIETY OF RADIOTHERAPISTS 


AT the first scientific meeting of this new society, 
held on Feb. 21st, the chair was taken by Dr. G. B. 
STEBBING, the president, and Mr. GEOFFREY KEYNES 
opened a discussion on the technique of 


Radiotherapy in Carcinoma of the Breast 


which has not been previously treated. He found 
it diltficult, he said, to adhere strictly to the title, 
for he regarded radiotherapy as a method to be 
used in conjunction with other methods ; sometimes 
surgery was the right treatment, sometimes surgery 
and radium, sometimes X rays, and sometimes 
radium alone. Radiotherapeutic technique had been 
retarded by the custom of confining it to late and 
advanced cases, because the patients died from 
metastases before the local effects could be assessed. 
He recognised more and more the limitations of 
radium, which would not give greatly better results 
than good surgery. He therefore used surgery before 
radium more often than in the past. It was important 
to recognise that radium was a strictly local method 


THE LANCET] 


and many patients did better if it were only used to 
clear up after surgery. Patients with supraclavicular 
extensions were unsuitable for radium and did better 
under a full course of X rays. The limitations of 
radium were difficult to define; it had not great 
penetrating power and its effect could be to some 
extent gauged by the size of the tumour. The 
palpable part, however, was by no means the whole, 
and the entire gland must be treated. Mr. Keynes 
preferred interstitial application because of the 
inevitable damage to superficial tissues caused by 
external radium. The radium must never be distri- 
buted in cartwheel fashion round the growth but in 
parallel lines right through the mamma, in order to 
produce a perfectly uniform field of radiation. If the 
needles were placed in a grid on a rigid framework, 
an almost mathematically uniform field could be 
obtained, but natural contours and variations in 
thickness interfered with such rigidity: the breast 
was not a pancake and greater penetrating power 
was needed in the centre. A more difficult problem 
was the treatment of the axilla; results had, however, 
shown that satisfactory irradiation was possible. 
A needle was introduced along each wall—at least 
four needles—and often one or two more, converging 
to form a cone of needles enclosing the axilla. A few 
long needles might be put down through the pectoral 
muscle from above, overlapping the others and 
increasing the intensity in the apex.' At least 6 mg. 
was placed above the clavicle for prophylactic 
reasons, in the absence of gross manifestations of 
cancer there. Results had shown, in 148 patients, 
five-year results closely corresponding with those 
of surgery. No attempt had been made in this series 
to dissect the axilla—which often failed, and did 
more harm than good. 

Dr. W. M. Levitt dealt with X ray treatment as 
carried out at St. Bartholomew’s Hospital—a modi- 
fication of the glancing or skimming method introduced 
independently by Finzi and Holfelder. They had 
two plants; in one they used 200 kv. at 8 ma. at 
40 om. f.s.d., the output being 25r. a minute. Appli- 
cator openings measured 27X18 cm. In the other 
plant they used 320 kv. at 50 cm., producing 15r. per 
minute. Powder had been found better than wax 
for secondary radiating purposes; it must have a 
specific gravity of 1 and must have such coherence 
as to be mouldable. A mixture of sodium bicarbonate, 
two parts, to one part of Fuller’s earth was used, 
sewn into mackintosh bags. For the anterior field 
one edge of the applicator rested on the midline of 
the chest and protective rubber was laid over the 
chest, humerus, and applicator mouth to limit the 
field. The posterior field was difficult and important. 
The applicator entered from behind the axilla, so as 
to irradiate the axillary contents. The ray must be 
pointed slightly upwards. There was deficient 
irradiation below and above the clavicle from these 
two fields, and this was compensated for by a third 
field from above the shoulder. The applicator for 
this field was 5 om. shorter than the required focal 
skin distance. The dosage was so arranged as to 
make the irradiation of the whole area uniform. 

The treatment took just under three weeks, one 
field only being treated on any one day and treatment 
given daily. The total dosage to the anterior and 
posterior fields was 1800 r. each and 1600r. to the 
supraclavicular field. On the other plant the dosages 
were 2100r., 2100 r., and 2000 r. over a period just 
under a month. In the delto-pectoral region there 
might be a deficiency if the arm was very mobile, 
but otherwise irradiation was uniform. The tissue 
dosage was about 2500 r. or 2900 r. everywhere. 


SOCIETY OF RADIOTHERAPISTS 


[FEB. 29, 1936 481 


Dr. RALSTON PATERSON described the three main 
techniques in use in Manchester: amputation plus 


radium implantation, radium treatment only, and 


X ray treatment alone. In so far as the radium 
implant was combined with a radical amputation at 
the time of operation, the first of these techniques 
legitimately came within the scope of the discussion. 
The general idea underlying this method was to 
irradiate all the gland-bearing areas just beyond the 
actual wound zone, but to avoid any implantation 
into the wound itself. Such gland areas included 
the apex of the axilla, the supraclavicular region, 
the intercostal spaces, and an implant extending 
down the rectus sheath from the wound. Although 


theoretically sound, he was doubtful whether the 


method actually improved the results of surgery to 
any greater extent than could be achieved by a 
radium implantation alone. The second method in 
use was called a Keynes’s implant, and followed, with 
certain modifications, the original technique pub- 
lished by Mr. Keynes, a technique which the speaker 
considered a definite contribution to radiotherapy. 
The modifications had been introduced in order to 
achieve a complete implantation of the whole 
mammary gland, to amplify implantation of the apex 
of the axilla, and to extend the scope of the inter- 
costal implant. In Manchester they had not met 
with any misadventures as a result of the retro- 
clavicular implant used to reach the upper part of 
the apex of the axilla. 


Dr. Paterson then presented an analysis of all 
published figures showing the various results of 
surgery, radium, and X rays in treatment of breast 
carcinoma, the striking point of the analysis being the 
unusually good results which appeared to be obtained 
in a considerable number of foreign clinics by means 
of X rays alone. As a result, in Manchester they 
had been developing an X ray technique pari passu 
with the radium technique. Several different field 
arrangements were used, all of them based on the 
fundamental tangent principles, the dose given 
amounting to some 4000 to 4500r. throughout the 
whole breast, and the reaction being carried to the 
stage of a vigorous moist desquamation. A slide 
was shown illustrating the very definite white blood 
count drop occurring as a result of intensive radiation 
therapy. The drop ‘was most marked in the 
lymphocyte count. 


Dr. FRANK ELLIs said that in Sheffield Mr. Keynes’s 
technique was followed, except that the axillary dose 
had been found too large, leading to skin atrophy 
and late reactions. He had therefore started irradiat- 
ing this area with needles in two planes, one in front 
and the other behind, 600r. being given to each 
field when the patient was subsequently to ungeree 
operation. 

Dr. DouGLas WEBSTER said he had dealt with 
350 primary cases and some patients remained 
perfectly well after ten years although their dose of 
radiation would now be considered quite insufficient. 
No doubt sensitivity varied in different individuals. 
He considered that the Finzi technique did not 
bring in the axilla satisfactorily and he supplemented 
it by an American method, using three or four fields 
converging on the breast. It was important to avoid 
damage to the heart when treating cancer on the 
left side. 

Dr. N. S. Finzi said that the maximum dose with 
the three-field method was delivered where it was 
most needed: in the apex of the axilla and just 
above the clavicle. He sometimes rotated the centre 
axis during the course of treatment so as to get even 


‘482 THE LANCET] 


irradiation. He thought that radium had a more 
marked effect on a growth than X rays, especially 
if it were a resistant growth. One case had recurred 
after 200 kv. irradiation and had cleared up again, at 
any rate temporarily, with 300kv. That was why 
he was trying to push the voltage still further. 

Dr. J. S. FULTON thought that the problem of 
irradiation of intercostal spaces was best met by 
using a field 15x7cm. which would embrace the 
intercostal region on both sides. 


The PRESIDENT pointed out the importance of 
using any method, even splinting, to keep the patient 
still while treatment was going on, and said that his 
aim was to deliver 3000r. in ten days and 4500r. 
in three weeks according to size. He usually 
employed only two fields, but sometimes four con- 
verging on a large breast and five in the axilla. If 
any appreciable growth was left after treatment of 
this kind he treated it by interstitial radium. 


ROYAL SOCIETY OF MEDICINE 


SECTION OF RADIOLOGY 


AT a meeting of this section held on Feb. 21st 
the chair was taken by Dr. C. G. TEALL, the president, 
and Prof. H. CHaout (Berlin) read a paper on some 


Recent Developments in X Ray Therapy 


He discussed short-distance low voltage high dosage 
therapy, designed to replace radium. Its superiority 
was due to the physical properties rather than to the 
quality of the rays. A voltage of 60,000 volts with a 
two-inch focal skin distance was employed. The 
small focal distance was obtained, he said, by using 
a monopolar X ray tube of unusual design. At 
3 cm. depth the intensity was still about three-quarters 
that at the surface. The aim was to give a high dose 
to the disease centre while sparing the surrounding 
and underlying healthy tissue to assist in the cure. 
Ulcerated and infiltrated and deep-seated tumours, 
not amenable to other treatments, could be treated. 
For cancer of the rectum, the lower part of the 
sacrum must be removed and the rectum opened up. 
Four cases had been so treated and all remained free 
of primary symptoms. Prof. Chaoul showed statistics 
of cancer of the lip, skin, and mouth treated by his 
method. Of 109 cases in the skin, 93-5 per cent. had 
given success; for cancer of the lip the figure was 
88-5 per cent. of 26 cases; for the oral cavity 
(28 cases), 53-6 percent. ; and of 12 melanoblastomata, 
83 per cent. had recovered. Sixty-three per cent. of 
sarcomata also had been successfully treated. The 
method was contra-indicated in tumours of large size 
or with many metastases, or after intensive X ray 
or radium treatment by other techniques. l 

Prof. Chaoul illustrated his technique by a cine- 
matograph film. This emphasised the sharp energy 
gradient, the area of irradiation limited to 9-25 sq. cm., 
the daily fractionated dose of 350-500 r., each appli- 
cation lasting only two to four minutes; and the 
total dosage of 7000-8000 r. spread over two or three 
weeks. It also showed the applicators and the results 
of treatment in a number of cases. In conclusion, 
he pointed out that there was not enough radium to 
treat all the patients for whom it was indicated, but 
this method was available to all countries, even the 
poorest. 

Dr. J. F. BROMLEY sketched the history of short- 
wave therapy and considered the pathological aspect 
of the problem. There was no difference between 


ROYAL SOCIETY OF MEDICINE : RADIOLOGY 


[FEB. 29, 1936 


the effects of varying wave-lengths; the important 
factor was the energy absorbed per c.cm. and the 
time spacing. The claims made by the supporters 
of this technique were: (l) The distribution of 
radiation was similar to that from surface applicators, 
and many patients could be treated in a short time 
with less cost than byradium. (2)Thehealthy tissues 
were spared, and the total dosage was of little 
importance provided the fractioning was kept up 
properly. Codperation between radiologist, patho- 
logist, and physician was essential. The limit of 
the practical depth dose was 14-2 cm. At first 
sight the preservation of healthy tissue seemed very 
attractive. Much work had been done on the effect 
of radiations on cancer cells, but less on the normal 
cell. Satisfactory healing depended on radio- 
sensitivity, good blood-supply, and healthy sur- 
rounding tissue. If, however, Sampson Handley’s 
theory were true, it would be desirable to irradiate 
surrounding tissues as widely as possible. The giant 
cells which appeared around tumours attacked 
cancer cells on one side and were attacked by reticulo- 
endothelial cells on the other side. The effect of 
radiation on them was not fully understood; they 
seemed to show no reaction. It seemed therefore 
that the natura] defence against cancer depended on 
several factors and that the effects even of heavy 
radiation resembled closely those of the body’s own 


defence mechanism, and were not so damaging as 


might be imagined. 

Another argument in favour of the Chaoul tube, 
however, and one insufficiently stressed, was its great 
convenience. Of 70 cases treated in Dr. Bromley’s 
department at the General Hospital, Birmingham, 
22 had recovered and 37 improved—results so good 
that the method was now a routine for rodent ulcer, 
only one sufferer from which had become worse. 
The method was also satisfactory for carcinoma of 
the vulva. Skin recurrences after cancer of the 
breast were being treated, with gratifying results. 
Doses comparable with those of radium therapy were 
well tolerated. The method filled a very definite 
and useful place in radiotherapy and offered a 
valuable sphere of research. It hardly replaced high 
voltage radiation, and did not absolve the radiologist 
from giving the usual care to glandular and other 
areas. 


Prof. J. WoopBURN Morison said that the 
apparatus he used was simple and easy to handle 
and gave no trouble, whereas high voltage tubes gave 
a great deal of anxiety and trouble and were not. 
really practicable for routine work in a hospital. 
The million-volt plant seemed to work better than 
the 400-volt. Clinical results from low voltage 
therapy could undoubtedly be obtained. It was 
interesting to find the absorption so comparable 
with that from a radium applicator and even some- 
what comparable with the one-gramme bomb. Work 
at the Cancer Hospital confirmed Prof. Chaoul’s 
results, but the problem of metastasis remained. 
Where there were metastases there was eventual 
failure of any method. The problem of cancer 
therapy was the problem of accessibility. Some 
observers thought the stomach and cecum could be 
exposed, without danger, long enough for the 
necessary irradiation. One day perhaps the esophagus 
would also be exposed. The real justification of 
radium bombs would only be established when they 
could treat cases at depth—through the abdominal 
wall, for instance. Education of the public was still 
necessary in order that cases might be treated earlier. 
A great deal of research was also needed. The low 


THE LANCET] 


voltage apparatus would be especially suitable for 
tropical regions, where a great deal of skin cancer 
was encountered. Prof. Morison concluded with a 
review of a number of successfully treated cases. 


Dr. DouGLtas WEBSTER expressed his interest in 
the method, and asked Prof. Chaoul if it had been 
used in benign conditions, for example, the treatment 
of tonsils. | 


_ Prof. CHAOUL, replying through Dr. E. W. Twining, 
said he had used the method for tonsils, a two-minute 
exposure every day for four days under local anzs- 
thesia yielding excellent results. 


MEDICAL SOCIETY OF LONDON 


AT a meetmg of this society on Feb. 24th Prof. 
G. E. Gasxk,.the president, took the chair, and a 
discussion on : 


B. coli Infections of the Urinary Tract 


was opened by Lord HorpEr. Additional knowledge, 
he said, justified another discussion on this condition, 
which was common and intractable. The discussion 
would be limited to xtiology and treatment, which 
went hand in hand. Lesions of the urinary tract fell 
roughly into two main categories: foci of sepsis 
and obstructive anatomical defects. It was vitally 
important to realise that in both categories the 
lesion might be small and easily overlooked or thought 
too trivial for treatment, but in this domain nothing 
must be regarded as trivial. It was not likely that 
the last word had been heard either of the incidence 
or of the variety of these lesions. The urgent thing 
was to recognise them and to hope that more and 
more of them would be remediable. It might be 
that by reducing the load of possible infection it 
would prove possible to cut in between the point 
of non-infection and of infection. There might be 
a sort of threshold of infection determined by con- 
genital defects and by residual acquired pathological 
defects. Congenital defects might be absolute or 
relative. The discovery of certain congenital abnor- 
malities which predisposed to infection was disturb- 
ing, as was also the realisation that the renal calyces 
had sphincters and that there was a peristalsis and 
a potential antiperistalsis in the ureters. In fact it 
was disconcerting as well as disturbing, for here 
were the materials for functional departures from 
normal. A prolonged spasm of one of the sphincters, 
or persistent antiperistalsis, might cause retention, 
which in its turn might prove an important factor 
in inducing infection by coliform organisms. There 
was general agreement that thorough drainage must 
be established if the urinary tract was to be guarded 
against infection from foci such as the appendix, 
gall-bladder, and diverticulitis. The tendency to 
infection from- general gastro-intestinal defects, 
such as enteroptosis, undoubtedly existed but the 
mechanism was less certain. Agreement ceased 
even on the premiss that a causative relation existed 
between urinary infections and colon stasis and con- 
stipation. Efforts to act rationally in assessing values 
for the relationship between intestinal stasis and 
other diseases had been hopelessly countered during 
the past 20 years by that wave of pseudo-scientific 
opinion which linked the hygienic salvation of the 
race irrevocably with an artificial and forced evacua- 
tion of the bowels several times a day. There had 
been recently some refreshing and constructive 


MEDICAL SOCIETY OF LONDON 


[FEB. 29, 1936. 483 


criticisms of this attitude. Dr. Geoffrey Evans had 
observed that diarrhoea was much more often com- 
plicated by pyelitis than was constipation. 

` There was general agreement on most points of 
the treatment, but the majority of writers said that 
fluids must be pushed from the first, and the speaker 
regarded a distended and splashing stomach as a 
quite unnecessary addition to a very uncomfortable 
inflammation.. It was no use attempting to flush 
the apparatus until the renal tissue was ready and 
willing to be so treated. The generally accepted 
indications for a thorough investigation of the urinary 
tract were: (1) the general survey suggests that a 
lesion is present; (2) an acute infection threatens 
to become chronic despite thorough medical treat- 
ment; (3) there are intermittent symptoms despite 
a medical routine calculated to keep the general - 
health sound and the bowel function at its best; 
(4) medical treatment fails and the condition becomes 
chronic. In the chronic case the aim must be the 
production of a soft, formed stool of reasonable 
bulk. Milk was to be avoided even in acute cases, 
but apparently it was the casein residue which did 
the harm, since junket and cream did not have the 
same baleful effect. Game, rechauffé dishes, and — 
salted meats and fish were to be avoided, and eggs 
and butcher’s meat excluded for a time. An increas- 
ing bulk of soft celluloses (sieved root vegetables 
and dried fruits) was added. If laxatives were 
needed. agar-agar or paraffin was suitable. Lord 
Horder had not seen any lasting good results from 
colon irrigation, and his experience of sour milk 
and Bacillus acidophilus had been disappointing. 
He still advocated antigen therapy in certain chronic 
and intermitting cases. 


DISCUSSION 


Dr. S. A. MILLEN uttered a plea against the hap- 
hazard use of acidification therapy. It was, he said, 
practically important to ascertain in each case whether 
the infection was ascending or blood-borne. The 
normal tract would drive out organisms by flushing ; 
acidification would help even the abnormal tract to 
free itself of infection. The difficult task was, how- 
ever, to prevent reinfection. In rather more than 


.50 per cent. of children and 40 per cent. of adults 


urinary obstruction, with consequent stasis, was 
associated with infection. Inflammatory foci 
were either intrinsic—e.g., tuberculosis and neo- 
plasm—or extrinsic, including such causes as an 
infected cervix. This predisposed to urinary tract 
infection for two reasons: the female external meatus 
was constantly bathed in bacterial secretions, and, 
secondly, the urethra and bladder base were in a. 
state capable of providing a suitable nidus for infec- 
tion. The analogue in the male was the infected 
prostate. Instrumentation, whether by the urethra 
or the ureter, was always unpleasant and dangerous, 
and should only be used if a case had lost ground 
under adequate medieal therapy; ureteric stasis 
was one indication, and another was an infective 
process due to incomplete emptying of the bladder 
behind a large prostate or incomplete emptying 
of a renal pelvis, when, drainage was urgently 
called for. 


Dr. CUTHBERT DUKES remarked that if B. coli 
was introduced deliberately into the bladder of 
100 healthy people only a small proportion would 
develop the infection. It would be interesting and 
instructive to discover why some persons became 
infected and others not. Such an experiment was 
provided daily by patients suffering from post- 


484 THE LANCET] 


operative retention of urine lasting for three or four 
days. Bacteria were almost always present in the 
stagnant urine. It did not matter whether they 
were introduced by the catheter or by the kidney or 
lymphatic channels. Observations on 214 such‘cases 
showed that infection was accompanied by a sudden 
rise of temperature about the fourth day. About 
46 per cent. developed B. coli infections: 59 per 
cent. of the women and 36 per cent. of the men. 
Urinary infections depended on defective function 
of the urinary organs, and any factor which disturbed 
the normal mechanism of urination would increase 
the likelihood of the infection. 


Mr. H. P. WINSBURY-WHITE stated that all chronic 
cases of urinary tract disease tended to become 
complicated by B. coli infection but a large group 
‘remained which did not fit into this category. In 
the former group a mixed infection often preceded 
the coliform infection—i.e., by staphylococci, strepto- 
cocci, and diphtheroid bacilli. This prepared the 
ground for the implantation of the coliform growth. 
Chronic frequency in women sometimes developed 
into acute pyelonephritis and sometimes settled 
down into a chronic B. coli infection. A single 
examination often revealed a sterile urine but a 
second test might well show a mild infection. In 
many cases of staphylococcal abscess of the kidney 
the urine was sterile or contained only B. coli. Caution 
was therefore necessary in interpreting a sterile 
urine. Cystoscopy and urethroscopy frequently 
gave the lie to the negative urine test. Several 
groups were recognisable among children—e.g., the 
B. coli infection of the urinary tract which super- 
vened upon a respiratory tract infection by cocci. 
Gastro-intestinal disease, impetigo, and other chronic 
skin lesions often set up a chronic infection, and 
persistence of infection in these cases called for 
investigation of the urinary tract for abnormality. 
The commonest finding was dilatation of some 
part of the tract. Phimosis, balanitis, and other 
local conditions of the tract in children might be 
responsible. 

Dr. O. E. J. McOustra confessed to bewilderment. 
He had considered, he said, that the origin of the 
B. coli infection must lie in the alimentary rather 
than the urinary tract, but the results of a series 
of test-meals in cases of B. coli infection had been 
completely negative and no common factor had been 
discernible. One remarkable case in a man of 35 
with chronic nasal and pharyngeal catarrh who had 
an acute attack of B. coli infection had been com- 
pletely and finally cured with potassium citrate. 


. Mr. E. M. RicHes maintained that the first essen- 
tial of successful treatment was accurate diagnosis. 
Acidifying remedies, particularly mandelic acid, gave 
excellent results in some acute and serious cases, the 
patient showing an immediate response provided 
that there was no anatomical abnormality of the 
urinary tract. 

Dr. P. H. Manson-Baur said that B. coli pyelitis 
often accompanied malaria and was a consequence 
of it. More frequently it was a sequel of bacillary 
dysentery. An investigation he had performed during 
the war showed that some 80 per cent. of chronic 
cases of bacillary dysentery also had B. colt infection, 
and he had traced the course of the infection from 
the bowel wall through the glomeruli of the kidneys— 
a proof that the disease was blood-borne. He had 
also isolated the organisms from urine or blood 
cultures—the true B. coli of Escherisch and its 
variations. He had cured with mandelic acid what 
he considered a unique case of severe an«mia due 


LIVERPOOL MEDICAL INSTITUTION 


(FEB. 29, 1936 


to B. coli infection in a man who had lived in the 
tropics. Abnormality in the tract must, of course, 
be eliminated. It was not necessary to produce 
acetone and oxybutyric acid in order to succeed. 
Albumin and hyaline casts were not necessarily an 
indication for stopping or modifying the treatment. 
There was no foundation for the belief that mandelic 
acid therapy, even if prolonged for two or three 
weeks, led to anything like chronic nephritis. 


Dr. JOUKES maintained that, whatever the diffi- 
culties might be in manufacturing a bacteriophage 
effective against streptococcal strains, it was fairly 
easy to produce one that would combat the coliform 
group. It was necessary to find a specific phage ; 
the stock commercial virus phage usually gave no 
result at all against B. coli. The phage was now 
generally instilled into the bladder and left as long 
as the patient could retain it. 


Sir RUSSELL WILKINSON described the case of a 
married woman with chronic pyelitis who had been 
unsuccessfully treated with alternate alkali and 
hexamine mixtures and had aborted a recent preg- 
nancy. She was now in the nineteenth week of treat- 
ment by mandelic acid. He had hoped to be able 
to report that she had been successfully delivered 
of a normal baby, but her labour was in fact due 
that evening. Whenever the acid was withheld the 
urine had become offensive. No renal elements had 
been found throughout the course. 


LIVERPOOL MEDICAL INSTITUTION 


AT a meeting of this institution on Feb. 6th, with 
Mr. G. C. E. Stimpson, the president, in the chair, 
a paper entitled 


Kidney Pain and its Treatment by Renal 
Denervation 


was read by Mr. J. B. OLDHAM. Section of the 
renal nerves, he said, resulted in increased flow of 
the blood to the kidney, secretion of a larger quantity 
of urine of low specific gravity (comparable to that 
of ordinary diuresis), relaxation of the sphincterie 
muscles surrounding the papille and calices and 
uretero-pelvic junction, and anesthesia of the kidney. 
Animal experiments and operations on the human 
kidney had proved that denervation has no untoward 
effects, and the operation had been suggested for the 
treatment of nephralgia, essential hæmaturia, non- 
mechanical hydronephrosis, reflex anuria and oliguria, 
certain forms of nephritis, arterial hypertension, and 
early renal tuberculosis, and also as a substitute for 
nephropexy and to prevent the re-formation of 
calculi after nephrolithotomy. The results of 
Mr. Oldham’s own operations and those of Papin, 
Harris, Hess, and others showed that, whatever the 
cause of renal pain, removal of the nerve-supply 
of the kidney made relief entirely probable. Non- 
mechanical hydronephrosis, he suggested, was due 
to overaction of the sphincters of the renal 
calices and pelvis, and he showed. radiograms 
demonstrating cases in which as the result of 
denervation pain had disappeared, renal function had 
improved, and the normal shape of the pelvis and 
calices had been regained. He agreed with Muschat 
that essential hematuria was often due to congestion 
of the renal papillae by overaction of the sphincteric 
muscles surrounding their bases, and described two 
such cases in which pain and bleeding had been 
cured by denervation. Mr. Oldham held that the 


THE LANCET] 


usual operations for nephroptosis, in which the 
kidney was anchored to the last ribs, were unphysio- 
logical; for normally the kidney, unlike the ribs, 
moved downwards on inspiration. The results were 
not infrequently good, but the benefit was due to the 
surgeon having unintentionally denervated the kidney 
when he was fixing it. He himself operated only 
when there was evidence of pelvic stasis and after a 
prolonged trial of conservative measures, and he would 
not consider operation where there was general 
visceroptosis or marked neurasthenia. But in suit- 
ably selected cases denervation seemed to offer a 
certain cure. He had performed denervation seven 
times when removing calculi from the kidney in the 
hope that the consequent diuresis might lessen the 
chance of recurrence. The nerves could be sectioned 
most certainly, simply, and safely where they 
surrounded the outer third of the renal artery ; 
none ran in front of the renal vein and it was 
unnecessary to strip this aspect of the vein. 

Mr. Oldham always operated under spinal anesthesia, 
for no other form of anesthesia gave the same access 
to the renal pedicle. He insisted on the importance 
of stripping the pedicle towards the kidney and 
suggested that the vein should be separated from the 
rest of the pedicle and retracted to one side. The 
nerves should be excised over a distance of about 
one inch, and he thought no attempt should be made 
to strip either the branches of the artery or the pelvis 
up to the hilum of the kidney since this was 
unnecessary and liable to cause troublesome bleeding. 
If aberrant renal vessels were present they too would 
be accompanied by nerves, which must accordingly 
be excised, but it should be remembered that the 
renal arteries were end-arteries, so that ligature of an 
aberrant artery inevitably led to partial necrosis 
of the kidney. After the vessels of the pedicle had 
been stripped as clean as possible they were painted 
with 10 per cent. carbolic, which not only destroyed 
the finer nerve-fibres but whitened any large fibres 
which had not already been divided and so allowed 
the surgeon to pick them up and divide them. After 
operation there was severe pain for two to three days 
and for the same time the amount of urine was 
diminished. After a few days the urine increased 
and examination showed that the denervated kidney 
was secreting more than the normal one. The 
excretion of indigo-carmine—usually delayed before 
operation—was also improved. These urinary 
changes gradually lessened and after 3-6 months 
the secretion of the two kidneys was usually equal. 
In every case before operation retrograde pyelography 
reproduced the pain of which the patient complained, 
even on the injection of small quantities of opaque 
medium. In every case after operation the kidney 
was quite insensitive to overdistension and 30—40 c.cm. 
could be injected without the patient being conscious 
of it. Within 6-12 months, however, there was 
a slight recovery of pelvic sensation; it was still 
impossible to produce typical renal colic with nausea, 
but the injection of large quantities into the renal 
pelvis caused an ache in the loin. No patient 
had had any recurrence of symptoms. 

In all Mr. Oldham had performed renal denerva- 
tion 40 times, but cases treated during the last year 
and patients on whom other operations had been 
performed on the kidney at the same time as the 
denervation were omitted from the discussion of the 
results. On the basis of the results obtained in 
28 remaining cases, he contended that if cases were 
properly selected and an adequate denervation was 
performed, relief of the patient’s symptoms was 
certain. 


LIVERPOOL MEDICAL INSTITUTION 


[FEB. 29, 1936 485 


Mr. C. A. WELLS agreed whole-heartedly with what 
Mr. Oldham had said. He had himself performed 
the operation of sympathectomy on the kidney some 
30 times, and had on the whole been delighted with 
the results. There could be little doubt that it 
offered hope of relief to many sufferers for whom 
otherwise little or nothing could be done. Careful 
selection of cases, however, was very necessary, and 
it was essential to exclude, by every possible means 
of investigation, other causes of renal pain. Like 
Mr. Oldham, he had relied mainly upon the reproduc- 
tion of pain by means of retrograde pyelography ; 
patients were usually able to express a definite 
opinion upon the resemblance or otherwise of this 
pain to that of which previously they had complained. 
Having established the diagnosis it was his custom 
to discharge his patients for 3—6 months’ observation 


. and treatment, after which, if their history remained 


consistent, the investigation was repeated and the 
operation performed if the indications seemed sound. 
In cases of hydronephrosis with gross dilatation 
he had employed a modification of Thomson- 
Walker’s plastic operation in conjunction with 
sympathectomy. 


Misleading Cases 


Dr. S. Barton HALL read a paper entitled Mislead- 
ing Cases or Psychological Investigation as a Diagnostic 
Measure. He had arrived, he said, at two general con- 
clusions : first, that clinical examination at the hands 
of the patient’s own doctor was often difficult to make 
effective in the nervous patient, owing to a mistaken 
and misleading modesty, if not actual though 
unintentional concealment, on the patient’s part; 
secondly, that the time had passed when the physician 
relying upon clinical acumen alone could feel, with 
any degree of assurance, that as a result of thorough 
examination of the patient he had excluded organic 
factors. Three postulates must be satisfied before 
a diagnosis of functional disease could be made: 
(1) the case must prove negative to all laboratory 
and clinical investigation ; (2) a positive psychogenic 
basis must be found; (3) the psychogenic factor 
must bear direct relation to the patient’s symptoms. 
Even were all these conditions fulfilled, such a 
diagnosis could not be made with certainty. The 
speaker thought that psychological investigation 
might assist in diagnosis from two aspects—notably 
from the knowledge gained with regard to types of 
individual and from the result of detailed investigation 
of the particular case. He pleaded for the subjective 
method in investigation since it might provide 
evidence of organic disorder at a much earlier stage 
of the disease. Dr. Barton Hall gave the results of 
psychological investigation of a series of 1000 cases 
referred in the routine manner—500 from hospital 
and 500 from private practice. In all, 67 (15 per 
cent.) of these ultimately proved to be organic in 
nature, the number of hospital cases (44) being 
approximately double the number of private cases 
(23). | 


ONE HOSPITAL SERVICE FOR MANCHESTER.—The 
scheme of codperation between the voluntary and 


municipal hospitals of Manchester, prepared by the Joint 


Hospital Advisory Board, was outlined by Mr. Walter 
Cobbett at the annual meeting of the trustees of the 
Royal Infirmary. The municipal hospitals are to be 
divided into medical and surgical units and are to have 
access to the honorary physicians and surgeons at the 
voluntary hospitals. This idea of a common staff should, 
he said, lead to a better distribution of patients and to the 
reduction and perhaps the abolition of waiting-lists. 


486 THE LANCET] 


[FEB. 29, 1936 


REVIEWS AND NOTICES OF BOOKS |. ' 


Post-graduate Surgery 


Vol. I. Edited by Ropney Marncor, F.R.C.S. 
Eng., Senior Surgeon to the Royal Waterloo 


Hospital. London: Medical Publications Ltd. 
1936. Pp. 1742. 70s. (£9 9s. per set of three 
volumes). . 


THouGH the undergraduate student has admirable 
text-books to choose from, the graduate who seeks 
more detailed information about the management 
of surgical cases must consult modern epitomes or 
search through monographs and periodical literature 
for the solution of his specific problems. The aim 
of this work is the collection of such material in a 


readily accessible form wherein senior resident . 


officers, candidates for the F.R.C.S., medical officers 
in the fighting services, and others who desire to 
keep abreast of the modern developments in surgery 
‘may find the guidance which they need in the prac- 
tice of their craft. As Lord Moynihan points out in 
a graceful introduction, there is a real call for such 
a book, and the editor is to be congratulated upon 
the choice of distinguished collaborators whose 
combined experience covers the whole range of 
surgery, including the care of the patient before and 
after operation. 

The first of the three volumes to reach us is devoted 
almost entirely to abdominal surgery, but it also 
contains a valuable section on anesthesia by C. 
Langton Hewer whose comments on the choice of 
anesthetic for operations in special regions are most 
helpful; also chapters on X ray diagnosis in alimen- 
tary and urinary tracts by H. Cecil Bull, and on 
radiotherapy by Stanford Cade and Malcolm Donald- 
son. It is noteworthy that Dr. Bull has confined his 
attention entirely to the interpretation of radio- 
grams without supplying any details, even when 
cholecystography and pyelography are under dis- 
cussion, about the technique of administering the 
appropriate opaque substances. It is doubtless 
assumed that the graduate will be familiar with such 
matters; but he would probably be grateful for a 
reminder. 

An outstanding feature of the main part of the 
work is the chapter by W. Ernest Miles on the rectum 
and anus, but 1200 pages are allocated to the surgery 
of the upper abdomen. Here the coöperation of 
A. F. Hurst and R. Sleigh Johnson on the medical 
side has been wisely enlisted in the chapters on the 
stomach; and the contribution by A. J. Cokkinis on 
intestinal obstruction is deserving of special praise. 
This part of the work might have been improved by 
careful planning, judicious exclusion of non-essentials, 
and concise diction ; there are too many “lists” of 
the kind favoured by the experienced examination 
candidate, which are of value chiefly when they are 
compiled by himself, and there is some lack of balance 
in the space allotted to the various organs. The 
stomach and duodenum occupy 550 pages, while 
diseases of the colon are dismissed in 30, volvulus 
and diverticulitis being allotted barely a page apiece. 
The chapters on ileus and on Egyptian splenomegaly 


are redundant, and this is not the only example of. 


overlapping and repetition. 

The opinions expressed by the several authors are 
in accord with the best surgical teaching, and this 
must be the ultimate criterion by which the work 
will be judged. It is specially to the credit of the 
editor that very little has been omitted, but it is 
not always easy to find the reference to a given 


subject. Alkalosis, for example, is mentioned only 
once in the index in reference to infantile pyloric 
stenosis, though the more important occurrence of 
alkalosis in adults receives due consideration in the 
section on the pre-operative treatment of peptic 
ulcer. The illustrations are well reproduced, but the 
book might well have been shortened by omitting 
a large number of pictures with which every 
undergraduate is quite familiar, and many others 
which show in unnecessary detail the steps of 
operations clearly explained in the text. It is to 
be hoped that the editor may be persuaded in future 
editions to improve an already good piece of work 
by ruthlessly cutting down redundant and unneces- 
sary matter so that it may resemble more closely the 
‘friendly book of reference” envisaged in the 
introduction. 


Disorders of Metabolism 


Diagnosis and Treatment. By JAMES S. MCLESTER, 
M.D., Professor of Medicine at the University of 
Alabama. London: Humphrey Milford, Oxford 
University Press. 1936. Pp. 318. 25s. 


METABOLISM is an elastic word and the term 
disorders of metabolism might be stretched to include 
the greater part of medicine. The first problem 
confronting the writer of a text-book on the subject 
is thus that of selection. He cannot steer clear 
of the pancreas, for instance, in considering 
disturbances of carbohydrate metabolism, but one 
hormone leads to another, and if he is not careful 
he wil end by writing a book on endocrinology. 
Prof. McLester has resisted this syren of modern 
medicine, however, and has held to his course. He 
has also discriminated between common and important 
conditions like diabetes and obesity, and mere 
interesting oddities like alkaptonuria. The British 
reader might perhaps feel that too much attention 
is devoted to gout, which seems to be following 
typhoid and the red squirrel into extinction in this 
country. Perhaps the prosperity associated with 
economic revival will give us back our tophi. 

In discussing obesity, a subject which can generally 
be relied upon to divide the profession into two 
opposing camps, the one composed of lean rationalists, 
the other of more rotund mystics, Prof. McLester 
steers an admirable middle course which should 
help to reconcile the two factions. His opinion 
that obesity causes direct cardiac damage will not 
be generally accepted. Exception must. also be 
taken to the statement that ‘‘chronic bronchitis 
and pulmonary emphysema are occasional accompani- 
ments of obesity, due in part to chronic pulmonary 
congestion of cardiac origin, and in part to the 
hindrance which the subcutaneous fat offers to the 
heat-regulating mechanism with consequent loss 
of protection against changes of temperature.” 
The gross pulmonary congestion of mitral stenosis 
does not give rise to emphysema, and it might also 
be argued that a generous lining of insulating fat 
might assist the heat-reculating mechanisms to 
maintain a constant internal temperature. However, 
there is much stil to be learnt about obesity. The 
insurance companies tell us that the stout are short- 
lived; the reason is a matter for speculation. The 
author rightly believes that the rational treatment 
should be a matter of diet and exercise, and he makes 
no reference to the drugs which have lately been in 
fashion, not always with happy results. 


THE LANCET] 


- The section on diabetes contains a great deal of useful 
information ; Prof. McLester is perhaps overbold in 
stating that the pituitary can be ruled out of the 
ætiology of the disease. The modern pituitary is 
burdened with many functions, real and reputed, 
but the fact that the diabetes which follows 
pancreatectomy in animals can be checked by remov- 
ing the pituitary leaves no doubt that the latter is 
intimately concerned. in normal carbohydrate 
metabolism. It cannot therefore be ignored in 
connexion with a state of abnormal carbohydrate 
metabolism, the cause of which is still unknown. 

This book should appeal to the physician who wishes 
to use the best available methods in investigating 
and treating cases of metabolic disease. It is 
essentially practical, and details 
and of the various diets are fully described. The 
clear type and the wide spacing Periyosn lines make 
for easy reading. 


Bacteriology in Relation to Clinical Medicine 


Theoretical and Applied. By M. N. De, M.B., 
M.R.C.P. Lond., Professor of Pathology, Medical 


College of Bengal, Calcutta ; and K. D. CHATTERJEE, 


M.B., Medical Registrar, Medical College Hospital, 
Calcutta. Calcutta: The Statesman Press. 1935. 
Pp. 599. 30s. 

THis text-book provides evidence of the strong 
root that pathological teaching has taken in Indian 
soil. Designed for senior medical students and for 
students of public health, it covers the necessary 
ground very well. Many of the most recent advances 
in bacteriology are described; these are selected 
with excellent judgment, and the student should 
never be in danger of losing sight of the wood for the 
trees. Naturally the requirements of Indian and 
other Eastern students are specially considered, and 
the student of tropical medicine will find this a 


useful text-book. Protozoology is not included, the 


authors recognising that it is too big and important 


a branch of tropical medicine to be treated as a side- 


line. It would seem ungracious to refer to the fact 
that the authors occasionally stumble over the 
niceties of English expression; at worst a venal 
fault—except that this takes away the finish of an 
otherwise admirable work. In a new work the small 
effort required to rectify this matter should be made. 
The work as a whole is a credit to Indian medical 
teaching and, we may add, to Indian printers and 
publishers, for the printing is excellent, and the 
profuse illustrations, many of them in colours, are 
beautifully reproduced. 


Endocrine Tumours | 
And Other Essays. By FREDERICK PARKES WEBER, 
M.A., M.D., F.R.C.P., F.S.A., Senior Physician to 
the German Hospital, London. London: H. K. 
Lewis and Co., Ltd. 1936. Pp. 207. 7s. 6d. 


WE welcome the publication of another volume 
-of the collected essays from the pen of so wise a medical 
scholar and philosopher as Dr. Parkes Weber. The 
main essay from which the book takes its title is 
written from a clinical standpoint, and is admirably 
lucid and informative. According to his habit the 
author is not content to quote merely from his own 
-experience but has drawn extensively from the 
literature, and no aspect of medicine, simple or 
complex, seems to have escaped attention. He 
writes with equal facility on ‘Change of air,” 
on the one hand and “The theory’ of the leu- 
k:emias as neoplastic mutations” on the other. 


REVIEWS AND NOTICES OF BOOKS 


of technique 


[FEB. 29, 1936 487 


The essay on _ thrombo-angiitis obliterans is 
especially interesting. It contains an account of a 
case he first described m THE LANCET before Leo 
Buerger’s publications on this disease. Dr. Weber 
has had this case under observation for 30 years, 
and has watched the patient gradually recover from 
the condition. With characteristic modesty he dis- 
claims all credit for the cure. Not all the essays are 
confined to strictly medical matters. He has some- 
thing interesting to say, for example, on Savagery 
in Myths and Dreams and on Pathological Money. 
The doctor, anxious to relax after a trying day’s 
work, will find this book sedative without being: 
soporific. 


Tropical Diseases 


An Epitome of Laboratory Diagnosis and Treatment. 
By Horace M. SHELLEY, F.R.F.P.S., M.R.C.S., 


D.T.M. & H. Eng. Government Pathologist, 
Nyasaland, East Africa. London: John Bale, 
Sons and Danielsson, Ltd. 1936. Pp. 81. 2s. 6d. 


In Dr. Shelley’s words “this little book is intended 
to supply the busy practitioner in the tropics with 
simple details concerning the laboratory diagnosis 
and treatment of diseases common to those climes. 
The essentials only are dealt with....” It is inevit- 
able that the author appears to have travelled beyond 
his reference in certain places and stopped short 
of it in others. For example, the certain diag- 
nosis of malarial infection depends essentially on 
the demonstration of plasmodia or pigmented leuco- 
cytes, and in the absence of both, no amount or 
variety of blood counting can help very much; on 
the other hand, the suggestion that the essential 
laboratory diagnosis of Japanese river fever rests 
upon the observation of the fact-that “‘there is a 
leucopenia’ under-estimates the complexity of the 
problem. The diagrams are poor, especially those 
on pp. 32 and 33, while those on pp. 14 and 64 give 
wrong impressions of the relative sizes of the objects 
depicted. In dealing with methods of treatment 
Dr. Shelley states that his object has been to empha- 
sise those of proved value rather than others of 
doubtful benefit, but unfortunately, as he himself 
says, details of therapy largely reflect personal bias 
rather than established principles. It is difficult to 
judge of the extent to which this book may prove 
useful. 


Diseases of the Skin 


‘Third edition. By F.C. KNow.es, M.D., Professor 
of Dermatology, Jefferson Medical College ; Member 
of the American Dermatological Association. 
London: Henry Kimpton. 1936. Pp. 640. 30s. 


SOME 14 pages of contents indicate the scope and 
arrangement of the subject matter of this book, 
which includes in addition to diseases of the skin 
those of the appendages and mucous membranes, 
and the eruptive fevers. Forty-five pages are devoted 
to syphilis, which in common with the dermatoses 
is illustrated by a generous number of clinical photo- 
graphs. The value of these from a diagnostic stand- 
point is somewhat discounted by their small size, 
sufficient perhaps for indicating the sites of pre- 
dilection, but not large or vivid enough to permit 
of a study of characteristic detail, The need for 
continuity of treatment in syphilis, which has been 
emphasised in America for some time past, receives 
due recognition, and a useful and easily compre- 
hended schedule is provided on pp. 460-61. Well 
managed too is the article on acne, Some points 


488 THE. LANCET] 


in the treatment based on theoretical considerations 
such as the potassium bromate content of white 
bread will be new to British readers, while the endo- 
crine treatment of persistent alopecia areata, which 
originated largely in the U.S.A., is quoted without 
extravagant claims. With such modern additions 
it is strange that in the discussion of ringworm of 
the scalp no mention is made of the thallium acetate 
method of epilation which in this country has proved 
most useful in children too young for treatment by 
X rays. It is not easy to place this work, for while 


NEW INVENTIONS 


[FEB. 29, 1936 


it may be regarded as too large for the busy practi- 
tioner, its scope is hardly sufficient to serve the 
purpose of a text-book. 


Guy’s HOSPITAL REPORTS is a quarterly journal of 
general medical interest directed to all professional 
classes. The annual subscription has now been 
reduced from £2 2s. to £1 10s. New subscribers are 
invited to communicate with the treasurer, Guy’s 
Hospital Reports, Guy’s Hospital, London Bridge, 
S.E.1. : 


NEW INVENTIONS 


OUTFIT FOR VASOTOMY 


WHATEVER. objections may be raised to vasotomy 
in the treatment of acute gonorrhea, few can object 
to it as a useful—I consider essential—measure 
for dealing with infection of the prostate and seminal 
vesicles 


and systemic complications arising there- 


~ N) 
FRERES 


eff} \ 
NY 
—— EE j 


—_ 
= © 


22 SWG 


from. An account of the outfit I use for the purpose 
may therefore be of interest. 
The needle (A) is so designed that it reduces to a 


minimum the possibility of damaging the intima of 
the vas. The point (Al) is blunt and has an outside 
bevelled edge, and in. from the point is a shoulder 
(a2) which prevents the introduction of the needle 
too far into the lumen. They can be had in four 


different calibres (21 to 24 swe). The needle is 
fitted by a bayonet joint to a 2in, length of rubber 
tubing (B) the other end of which fits by another 
bayonet joint to a 20 c.cm. Record syringe. This secures 
the absence of wobbling of the needle-point in the 
lumen of the canal. The bridge (C) through which 
the needle is passed still further secures steadiness 


wer wm wm ene we ew, 
> 


= RIIT TPAR., PN 
EA e 


UN 1 


Z ALLEN SMANBUAYS LO | 


and also holds the needle parallel with andat the 


The vasotomy clamp (D) will be found very useful 
for grasping and steadying the vas during incision, 
and is very easily manipulated. 

The outfit, which is neatly contained in a metal case 
(6in. by 3} in. by 1} in.) as shown in the illustration, 
has been made for me by Messrs. Allen and Hanburys 
Ltd. of Wigmore-street, London, W. 


_ J. F. Peart, F.R.C.S. Irel. 


i 23 SWG level of the lumen of the tube outside the skin surface. 
| 


AN IMPROVED TYPE OF GALVANOCAUTERY 


THE instrument here illustrated is particularly 
suitable for the treatment of warts, nevi, &c. The- 
holder is about the thickness of a pencil and has 
obvious advantages over the usual type of instru- 
ment. Instead of a press switch on the handle which 


in use often becomes unbearably hot, a pear switch. 
is fitted in continuity with the wire flex about 3 ft. 
from the cautery handle. This switch is held and 
easily operated by the left hand leaving the right 
hand free for the careful manipulation of the cautery 
point. 

The instrument has been made to my design by 
Messrs. Mayer and Phelps, New Cavendish-street, 


London, W. 
R. T. Brain, M.D., F.R.C.P. Lond. 


THE LANCET]. 


WATER METABOLISM IN EPILEPSY. 


[FEB.-29, 1936. 489 


THE LANCE 


“LONDON: SATURDAY, FEBRUARY 29, 1936 


WATER METABOLISM IN EPILEPSY 


Dvrine the past few years the field of epilepsy 
research has been inundated with water. ‘The 
flood reached its height a year or two ago, and, 
having damped the ardour of all but a few 
enthusiasts, has since been receding rapidly, so 
that it is now possible to take stock of the situation. 
Apart from a few damp patches, the field seems 
remarkably ‘unchanged. The idea that epilepsy 
might have something to do with water metabolism 


is not new. HIPPOCRATES is credited with the © 


statement that “ whoever is acquainted with such 
a change in men and can render a man humid 
and dry, hot or cold by regimen could also cure 
this disease—without minding purifications, spells 
and all other illiberal practices of a like kind,”’ 
LENNOX and CoBB have aptly paraphrased this 
as follows: “‘ Whoever is acquainted with physio- 
logy and can render a man acidotic, dehydrated 
and fully oxygenated could also repress this 
disease, without minding purification of nar- 
cissistic personalities, ritualistic empirical diets 
and all other illiberal practices of a like kind.” 
Both the original dictum and’ the paraphrase 
have been frequently repeated, in our own columns 
and elsewhere, and they stand repetition. But 
neither the Father of Medicine nor his interpreters 
would be pleased to see their words construed as 
meaning that epilepsy is due to waterlogging of 
the brain. It is true that modern research has 
confirmed the intuition of HiprocraTEs in that it 
has shown that anything conducive to dehydra- 
tion—be it starvation, a ketogenic diet, or drastic 
restriction of fluid intake—will often lessen the 
frequency of fits in the epileptic, and that on the 


other hand forcing of fluid will precipitate con- 


vulsions. But it is a perilous jump from these 
facts to the conclusion that epilepsy is an expression 
of disturbed water balance. It would be just as 
logical, or illogical, to assume that because alcohol 
induces a state of euphoria, schizophrenia is due to 
a deficiency of alcohol. Po. ae 

Another source of misapprehension is the fact 
that the convulsion itself gives rise to severe 
though temporary dislocations of physiological 
equilibrium in general and of fluid balance in 
particular. During and immediately after con- 
vulsions the body loses a considerable amount of 
extracellular fluid, and this temporary dehydration 
is naturally followed by a reactionary phase of 
water retention. .The body, in short, loses water 
during fits and recovers it in the intervals. But 
somehow this has been twisted round into the 
statement that the body retains extra fluid between 
convulsions and discharges it during the fit. 
Epilepsy is therefore due, argues the enthusiast, 
to retention of water. When he is reminded that 


convulsions are nota symptom. of cedema, he 
shifts ground and postulates a local oedema of the 
brain due to obstruction of venous return. Counter 
this with the fact that the tension .of cerebro- 
spinal fluid is normal in epilepsy and he falls back 
on local shifts of water between the neurone and. 
its environment. Surrounded thus by the cell | 
membrane he is safe from assault. Nevertheless 
the onus of proving his hypothesis rests on him ; 
and in point of fact no single metabolic aberration 
has yet been demonstrated to precede the epileptic 
fit. The normal activities of the neurone are 
responsive to changes in- its environment, and it 
is therefore no cause for surprise that its patho- 
logical activities can be similarly modified. 

But while informed opinion may remain 
unmoved by inconclusive evidence, it must always 
leave some impression on the general reader who 
has neither time nor training to assess it at its true 
worth. In consequence much of the time and 
resources of medical research workers must be 
spent in disproving “theories ” which ought never 
to have been propounded. A recent publication 
by Dr. H. S. TEGLBJAERG! is a case in point. 
Dr. TEGLBJAERG records the results of exhaustive 
investigation into all aspects of the relation of 
water metabolism to epilepsy, during the course 
of which he has carefully tested the data and 
criticised the conclusions of his predecessors. The 
net result of a great deal of expenditure of time, 
money, and labour is that there is no positive 
evidence to incriminate water metabolism in the 
etiology of epilepsy, but that forcing of fluids, 
associated with injection of pitressin, may be 
useful in diagnosing the disease. Such negative 
inquiries seem inevitable, but one is left with a 
feeling of regret that the resources at Dr. 
TEGLBJAERG’S command have had to be used to 
such small gain. : 


NON-SPECIFIC PROTEIN THERAPY 


ABOUT twenty years ago it was shown. that 
the course of typhoid fever is often favourably 
influenced by intravenous injections of ‘typhoid 
vaccine. It was soon found that similar results 
could be got with Bacillus coli vaccine? or 
albumose,* and non-specific protein therapy dates 
from’ these observations. A great variety of 
proteins has since been used to treat an even 
greater variety of conditions, both acute and 
chronic. The American Council on Pharmacy and 
Chemistry, believing that there are many pro- 
prietary preparations of this type‘ of unproved 
value, and that the indications for the use of non- 
specific protein therapy are not widely appreciated, 
has recently authorised the publication of two | 
informative articles on the subject. In the first 
of these CEC * provides a critical review of 
the whole field. The three proteins most often 
used in the United States are typhoid vaccine, 


* Investigations on Epilepsy and Water Metabolism. By H. 
Stubbe Teglbjaerg. Acta Psych. et Neurol. Suppl. Xi., 1936. 
? Kraus, R., and Mazza, S.: Deut. med. Woch., 1914, X]., 1556. 
? Kraus, R., Penna, J., and Bonorino, C. L.: Wien. klin. 
Woch., 1917, xxx., 869. 
t Lüdke, H.: Münch. med. Woch., 1915, lxii., 321. 
s Cecil, R. L.: Jour. Amer. Med. Assoc., 1935, CV., 1846. 


490 


boiled milk, and diphtheria antitoxin, the latter 
being employed not because of its antitoxic 
property but because it is an available form of 
horse serum. Ceci thinks it very unlikely that 
any of the proprietary remedies offered as sub- 
stitutes have any virtues not inherent in these 
substances, but the Gram-positive bacteria such 
as pneumococci are said to be less likely to cause 
febrile reactions than Gram-negative organisms 
such as typhoid bacilli, when given intravenously. 
It is essential, however, to distinguish sharply 
between the effects of intravenous and of intra- 
muscular or subcutaneous injections. The two last 
provoke comparatively mild reactions, and there 
are very few patients indeed who cannot safely 
be given them. On the other hand, though such 
injections do no harm, they very often do no good, 
and Crci believes that intravenous injection of 
typhoid vaccine is not dangerous, provided it is 
not applied to patients in a state of exhaustion, 
and that the first dose given is a small one. It 
is also wise to avoid treating patients who are 
known to be protein-sensitive, those who have 
active or quiescent pulmonary tuberculosis, and 
cases of congestive cardiac failure and hyper- 
thyroidism. 

It is extremely difficult to assess the merits of 
any form of therapy in chronic disorders, especially 
in those characterised by natural remissions. It 
is. therefore not surprising that opinions about the 
value of non-specific protein therapy in such 
conditions as chronic arthritis should be conflicting, 
though the balance of evidence is in favour of its 
trial, especially in early cases. Crci holds that 
the greatest usefulness of protein injections is in 
acute and subacute infections, and in these it is 
usually possible to be surer that benefit is being 
obtained. The method having been first applied 
to typhoid fever, there are numerous series of 
cases on record treated by protein therapy, and 
with great success. In pneumonia, although’ the 
statistical evidence is distinctly in favour of 
protein fever therapy in Group IV. cases, it is 
felt that this form of treatment is too drastic, 
especially as several fatalities have been recorded. 
In dementia paralytica malarial therapy holds a 
secure place, but although this is almost certainly 
a further example of protein therapy, there is as 
yet no certainty that injections of typhoid vaccine 
are equally efficient in bringing about a cure. In 
tabes dorsalis the results are less consistent, and 
in other diseases of the nervous system relief is 
the exception. Cec states that protein therapy 
should always be considered for cases of acute 
arthritis, especially for those that do not respond 
to salicylates. The treatment of inflammatory 
diseases of the eye—especially acute iritis, uveitis, 
keratitis, and conjunctivitis—is the subject of 
numerous reports claiming successful results. In 
gynecology, acute and subacute infections of the 
adnexa have often been treated by foreign proteins, 
and L. H. StuH er, of the Mayo Clinic, goes so 
far as to say that if he were limited to one method 
of treatment in salpingitis, it would be this. In 
the treatment of allergic diseases and dermato- 
logical conditions reports are more conflicting, and 


THE LANCET] 


‘ NON-SPECIFIC PROTEIN THERAPY 


[FEB. 29, 1936 


striking improvement should not be expected. 
Of especia] interest, perhaps, is the use of proteins 
in the treatment of diseases of the peripheral 
vessels, for which comparatively little can other- 
wise be done. G. E. Brown has described 
intravenous injections of typhoid vaccine as the 
best medical measure for the relief of the severe 
pain of thrombo-angiitis obliterans. N. W. BARKER 
prefers typhoid H antigen, which when injected 
intravenously produces fever with fewer rigors 
than typhoid vaccine. And though the suggested 
mechanism is not the same, it may not be 
irrelevant to recall also the impressive results 
obtained from the use of muscle extract .® 

A second paper, by HEKTOEN,’” deals in more 
detail with the changes which occur in the organism 
in response to foreign proteins. The benefit 
derived bears some relation, he believes, to the 
degree of the general reaction and of the fever. 
There is a dilatation of the vessels in the splanchnic 
area with contraction of the peripheral vessels, 
and it is this which gives rise to the rigors ; later 
this state of affairs is reversed. At first there 
is a leucopenia which is followed by a leucocytosis. 
Numerous other alterations occur in the various 
chemical constituents of the blood, such as an 
increase in the proteolytic and lipolytic enzymes. 
It is surprising that it has not yet been determined 
whether the normal antibodies and bactericidal 
constituents of the blood are increased in man in 
non-specific protein therapy, nor is it known 
whether in typhoid fever the production of specific 
antibodies is as great after typhoid vaccine has 
been given as after a non-specific protein. In 
some types of disorder, it may be, specific immune 
bodies are manufactured and assist the natural 
defences of the body ; in others it is possible that 
the leucocytosis is the important reaction, and 
in yet others the fever, which by giving rise to 
vasodilatation floods the infected or injured tissues 
with antibodies. In vascular disease it is certain 
that the degree of vasodilatation is of prime 
importance, and in a sense the treatment here is 
specific rather than non-specific. There obviously 
remains a wide field for further research, not only 
into the practical value of the method, but also 
into the processes underlying it. 


CONGENITAL GP.I. 


SINCE the advent of malaria therapy so much 
attention has been focused on acquired general 
paralysis of the insane that the inherited form 
of the disease has suffered relative neglect. At 
a meeting of the neurological section of the Royal 
Society of Medicine on Feb. 20th a clinical 
demonstration of cases of congenital G.P.I. treated 
at the Maudsley Hospital was therefore welcome 
and provided the basis for a lively discussion. 
Some 27 patients thus afflicted had been under 
the care of Dr. T. TENNENT during the last nine 
years. Of these 9 belonged to a group for whom 
no form of therapy offered any hope, some degree 
of amentia being present. In the remaining 18 


6e Sce Schwartzman, M.: THE LANCET, 1935, i., 1270. 
? Hektoen, L.: Jour. Amer. Med. Assoc., 1935, cv., 1765. 


THE LANCET] 


cases the child was normal until the development 
of the clinical picture of G.P.I.; of these, 14 had 
received malaria plus tryparsamide, with the 
result that 5 had improved to an extent which 
made them fit to remain at home and to assist 
in household duties—a result as gratifying as it is 
unusual; 4 had made slight improvement, 2 
remained stationary, 1 was in a mental hospital, 
and 2 had died. The incidence was the same in 
both sexes ; in 16 cases syphilis could be definitely 
traced to one or other parent, and in 7 one or other 
parent had G.P.I. (6 fathers and! mother). In 
one of: the families there were 3 juvenile victims 
of G.P.I. The diagnosis‘was made on a icurfold 
basis—history, mental picture, and the neuro- 
logical and serological findings all being considered. 
The treatment adopted in suitable cases consisted 
of induced malaria (8 rigors) followed by repeated 
courses of tryparsamide. The older the age of 
onset, and the shorter the time during which 
symptoms had been observed before steps were 
taken the more favourable appears to be the 
prognosis. 

Another series of treated cases was described 
by Dr. W. D. Nicot and Dr. E. L. HUTTON in 
a joint communication from Horton. Over a 
period of ten years they had 16 such cases (2 boys, 
14 girls) of whom 7 were dead. Asin the Maudsley 
series congenital stigmata were comparatively 
rare, the incidence of pupillary changes was 
extremely high, and slurred speech was common ; 
fits occurred in half the cases, but none had tabes. 
All but one of the cases had malaria treatment ; 
salvarsanised serum had been given to 2 patients 
and arsenical treatment to 4 others, but none had 
had tryparsamide. Serological findings were 
positive in every case, and in 9 there was evidence 
of syphilis in parents, 4 of whom had developed 
G.P.I. Results of treatment were disappointing ; 
in only one case had the progress of the disease 


been arrested. Three patients were still alive. 


15, 11, and 10 years after the onset of symptoms ; 
one of these was now held to be suffering from 
neuro-syphilis rather than G.P.I. Diagnosis indeed 
seems to be a difficult matter, since other neuro- 
syphilitic manifestations such as epilepsy and 
meningovascular disease cannot always be excluded. 
In the course of the discussion Dr. J. BRANDER 
pointed out the pitfalls which are encountered 
when too much reliance is placed on serological 
findings, in the adult as well as in the child. Even 
in young children, moreover, the possibility of 
acquired syphilis must be borne in mind, though 
proved instances of this are very rare. D.C. 
JEANS and J. V. CooKE’ could find only 34 cases 
of syphilitic infection acquired between the ages 
of 2 and 9 in their examination of more than 
75,000 children. Some of the family trees of the 
Horton cases shown on the screen proved to be of 
great interest and supported Dr. Nico1’s plea 
for the investigation of family histories. Dr. DAVID 
NABARRO also emphasised the value of the informa- 
tion to be gained from the study of family history. 
His vast experience of congenital syphilis in 


1 Prepubescent Syphilis, New York, 1930. 


PROSTIGMIN AND MYASTHENIA GRAVIS | 


[FEB. 29, 1936 491 


children, of which he discusses another aspect 
on p. 498 has convinced him that neuro-syphilis 
is far more common than is generally supposed— 
probably as high as 50 per cent. He maintains 
that the early discovery of a positive cerebro- 
spinal fluid demands energetic antisyphilitic treat- 
ment if the risk of G.P.I. occurring in ány of these 
children is to be forestalled. 

It is fortunate that congenital G.P.I. is a rare 
disease, for the general consensus of opinion appears 
to be that once clinical symptoms have supervened 
the condition is almost hopeless. Dr. R. M. 
STEWART confirmed this melancholy verdict as the 
outcome of considerable experience. W. C. 
MENNINGER * has reviewed records of 610 cases 
from the literature in none of which was treat- 
ment of any avail. H. W. POTTER reports 60 
cases which include 6 remissions after treatment. 
It would appear that these together with the few 
shown by Dr. TENNENT are the only ones in whom 
any degree of improvement has been reported. 
It remains to be seen whether even in those 5 
children the amelioration will be maintained. 


PROSTIGMIN AND MYASTHENIA GRAVIS 


THE nervous system contains at least three 
types of junction between functionally linked 
structures: (1) between a stimulus receptor and 
its afferent neurone, (2) between one neurone and 
another, and (3) between an efferent neurone and 
the muscle-fibre or other effector organ which it 
innervates. The separate activities of each of 
these structures have one common accompani- 
ment: an electrical ionic shift that can be 
objectively recorded by means of suitable apparatus 
and which may be taken as the most reliable 
indicator of functional activity. A natural 
inference is that activity passes from each of these 
structures to the next in virtue of this electrical 
change—i.e., that transmission of activity across 
the junction is mediated directly by electrical 
influence. This simple explanation becomes less 
satisfactory with every addition to our knowledge 
of the behaviour of those functional units which 
embrace both discontinuous structures and the 
junction between them. So little is yet known of 
the mode of action of stimulus receptors that we 
have not yet reached the stage of a simple explana- 
tion of the transfer of their activity to their 
afferent neurones, though LEwIs’s suggestion that 
peripheral excitation of afferent neurones that 
give rise to pain is brought about by the liberation 
of histamine or of some pharmacologically similar 
substance is a plausible one. . 

To explain the observed facts of spinal reflex 
physiology SHERRINGTON found it necessary to 
hypothecate the liberation at the interneuronal 
junction, or synapse, of two mutually antagonistic 
substances—excitatory (E) and inhibitory (1)— 
instead of the simple transfer of electrical instability. 
These (£) and (1) substances still remain physio- 
logical abstractions, but the work of DALE 
and his collaborators has drawn attention to a 


3s Amer. Jour. Syph., 1935, xix., 257. 
3 Psychiat. Quart., 1933, vii., 593. 


THE LANCET] 


492 


PROSTIGMIN AND MYASTHENIA GRAVIS 


[FEB. 29, 1936 


substance of undoubtedly objective existence— 
acetylcholine—which appears to provide all that 
our present knowledge of neuromuscular activity 
demands of a chemical transmitter, and it is at 
the moment sufficient to assume that the exciting 
impulse in the motor neurone causes at this 
junction the liberation of acetylcholine which in 
turn excites to activity the contractile elements 
in the muscle-fibre. Although this is still barely 
beyond the stage of an hypothesis, not universally 
accepted, clinical neurology has already found in 
it a ready explanation for one of its own particular 
problems—i.e., the nature and the relief of the 
muscular weakness in myasthenia gravis. This 
muscular weakness is associated with a form of 
myogram peculiar to this condition ; the prompt 
and dramatic relief afforded by Prostigmin can thus 
be actually charted, also the gradual reversion of 
the myogram to its characteristic pathological 
form as the effect of the drug wears off and the 
clinical improvement disappears. There are there- 
fore good grounds for believing that prostigmin, 
unlike glycine and ephedrine, has an effect in 
myasthenia gravis which is not merely adjuvant 
or compensatory, but which is concerned directly 
with the reversal of the change responsible for the 
muscular weakness. This pathological change 
undoubtedly occurs at the neuromuscular junction 
between voluntary nerve and skeletal muscle. 
If it is assumed that excitation is normally trans- 
ferred from nerve to muscle at this junction by 
acetylcholine, it is to be expected that the change 
is concerned at some stage with the liberation, the 
migration, or the exciting action of this transmitter. 
When it is further demonstrated that prostigmin 
has also the property of protecting acetylcholine, 
from destruction by the esterase normally present 
in the blood, its therapeutic value in myasthenia 
gravis is easy to understand. 

In normal persons, according to this theory, 
the quantum of acetylcholine released by each 
impulse is immediately attacked and rapidly 
destroyed by the esterase locally present. The 
excitation is transferred to the muscle-fibre only 
when an adequate amount of acetylcholine escapes 
destruction and reaches the motor end-plate or 
whatever other structure effects the immediate 
stimulation of the contractile elements. In the 
myasthenic patient the weakness of voluntary 
movements is due either to the smallness of the 
amount of transmitter liberated by each nervous 
impulse, or to the over-activity of the destructive 
esterase, so that the transmitter does not accumulate 
in quantity sufficient to excite the normal number 
of muscle-fibres to contraction. Prostigmin presum- 
ably relieves this weakness by slowing the rate of de- 
struction of acetylcholine, the effect being achieved 
either by giving extra protection to the abnormally 
small amounts produced, or by protecting normal 
amounts against destruction at an excessive rate. 
The latter possibility can be discarded in the light 
of other observations; the former fits in well 
with the phenomena of myasthenic fatigue as 
observed clinically and with the characteristic 
myasthenic myogram. A delay in the synthesis 
of the inactive precursor of acetylcholine from its 


chemical components would account for the 
experimentally recorded abnormalities of the 
myogram, but would not account for the clinically 
observed weakness of the victims of myasthenia 
gravis; if we are to retain this hypothesis we 
must therefore make the further assumption that 
there is delay in the mobilisation of these com- 
ponents to the point where they can be used. The 
probability that this, and possibly other change, 
is present in myasthenia gravis is perhaps to be 
inferred from the fact that the therapeutic effect 
of prostigmin is limited to the very transitory 
relief of a symptom and does not include any 
favourable influence upon the course of the disease. 

Another line of approach to the problem has 
been pursued by Lady Briscoxr, who records the 
outcome of her investigations elsewhere in this 
issue. She has introduced an entirely different 
conception of the essential pathological change 
responsible for myasthenic weakness. The hypo- 
thesis advanced by her, in conjunction with 
DALE, is derived from the long recognised similarity 
between the behaviour of a myasthenic patient 
and that of a curarised muscle-nerve preparation. 
It seems likely that curarine acts not by reducing 
the amount of the transmitter (acetylcholine) 
Jiberated at the neuromuscular junction, but 
by raising the threshold for excitation of the 
muscle-fibre so that a previously effective amount 
of the transmitter becomes no longer adequate. 
The question immediately arises: is the weakness 
in myasthenia gravis due in the same sense to a 
pathologically high stimulation threshold of the 
muscle-fibre receptor? If we adopt this view, 
as Lady Briscor has pointed out, the clinical 
action of prostigmin can still be accounted for, 
in terms of its esterase-inhibiting action, enabling 
abnormally large amounts of the transmitter to 
accumulate in contact with the muscle-fibre and 
thus to reach a value which is once more adequate 
in relation to the pathologically raised threshold. 
But she has shown further that prostigmin has 
a toxic effect on the muscle-nerve preparation which 
reduces both the height and the maintenance of 
contraction produced by repetitive stimulation of 
the motor nerve, and that this effect is exercised 
most markedly upon the muscle responses to 
higher rates of supramaximal stimulation. These 
toxic effects can be quantitatively antagonised 
by curarine, but they cannot be explained as due 
to an opposite effect—i.e., to a lowering of the 
muscle threshold for excitation—because the 
anticipated result of such Jowering would be 
to make stimuli of subminimal strength and 
of any rate of repetition adequate, and to 
make stimuli effective at a rate of repeti- 
tion too high for transmission to normal 
muscle. It would be equally difficult to explain 
the toxic effects in terms of the esterase-inhibiting 
action, since the anticipated effect of this would 
be identical with that of a lowering of the muscle 
threshold. Moreover, prostigmin given in this 
way produces, according to Lady BRISCOE, a very 
definite change in the uprising or tension-increasing 
limb of the myogram, a change which has no 
clinical counterpart in myasthenia gravis and for 


THE LANCET] 


which no explanation is available. These interest- 
ing experiments thus bring us nearer to an under- 
standing of the essential pathological change 
responsible for myasthenic weakness, but not as yet 
to any explanation of the mode of action of the 
drugs which completely relieve this weakness. Any 
attempt that we may now make at an explanation 
must take into account additional effects which 
at present seem entirely unrelated to therapeutic 


EXPERIMENTS ON ANZEMIA 


[FEB. 29, 1936 493 


value. Indeed, so many different phenomena 
appear to be taking place and so many different 
varieties of activity have been disclosed in this 
zone of structural discontinuity between nerve and 
muscle that we cannot but regret the time when 
it was possible to think in terms of electrical 
excitation alone and to picture a succession of 
subdued sparks jumping across a gap which, the 
microscope assured us, was very small indeed, 


ANNOTATIONS 


EXPERIMENTS ON ANAEMIA 


- THE technique developed by Whipple! has proved 
one of the most useful means of assessing the value of 
remedies for anemia. In his experiments dogs are 
given a standard diet and are maintained at a given 
level of anemia by bleeding at regular intervals. 
The degree of anemia—about 45 per cent. hemo- 
globin—is insufficient to impair the appetite or 
materially affect the physical activity. The amount 
of blood which must be abstracted to maintain the 
anemia is obviously a measure of the hemoglobin 
production, and under the standard conditions the 
dogs produce 10 to 15 grammes of hemoglobin a 
week or 1 to 2 per cent. of hemoglobin a day. Anti- 
anæmic substances are tested by adding them to the 
basal diet and noting the increase, if any, in hemo- 
globin production. The rate at which the dogs 
manufacture hæmoglobin is remarkable. When 
supplied with suitable amounts of hematinic material 
they may produce an average increment of 4 per 
cent. of hemoglobin a day, with a peak output up 
to 10 per cent. 

Whipple defines the optimum dose as the amount 
of a preparation which is utilised to the best advantage 
in hæmoglobin manufacture when added to the basal 
diet. As the dosage is increased beyond a certain 
point, which varies of course in different animals, 
utilisation falls off, and ten times the optimum dose 
gives less than twice the return in new hemoglobin. 
The optimum dose of iron by mouth in a dog weighing 
approximately 15 kg. averages 40 mg. a day, which 
is equivalent to about 200 mg. in a human being. 
In the dog it appears to make no difference what 
soluble iron salt is used and ferric citrate scales are 
just as effective as ferrous salts. In man it is generally 
believed that the various preparations of iron differ 
greatly in availability, the average effective doses of 
ferrous chloride and iron and ammonium citrate being 
given as 200 and 1600 mg. Fe respectively.? Another 
difference between the dog and man is the considerable 
increase in hemoglobin production when whole liver 
is combined with massive doses of iron. Hiemo- 
globin production in these dogs is likewise accelerated 
when amino-acids are given along with massive 
doses of iron. Thus there seem to be substantial 
differences in response to treatment between the 
experimental hemorrhagic anemia of dogs and human 
idiopathic hypochromic anemia. 
cent. of an optimum dose of iron by mouth in the 
dog is converted into hemoglobin and about 40 per 
cent. of the food iron. Elvehjem è? has shown that 
very little of the iron of hemoglobin and similar 
preparations is absorbed from the alimentary tract 
in rats and Whipple finds that only about 10 per 


1Whipple, G. H., and Robscheit-Robbins, F. S.: Amer. 
Jour. Med. Sci., January, 1936, p. 11 
2 Witts, L. J.: THE LANCET, Jan. 4th, 1936, 3. 


sie C. A.: Jour. Amer. Med. Assoc. > 1932, xcviii., 
1 š ; 


About 35 per. 


cent. of it is utilised by his dogs—a result in Kening 
with the low therapeutic efficiency of organic iron 
compounds in man. Whipple also studied the 
effect of intravenous injections of ferric hydroxide. 
Starkenstein 4 maintains that trivalent ferric iron is 
therapeutically inactive, but Whipple found that it 
was quickly and completely converted into hæmo- 
globin. Efforts to determine the site of hæmoglobin 
manufacture met with great technical: difficulties, 
but there is a suggestion that the iron is very rapidly 
taken up by the bone-marrow.5 

Whipple has often emphasised the necessity for 
adequate control periods to obtain stable conditions 
and the long time taken to exhaust the hæmatinic 
stores of the organism. The importance of these 
points is emphasised by work lately done in Denmark ° 
on the production of anæmia in dogs by operations 
on the stomach and duodenum. The experiments 
were at first sight disappointing, since nothing 
resembling pernicious anæmia was produced even 
though the upper duodenum and the distal half of 
the stomach were resected—the area from which 
(according to Meulengracht’s observations) the anti- 
pernicious anæmia ferment is secreted. But in a 
postscript to the paper it is stated that a year later, 
after a period of apparent recovery, one dog on which 
this operation was performed had developed a condi- 
tion similar to pernicious anæmia. 


PROGNOSIS IN THE CONVULSIONS OF 
CHILDHOOD 


A FOLLOW-UP investigation by Dr. N. Faxén,! 
of Gothenburg, has contributed some valuable data 
on the prognosis of convulsions in childhood. In 
the period 1922-1931 the children’s hospital to 
which he is attached dealt with 365 cases of attacks 
of loss of consciousness or convulsions in children. 
Convulsions immediately preceding death or due to 
some organic disease such as meningitis or a tumour 
of the brain were excluded. At the end of 1934 
a questionary was addressed to the parents of the 
children, and the answers received form the basis 
of this study. Among the 365 children were 95 whose 
convulsions were diagnosed in hospital as epileptic. 
Only 15 of these 95 children could be said to be 
psychologically normal and free from convulsions 
after an observation period of at least three years; 
and only 9ofthe 15 had had no attack since discharge 
from the hospital. As many as 78 of the 95 children 
were still subject to convulsions, 36 were mentally 
defective, 17 were undergoing institutional treatment, 
and 7 were already dead. Small as is the proportion 
of 15 to 95, Dr. Faxén insists that provided 


t Starkenstein, E.: Eisen. Handb. d. exp. Pharmakol., A. 
Heffter and W. Heubner, Berlin, Lo: vol. iii., part 2, p. 682. 
$ Hahn, P. F., and W hipple, G. H. Amer. Jour. Med. Sci. 
January, 1936, p. 24. 
¢ Petri. S.. ae A. S., and Boggild, D.: Acta Med. Scand., 
1935, IXXXVii., 
7 Nordisk Medicinsk Tidskrift, Jan. 18th, 1936, p. 81. 


494 THE LANCET! 
treatment is skilled and prolonged, the prognosis in 
epilepsy beginning with convulsions in early child- 
hood must not be considered as hopelessly gloomy. 
In another group of 40 cases, in which the con- 
vulsions had a psychogenic basis, the follow-up 
inquiries were unsatisfactory in that only 23 of these 
children could be traced. By far the largest group 
was composed of the children whose convulsions were 
due to some infectious disease. The follow-up study 
showed that 12 of these children had subsequently 
developed epilepsy, and 6 had shown themselves to 
be mentally defective. A comparison of the children 
in the epileptic and the other groups suggested that 
after the age of 4 years the prognosis in convulsions 
becomes progressively worse. The frequency with 
which they occur has some prognostic significance, 
for while the convulsions with an epileptic basis 
are usually isolated and separated from each other 
by fairly regular intervals, those due to other causes, 
.such as an infectious disease, are apt to recur in 
frequent bouts. 


SCHISTOSOME AND MOLLUSC 


IN a valuable article! entitled “‘ the carriage of 
schistosomes from man to man, with special attention 
to the molluscs which are their larval hosts in different 
parts of the earth,’ Lieut.-Colonel Clayton Lane 
reviews, with additions, the most important papers 
on the subject which have been epitomised in the 
Tropical Diseases Bulletin. He begins by recalling 
how Leiper and Atkinson in 1915 demonstrated that 
Schistosoma japonicum develops from miracidium 
to cercaria in a mollusc, thus confirming Miyairi’s 
previous discovery. Owing to war conditions the 
steps they took to identify the species of mollusc 


responsible were not perhaps the best possible; 


the molluscs were not of laboratory growth, and the 
method used was based upon the differential degree 
of attraction shown by various species for the 
mniracidia, and upon the examination of fully developed 
worms in animals infected with cercariz obtained 
naturally from various species of snails. Nevertheless 
Leiper and Atkinson were in no doubt that the 
development of the worms was as they said, and 
with this conclusion there has been full agreement. 
Clayton Lane suggests that the best chain of facts 
which can be offered to support the view that a certain 
mollusc is the intermediate or larval host of a certain 
schistosome is that put forward by Gordon, Davey, 
and Peaston. The snails used by these workers were 
of laboratory growth, so that unnoted natural 
infection was impossible; infection was given by 
miracidia from eggs whose species was certain ; 
and the cercariz coming from the molluscs gave the 
infection to clean animals, as was clear when worms 
of full development were seen in the veins. Following 
up his earlier work Leiper in 1916 showed not only 
that two sorts of eggs came from worms which, when 
of full growth, had a different structure, but also 
that the carriage of the two species from man to 
man took place in Egypt through molluscs which 
zoological grouping had placed in different genera. 
Clayton Lane next discusses the statement that 
besides the three blood flukes of which human beings 
are the optimum  host—viz., S. hematobium, 
S. japonicum, and S. mansoni—man is also the 
harbourer of others. This statement has sometimes 
been based upon the size and outline of the egg; 
while sometimes the morphology of cercari which 
have come out of a snail has been used to put that 
mollusc among the larval hosts of a schistosome of 


1 Trop. Dis. Bull., January, 1936, p. 1. 


PROGRESSIVE GANGRENE ROUND OPERATION WOUNDS 


[FEB. 29, 1936 


man. He draws attention to several papers on the 
variation in size of the eggs of a single species in 
various circumstances, and examines critically many 
others dealing with differentiation based upon 
differences in the appearances of eggs. Turning to 
the morphology of cercariz he states that unhappily 
there is no agreement about the anatomical details 
of the cercarix of the schistosomes of man, and he 
thinks that attempts to say with our present know- 
ledge that cercariz coming from a mollusc are those 
of a certain species of schistosome, and that that 
molluse is the larval host of that species, are of no 
value. He is forced, therefore, to the decision that. 
at present only S. hematobium, S. japonicum, and 
S. mansoni come into the picture of schistosomiasis 
in man. The rest of his article is a concise account 
of the geographical distribution of the schistosomes 
of man and their larval hosts. Observations on the 
ecology of the molluscs, with special reference to 
their control, come in for discussion. 

This review by Colonel Clayton Lane is of further 
interest since; apart from words necessary for biology, 
parasitology, and medical science, the paper is in 
basic English, keeping to 850 words in the general 
list and those in the special lists for science. In 
this way, the author believes, the information 
collected in the Tropical Diseases Bulletin can be 
made more easily intelligible to those whose language 
is not English. 


PROGRESSIVE GANGRENE ROUND OPERATION 
WOUNDS 


A RARE complication of operations on the serous 
cavities is the spread of gangrene of the skin on one 
or both sides of the scar. The course of the gan- 
grenous process is rather slow, and healing by scar 
tissue follows gradually in the wake of the ulceration, 
but the advance of the process is quite relentless, 
until the trunk may be encircled by the ulcer, and 
death follows unless drastic treatment is undertaken. 
During the past six years 5 cases have been reported 
in this country; of these, 2 have died and 3 have 
recovered. The usual history is that of the fruitless 
trial of all types of local application, the onward 
spread of the gangrene being quite unchecked by 
these or by antivirus, antitoxin, vaccines, or ultra- 
violet light. The heroic measure, a wide excision of 
the edges of the wound, was necessary to ensure 
complete arrest of the disease and the promotion of 
healing. This was the treatment adopted in the 
3 cases which recovered ; it is the recognised treat- 
ment in America where the condition has been the 
subject of much discussion. Excision may be either 
by the scalpel or by the diathermy cautery. A trench 
cut an inch or so outside the growing edge of the 
ulcer will effectually stop its advance, and the 
sloughing edge can be excised at a future operation. 
The infective process is in the skin, and it will not 
advance across scar tissue; it never affects the scar 
of the operation wound, so that the secret of its 
arrest seems to be the formation, well outside the 
area of affected skin, of a line of scar tissue. In the 
most recent case, reported by H. T. Cox,! the nature 
of the condition was recognised 26 days after the 
first operation, and the treatment by.excision success- 
fully carried out, with complete epithelialisation 
three months later. The primary operation in this 
case was for repair of a perforated duodenal ulcer, 
as it was also in the cases reported by R. Owen-Jones 
and L. M. Hawksley in 1931,? and by H. J. Nightingale 


1 Brit. Jour. Surg., 1938, xxiii., 576. 
2 Brit. Med. Jour., 1931, i., 537. 


- 


THE LANCET] 


and E. C. Bowden in 1934.5 F. H. Scotson’s case, 
reported in THE LANCET in 1933,‘ followed operation 
for an appendix abscess; and A. M. Stewart-Wallace 
in 1935 ë reported a case following drainage of an 
empyema. The gangrenous process may start around 
the edge of a sinus at the site of drainage, or around 
one or more punctures made by deep tension sutures. 
The sinus itself always heals, and there is an immune 
island of tissue around the scar. Outside this is the 
denuded base of the ulcer, possibly with granulations 
covering it; then a slough of varying extent; the 
blackish gangrenous edge; and, at the periphery, a 

ted, usually very tender, serpiginous margin, raised 
and cdematous, and largely undermined. 

The cause of the gangrene has given rise to much 
speculation. One difficulty is that secondary infec- 
tion may render impossible culture of the original 
organisms. In Owen-Jones and Hawksley’s case 
long-chained streptococci were found invading the 
tissue, but the peculiar nature of the microscopical 
appearances led to them being reported as “‘ corre- 
sponding with the appearances of granuloma 
fungoides.” The most usual finding is of a com- 
bination of a non-hemolytic streptococcus with a non- 
specific staphylococcus. Stewart-Wallace gives it as 
his opinion that the streptococcal infection comes 
from the serous cavity, and that the particular 
streptococcus at fault is capable of adaptation to 
aerobic and non-aerobic conditions. The symbiosis 
of this organism with a non-specific staphylococcus 
introduced from without produces the peculiar type 
of skin reaction. He suggests that cutaneous hyper- 
sensitivity may play an important part, and this 
seems likely from the rarity of the complication. 


THE DETECTION OF STRYCHNINE 


Ir is a remarkable fact that no sensitive qualitative 
test, based on the formation of a well-defined 
derivative, is available for strychnine. The laborious 
work of Dr. Douw G. Steyn,! veterinary research 
officer at Onderstepoort, South Africa, on the detec- 
tion of this alkaloid in carcasses and corpses 1s, 
therefore, of considerable interest. Authorities on 
toxicology differ greatly as to the limiting dilution 
at which the characteristic bitter taste of strychnine 
can be detected, some placing it as low as 1 in 700,000 
and others as high as 1 in 67,000. In this connexion, 
Dr. Steyn points out, an hour or more should be 
allowed to elapse between each test since the taste 
nerves very soon become exhausted. Even with this 
precaution he himself was unable to detect strychnine 
in a solution of 1 in 200,000 when only one drop 
was placed on the tongue, but he could appreciate 
the bitter taste of 1 c.cm. of the same solution. The 
most delicate precipitating agent for strychnine seems 
to be Wagner’s reagent No. 1 (prepared by dissolving 
2 g. iodine and 6 g. potassium iodide in 100 ml. of 
water), which, he found, will give a macroscopic 
recognisable precipitate with one drop of a 1/20,000 
solution of the alkaloid, whilst the next sensitive 
reagent is Mayer’s solution, of which the limit is 
1/8000. Steyn appears to consider the well-known 
Otto test, with bichromate or other oxidising agent 
and sulphuric acid, to be the most delicate colour 
test for strychnine, but it is not, in his experience, 
specific, as he obtained from a decomposed liver 
which was known not to contain strychnine a positive 
sulphuric-bichromate test and the solution was 


3 Brit. Jour. Surg., 1934, xii., 392. 
* THE LANCET, "1933, i., 0. 
$ Brit. Jour. Surg., 1935, xxii., 642. 
* Onderstepoort Journal of Veterinary Science and Animal 
Industry, 1935, v. 


TREATMENT OF BACTERIAL MENINGITIS 


[FEB. 29, 1936 495 


bitter to the taste. In order to express a definite 
Opinion as to the presence or absence of strychnine 
in purified extracts of specimens of organs, it is 
essential, in Steyn’s view, to conduct the following 
tests : (a) taste test, (b) colour test, and (c) a biological 
test. For this latter he prefers immature white mice 
(about 14 days old) to frogs, on grounds that mice 
are always obtainable and behave uniformly, whilst 
the sensitivity of various species of frogs differs and 
some are not obtainable at all seasons of the year. The 
stability of strychnine in the bodies of animals which 
have been killed by this alkaloid is still a matter of 
discussion. Steyn, using Glaister’s method of extrac- 
tion, which he finds the best, was able to detect it in 
three carcasses of dogs exhumed 10 weeks after 
death, but in only one of four dogs exhumed 18 weeks 
after death, and in only four out of eight which had 
been buried for 11 months, 


TREATMENT OF BACTERIAL MENINGITIS 


THE wireless appeal on Feb. 24th to any doctor 
with a patient recently recovered from infection with 
Pfeiffer’s bacillus met with immediate response. It 
suggested a confidence that the life of a child suffer- 
ing from meningitis might be saved by some form of 
serum therapy or immuno-transfusion which may 
not be generally shared; but the discovery, usually 
after repeated examinations of the cerebro-spinal 
fluid, of the infecting organism in bacterial meningitis 
naturally brings with it the impulse to try specific 
therapy. A recent analysis by C. J. Tripoli! of all 
the cases of bacterial meningitis admitted to the 
State Charity Hospital of Louisiana during the past 
ten years, many of them being under his personal 
observation, gives little encouragement to the use 
of serum in meningitis other than the cerebro-spinal 
form. The total was 468, and among them meningo- 
coccal meningitis heads the list with 221 cases (47 per 
cent. of the total) and 144 deaths, a case-mortality 
rate of 65 percent. There were 111 examples of pneu- 
mococcal meningitis (24 per cent.), 90 being untyped, 
and all save one of these proved fatal. From tuber- 
culous meningitis (51 cases, 11 per cent.) there were 
no recoveries. The remaining 86 cases included 
streptococcal and staphylococcal infections of varying 
strains, mixed infections, and purulent meningitis 
of unknown causation. 

In the treatment of meningococcal meningitis 
(cerebro-spinal fever) six different methods were 
employed ; serum administration was the basis of 
five. Simple lumbar drainage was used for 14 patients, 
all of whom died ; but since most of them were mori- 
bund on admission, the results are not a true index 
of the value of the method. Many of the patients 
(130) suffering from cerebro-spinal fever were treated 
by repeated intravenous, intramuscular, and intra- 
spinal injections of antimeningococcal serum after 
withdrawal of “as much spinal fluid as possible.” 
Of this group 87 died (a case-mortality of 67 per cent.). 
Tripoli points out that with the foregoing methods 
no attempt is made to maintain the normal spinal 
fluid pressure, and further it is difficult for the serum 
to reach the ventricles and particularly the more 
important subarachnoid spaces. Serum injected 
intravenously does, it is true, ultimately reach the 
cerebral ventricles but in a very much diluted form. 
Therefore, in 54 patients, the intracisternal route 
was utilised alternately with the intraspinal. Of 
these patients 26 died (case-mortality 48 per cent.). 
Tripoli describes a modification of the Lyon? 


2 Jour. Amer. Med. Assoc., Jan. 18th, 1936, p. 171. 
3? Lyon, G. M. : Amer. Jour. Dis. Child., 1932, xliii., 572. 


496 THE LANCET] 


“ substitution °? method of serum therapy, by which 
serum containing phenolphthalein as an indicator 
is introduced into the ventricle at the same time as 
cerebro-spinal fluid is being drained by lumbar 
puncture, the process being stopped when serum 
appears at the lumbar site. Tripoli places the patient 
on his side, the head of the table being raised 9 inches. 
He then introduces a needle into the basal cistern 
and a second needle into the lumbar cistern, and 
allows spinal fluid to escape from both needles. The 
flow from the basal cistern usually ceases first, and 
as soon as this happens, the lumbar flow continuing, 
warm serum containing a phthalein indicator is 
introduced cisternally. The table is then lowered 
immediately, so that the foot is 6 inches higher than 
the head, and the serum is allowed to flow into the 
cistern until it fills the ventricles and appears at the 
lumbar tap. At the same time, up to 80 c.cm. of 
serum is given intravenously and up to 100 c.cm. 
intramuscularly. Of 19 successive cases treated by 
this method 8 were fatal (case-mortality 42 per cent.), 
a result which Tripoli, while drawing no definite 
conclusions, points out is more favourable than 
those of other methods. He mentions the satisfactory 
reports upon Ferry’s meningococcal antitoxin, but, 
pending the completion of his own comparative study, 
expresses no opinion on it. 

The methods employed for the treatment of the 
247 cases of meningitis other than meningococcal 
were many and various. Simple lumbar drainage 
used in 181 cases resulted in 1 recovery, the organism 
in this case being Hemophilus influenze (Pfeiffer’s 
bacillus). Intraspinal administration of chemical 
agents such as mercurochrome proved to be use- 
less in 7 cases; indeed death occurred so quickly 
in 4 of them that the chemical employed was suspect. 
For pneumococcal meningitis, specific and non-specific 
sera and vaccines were without avail; severe reactions 
“sometimes causing death” are stated to have 
attended the use of antipneumococcus serum. Per- 
manent and forced drainage of the basal and lumbar 
cisterns (L. S. Kubie), or surgical drainage of the 
focus and replacement of the spinal fluid by non- 
specific serum with and without intracarotid injec- 
tion of chemical agents were among the heroic 
methods employed in other cases in Tripoli’s series. 
It is true that in 4 cases of non-meningococcal menin- 
gitis treatment by spinal lavage with non-specific 
serum and the eradication of primary foci of infec- 
tion was successful; but, on the whole, the results 
of therapy in forms of meningitis other than cerebro- 
spinal fever were almost uniformly bad. 


SCIENTIFIC SOCIETIES AND RATES 


WHILE the de-rating of hospitals is still awaiting 
the serious attention of Parliament, a recent case at 
Liverpool is a reminder that scientific societies can 
sometimes escape assessment. An Act of 1843 
exempted non-profit-making societies instituted for 
the exclusive purpose of science, literature, or the 
fine arts, and supported wholly or in part by annual 
voluntary subscriptions. The Liverpool Amateur 
Photographic Society, founded in -1853, claimed to 
come within the statutory exemption. It seemed to 
be wholly or partly supported by voluntary contri- 
butions, and it was precluded from making any 
dividend, gift, or bonus to its members. The society 
had a distinguished history, and one of its members 
had invented the dry-plate process. Counsel for the 
assessment committee replied that the yearly pay- 
ments of the members could not be regarded as 
voluntary contributions within the words of the 


SCIENTIFIC SOCIETIES AND RATES 


[FEB. 29, 1936 


Act. Photography, he said, might be a science; to 
some it was a business, to others a hobby; all 
that the members of the society appeared to do was 
to congregate for intercourse relating to their com- 
mon hobby. The Recorder of Liverpool decided 
against the society. He held it was not instituted 
exclusively for the purposes of science or the fine 
arts, nor did the annual subscriptions and occasional 
gifts of its members amount to ‘ annual voluntary 
contributions.” According to a dictum of Lord 
Herschell in the case of the Art Union of London in 
1896, members’ yearly subscriptions, which purchase 
them an advantage and are not made as a gratuitous 
offering for the benefit of others, do not comply 
with the statutory condition that the society should 
be supported by ‘‘ annual voluntary contributions.” 
The Act of 1843, be it noticed, speaks of ‘‘ science 
or fine arts.” The Royal College of Music obtained 
exemption from rates in 1898, music being one of 
the fine arts. The Institution of Civil Engineers 
had earlier been refused exemption. A professional 
art, it seems, is not a fine art. 


A PLEA FOR COORDINATED TOWN PLANNING 


THE National Housing Committee, a voluntary 
band of nine public-spirited men who are working 
under the chairmanship of Lord Amulree, had 
already published two important constructive reports ! 
before the Housing Act of 1935 came into force. 
In a further interim report, they point out that this 
Act marks a definite stage in the evolution of national 
housing policy, and that if the Government’s antici- 
pations are fully realised, one side of the housing 
problem—the provision of a very large number of 
dwellings for overcrowded populations—should be 
solved in measurable time. It isnot enough, however, 
to provide dwellings; it is at least equally important 
that these dwellings should be built in the right 
places and in the right relationship to transport 
facilities, to places of employment and recreation, 
and to all the other elements which compose the 
physical pattern of the country’s development. 
Without an ellicient system of town and country 
planning, the national housing campaign may create 
as many problems as it solves. The committee give 
examples of fundamental errors both of distribution 
and of interrelation in the development of housing 
(municipal as well as private enterprise), of industries, 
of road and rail transport, and of public services, in 
various parts of the country. All will agree that the 
safety and efficiency of the Great West-road as a 
long-distance fast-traflic artery has been permanently 
damaged and its amenities ruined by the failure to 
restrict and plan its frontage development, and those 
who have recently driven. along the Barnet by-pass 
road on the London side of Hatfield, near the road 
to Lemsford, will have been horrified by a mushroom 
development of. similar unplanned type. Local 
authorities have been invested with considerable 
powers of control, but the powers are permissive, and 
there is no national and often no regional master- 
scheme to guide the planning work of individual 
authorities. The committee’s plea is for machinery 
through which a policy and a broad master-plan for 
the physical pattern of national development can be 
worked out at the centre, and imposed as a con- 
trolling background and purpose on local schemes 
and projects. The machinery must operate con- 
tinuously, for its plans and policies must be readily 
adjustable to. suit changing circumstances. It must 


` 


1 Sec THE LANCET, 1934, i., 1123, and ii., 148. 


THE LANCET] 


command the highest technical skill and be sufficiently. | 


independent to obtain its own information by surveys 


and investigations, to stimulate and, where necessary, . 


to compel the requisite local action to implement its 
schemes, and to formulate, for the Government’s 
consideration, such proposals as it thinks necessary 
for the modification and extension of the planning 
‘system. In conclusion the committee stress the 
intimate connexion between their proposals and the 
efforts which are being made to bring back prosperity 
to the distressed areas, holding rightly that a well- 
planned national housing policy should be an effective 
‘weapon in the campaign for their rehabilitation. 


LONG SURVIVAL WITH METASTATIC 
- MAMMARY CANCER 


THE attitude of the medical profession to mam- 
mary cancer is, in general, pessimistic, for though 
no problem in surgery or pathology has been more 
diligently studied, at any rate during the last twenty 
-years, little improvement in survival rates can be 
recorded. It is now accepted that the possibility 
of cure or at least of considerable prolongation of 


life is dependent, in the main, on the stage the disease . 


has reached when the patient first presents herself 
for treatment; local recurrence after operation or 
the development of metastatic growth is therefore 
regarded as an ominous, if not more or less hopeless, 
sign pointing to widespread dissemination. A case 
recently recorded by M. C. Tod and E. K. Dawson,} 
of survival with maintenance of health for 24 years 
after operation for mammary cancer, in spite of 
recurrence and metastases, suggests that a pessi- 
mistic outlook is not necessarily justified, and that 
in some patients there may be an undefined and, at 
present, undefinable factor of ‘‘resistance’’ which 
prolongs life in spite of widespread tumour develop- 
ment. The patient in this case, a married women of 
47 years when first treated, developed a local recur- 
rence 12 years after radical operation, and subse- 
quently metastases in the opposite breast and axilla, 
which were treated by irradiation and excision. 
Tumour tissue} if still present, is now quiescent, and 
the general condition of the patient is satisfactory. 
Though such a long survival is probably very rare it 
provides an encouragement to clinicians, and also 
suggests that adequate post-operative irradiation 
of the primary tumour area might in similar condi- 
tions serve to prevent local recurrence and the 
possibility of further dissemination. 


PROSPECTS IN THE INDIAN MEDICAL SERVICE 


ALTHOUGH no official pronouncement has yet been 
made it is now a matter of common knowledge that a 
considerable number of attractive posts in the 
Provinces will be reserved for European officers of 
the Service. The Secretary of State for India has 
recently given a public assurance that the standard 
of medical aid by European doctors for European 
civil officials and their families in India will be 
maintained. For the purpose of honouring this 
undertaking, and also of providing a war reserve 
of European medical officers, it has been found 
necessary to reserve for European members of the 
Service a number of specialist clinical posts and civil 
surgeoncies in the Provinces, in addition to a con- 
siderable number of posts in the Foreign and Political 
department. Apart from the posts which have been 
specifically reserved for European officers there will 
also be many clinical, research, and public health 


—_—. 


1Surg., Gyn., and Obst., January, 1936, p. 90. 


PROSPECTS IN THE INDIAN 


MEDICAL SERVICE [FEB. 29, 1936: 497 


‘appointments for which all I.M.S. officers will be 


eligible. It has been asserted indeed by responsible 
people that the prospects of highly qualified recruits 
to the Service have never been better than they 
are at present. Although some of the prize appoint- 
ments will be open only to men with special qualifica- 
tions there will be excellent prospects of attractive 
careers both in military and civil employment for 
men of good all-round attainments. In view of the 
number of recruits likely to offer themselves after 
an official announcement young graduates who are 
thinking about going to India may be well advised to 
lose no time in making inquiries about the conditions 
of life and work in the I.M.S. An important point 


which has been overlooked by many candidates 


for commissions in the military services is that 
permanent commissions are given at the outset to all 
who join the I.M.S., so that unless the officer himself 
prefers to retire with a gratuity after a few years he 
automatically retains his commission, instead of find- 
ing himself in the position of an applicant for a per- 


‘manent commission after several years of temporary 
‘service. 


We are informed that in the other military 
medical services less than half of those who obtain 
temporary commissions are likely to be retained after 
their first contract has expired. Many young 
graduates have entered the I.M.S. with the intention 
of taking the gratuity for which they become eligible 
after six years, but few exercise their right to retire ; 
this fact speaks for itself. In the column containing 
details concerning the Services information is given 
as to application for commissions. 


At the Royal College of Physicians of London 
on Thursday, March 5th, at 5 p.m., Dr. R. A. McCance 
will deliver the first of his Goulstonian lectures on 
medical’ problems in mineral metabolism. His 
second and third lectures will be given on March 10th 
and 12th. 


Dr. R. Kuczynski, formerly director of the 
statistical office, Berlin-Schénberg, is giving three 
lectures at University College, London, on March 
3rd, 6th, and 10th, at 5.30 pm. His subject will be 
Recent Population Trends, and Lord Dawson will 
take the chair at the first lecture. 


King Edward’s Hospital Fund for London have 
issued a revised edition of their pamphlet which 
gives particulars of the provision made for the 
professional and middle classes at voluntary hospitals 
in London. This shows a substantial increase in the 
number of beds for paying patients, as compared 
with the accommodation available in 1928, when a 
special committee of the King’s Fund inquired into 
the situation. The total number is now 1997 at 
108 hospitals. It should be emphasised that the 
increase in the number of pay-beds is in addition to 
an extension of the accommodation for patients in 
‘tthe ordinary wards of the hospitals. This pamphlet 
gives full particulars of the charges at each individual 
hospital, and copies may be had from Messrs. Geo. 
Barber and Son Ltd., Furnival-street, E.C. 4, 
price 3d., post free. 


CONGRESS ON FEVER THERAPY.—As already 
announced, the first International Congress on Fever 
Therapy will be held in New York City from Sept. 29th 
to Oct. 3rd. It is suggested that an English com- 
mittee should be formed to collect reports which 
have appeared in this country, and all those who have 
information which they wish to be brought forward in 
New York are invited to write to the medical secretary, 
the International Clinic, Sherwood Park, Tunbridge Wells. 


498 THE LANCET] 


[FEB. 29, 1936 


PROGNOSIS 


A Series of Signed Articles contributed by invitation 


XC.—PROGNOSIS OF CONGENITAL 
SYPHILIS 


In discussing the prognosis of congenital syphilis 
it is necessary to consider (a) the outlook for an 
affected patient, and (b) the history and course of 
the disease itself. 


Outlook for an Affected Patient 


This depends upon several factors: (a) the severity 
of the disease; (b) the age of the patient when the 
disease is first diagnosed and adequately treated ; 
and (c) the adequacy of the treatment given. 


SEVERITY OF THE DISEASE 


As a general rule the more recent the infection in 
an untreated mother the more severe is the infection 
in the infant, and occasionally an infant is born so 
heavily infected suffering, for example, from syphi- 
litic pemphigus or syphilitic nephritis that it dies 
within a few days or weeks of birth, in spite of the 
best nursing and antisyphilitic treatment one may 
give it. If, as is usually the case, the infant is born 
apparently healthy, and shows signs of the disease 
during the first four or five weeks of life, even though 
the rash be extensive and severe and be accom- 
panied by much nasal catarrh with consequent 
snuffles, life can usually be saved by appropriate 
treatment and good nursing. In my experience, 
the nursing is of importance, as great as, if not 
greater than, the antisyphilitic treatment itself. Ifthe 
infant’s strength is to be maintained for example 
adequate nourishment is essential. A syphilitic baby 
whose nasal passages are blocked with discharge 
from a diseased mucous membrane is unable to take 
its feed either from the breast or from a bottle. 
The toilet of the nose and mouth should be rigorously 
attended to before the feeding is started by wiping 
away all mucus with moistened swabs of cotton- 
wool, and the utmost patience is needed in feeding. 
It may take as long as two hours to get the baby 
to take a feed of two ounces, but recovery may 
depend upon perseverance in this respect. Since 
constant attention to the rash on the body and face 
is also essential, it can be readily seen how a bad 
case of congenital syphilis may occupy a nurse’s 
whole time for several weeks. I have had several little 
patients with disease of such severity (one or two of 
them with cedema from nephritis) as to make the prog- 
nosisseem almost hopeless who neverthelessmadea good 
recovery and appeared to be well several years later. 

At the present time severe cases of congenital 
syphilis seem to be less common than they used to 
be. This may be due to a natural diminution in 
the pathogenicity of the spirochaxte and/or to the 
effect of a certain amount of treatment of the parents. 
The symptoms may be vague and inconclusive, 
such as malnutrition, pylorospasm, anemia, and so 
forth, and the infant who fails to respond to ordinary 
treatment may at once improve and eventually be 
cured if the presence of syphilis is suspected and 
confirmed, and treatment is pursued vigorously. 


AGE OF THE PATIENT WHEN THE DISEASE IS FIRST 
DIAGNOSED 


This factor is of prime. importance in prognosis. 


Provided that an infant is not overwhelmingly > 


infected by the spirochxte, adequate treatment 
started during the first three to six months of extra- 
uterine life and given over a sufliciently long period 


will result in a complete cure in almost all cases. 
This statement, however, raises questions to which 
different pediatricians and syphilologists will give 
varying replies; notably (a) what is adequate treat- 
ment? (b) How long should treatment be con- 
tinued ? (ce) What criterion of cure should be adopted? 

(a) What is adequate treatment i—Certainly the 
time-honoured treatment with mercury cannot be 
relied upon for a cure except perhaps of an occa- 
sional very mild infection in a child whose father 
had contracted the disease many years previously 
and had had some treatment for it. I have seen a 
few cases of this kind. The recognised treatment 
to-day is injections of arsenicals together with mercury 
(by mouth or inunction) or injections of bismuth. Some 
authorities rely on bismuth alone. In many German 
clinics congenital syphilis is being treated solely by 
the oral administration of spirocid (stovarsol, orarsan, 
acetarsone) with, it is claimed, successful results. 

(b) About the duration of treatment no stereotyped 
rule can be given though certain general principles 
may be followed. Some authorities give at least 
two years’ treatment; Tytler Burke recommends 
five years’ treatment which is in my view unneces- 
sary as a routine, and must prove difficult to apply 
in practice. So long a course of treatment must 
imply a number of defaulters. On account of the 
possible psychic effect of the weekly visits to the 
clinic and of the discomfort or pain associated with 
the injections—and it is remarkable how even young 
infants seem to remember their previous experiences 
directly they come into the injection room—I decided 
at one time to curtail treatment as much as possible, 
and gave one complete course of eight arsenic injec- 
tions after the Wassermann reaction had become 
negative. This seemed to be satisfactory in some 
cases, but in others there was a serological relapse 
and further treatment had to be given; so my 
present practice is to treat for at least two years, 
with intervals of one month between the courses, 
provided the Wassermann reaction in blood and 
spinal fluid is negative during the whole of the second 
year and there are no symptoms of the disease. If 
the Wassermann reaction and flocculation tests are 
positive, treatment should be continued through a 
third and if necessary a fourth year. 

(c) The criterion of “ cure.’—A negative blood test 
and a normal cerebro-spinal fluid together with 
absence of all clinical manifestations of active syphilis 
for a period of years is to be aimed at, and can usually 
be attained in the case of infants who have been 
adequately treated. In older children, who first 
come under observation and treatment at the age 
of, say, five to ten years, the prognosis is not so good, 
because even although the blood serology may have 
proved satisfactory, there is no guarantee that later 
manifestations of the disease may not arise. I have 
seen interstitial keratitis in children whose blood 
Wassermann had been negative for four and six 
years and who had shown no sign of active disease 
at any of their annual examinations since the Wasser- 
mann test was first found to be negative. Some 
authorities go so far as to say that congenital syphilis 
in older children can never be regarded as cured. 
Personally I think this extreme view is too pessi- 
mistic, but a follow-up for at least ten years and 
preferably until adult age is certainly desirable. 
This often proves a dilficult matter, and necessitates 
in institutions an eflicient social service organisation. 


7 


THE LANCET] 


THE SERVICES 


[FEB. 29, 1936 499 


ADEQUACY OF THE TREATMENT GIVEN 


A young child who shows only a mild infection 
because the disease in the parents is not recently 
acquired or because the mother had some treatment 
during pregnancy will probably be cured after one 
year’s thorough treatment. Older children, provided 
they have no gross vascular or organic lesion of the 
central nervous system, appear to make a good 
recovery with adequate treatment, but this may 
have to extend over four or more years and neces- 
sitate the giving of 15 to 20 grammes of arsenicals 
in forty or fifty injections as well as malaria therapy 
in Wassermann-fast and positive cerebro-spinal fluid 
eases. The most tragic cases are those of congenital 
neuro-syphilis which are not diagnosed until an 
“encephalitis or a hemiplegia draws attention to the 
patient’s condition. The prognosis in such cases is 
often hopeless as regards life; there is progressive 
mental deterioration involving a stay in a mental 
hospital for several years where life may be pro- 
longed by treatment, though there is no question as 
to the outcome of the disease. Children with a syphi- 
litic hemiplegia will be permanently disabled, though 
if the blood and spinal fluid can be rendered per- 
manently negative, their lives may be saved. 

Special manifestations of congenital syphilis, such 
as periostitis of the long bones, interstitial keratitis, 
gummatous lesions of the skin or mucous membranes, 
hemoglobinuria, and anemia, respond readily to 
prompt antisyphilitic treatment, but the ultimate 
prognosis as regards cure will depend upon the factors 
already considered. 


History and Course of the Disease 


Although in the eighteenth and nineteenth cen- 
turies a few physicians recommended the antenatal 
treatment of expectant syphilitic mothers to protect 
the child, it was noj until the discovery of ‘‘ 606” 
by Ehrlich and Hata in 1909 that the prevention 
of congenital syphilis was seriously considered. 
Since that time an ever-increasing volume of evidence 
has been accumulated to show that adequate treat- 
ment of the expectant mother will fully protect her 
child in a very large percentage of cases, as high as 
95 per cent. according to N. R. Ingraham (Amer. 
Jour. Syph. and Neurology, October, 1935, p. 556), and 
even if the infant shows signs of congenital syphilis 
early and appropriate treatment will cure it. 

Knowing as we do how difficult some cases of the 
disease are to diagnose, and also that in older children 
a ‘‘ cure”? may take four or more years to attain, it 
behoves us to take all possible steps to prevent the 
disease. Women who receive treatment at the 
ordinary clinics should be warned to apply for further 
treatment as soon as they realise that they have 
become pregnant. All women attending antenatal 
clinics should have a Wassermann test, and if found 
positive, should be treated by injection. In my view 
the ideal to be aimed at is a blood test for every 
pregnant woman; if it were realised that this was 
the usual practice, no difficulties would arise. Con- 
genital syphilis would be almost non-existent after 
the lapse of a generation; many stillbirths would 
be prevented; many children who are now doomed 
to die young, after some years of miserable existence 
in mental homes, and others who perforce lead incom- 
plete lives owing to physical disabilities, would be 
spared to live useful lives. 


DAVID NABARRO, M.D., F.R.C.P., 


Director of the Pathological Department and Medical 
Officer in Charge of the Venereal Diseases Clinic, 
Hospital for Sick Children, Great Ormond-strcet. 


THE SERVICES 


ROYAL NAVAL MEDICAL SERVICE 


. Surg. Capt. Sheldon F. Dudley, O.B.E., M.D., F.R.C.P., 
to rank of Surg. Rear-Admiral in the vacancy caused 
by the retirement of Surg. Rear-Admiral J. S. Dudding, 
C.B., O.B.E., on relinquishing command of the R.N. 
Hospital, Plymouth. 


Surg. Rear-Admiral Dudley, at the age of 52, has been 30 years 
in the Royal Navy, having been appointed Sure. Lieut. Com- 
mander in 1914, and Surg. Captain in 1929. In THE LANCET 
oi Mayd 1th, 1935, we noted his appointment as Deputy Director- 

onera 


Surg. Lt.-Comdrs. H. J. McCann to Bee, and E. B. 
Pollard and J. C. Souter to rank of Surg. Comdr. 


ROYAL NAVAL VOLUNTEER RESERVE 


Surg. Lt.-Comdr. R. J. Matthews to Royal Sovereign. 
Proby. Surg. Lt. R. W. G. Lancashire to be Surg. Lt. 


ROYAL ARMY MEDICAL CORPS 


Short Serv. Commissions: Lt. (on prob.) J. McN. 
Lockie is restd. to the estabt. 

Among the results annouņced of the examination (in 
written subjects) of officers with a view to promotion in 
the Regular Army and Indian Army, which was held in 
India and Burma in October last, are the following successful 
candidates: Major W. A. D. Drummond, Capt. D. Bluett, 
and Capt. R. J. G. Hyde. 

The War Office announces that applications are invited 
from medical men for appointments to commissions in 
the Royal Army Medical Corps. Candidates will be 
selected for commissions without competitive examination, 
and will be required to present themselves in London for 
interview and physical examination on or about April 23rd 
next. Further information may be seen in the advertise- 
ment which appeared in THE LANcET last week (p. 52), 
and full particulars may be obtained on application to 
the Assistant Director-General, Army Medical Services, 
The War Office, London, 8.W.1. 


REGULAR ARMY RESERVE OF OFFICERS 
Capt. F. W. Oldershaw resigns his commn. 


TERRITORIAL ARMY 


Lt.-Col. J. L. Hamilton, M.C., T.D., 
and vacates comd. of 167th Fd. Amb. 

Lt.-Col. W. A. Lethem, M.C., to be comd. 167th Fd. Amb. 

Maj. A. C. Haddow, T.D., to be Lt.-Col. 

Supernumerary for service with O.T.C.: Maj. R. B. 
Green (empld. Durham Univ. Contgt. (Med. Unit), Sen. 
Div., O.T.C.) resigns his commn. and retains his rank, with 
permission to wear the prescribed uniform. 

Capt. A. T. Fripp resigns his commn. 

Lts. H. F. Apthorpe-Webb, R. I. Hyder, E. C. Murphy, 
and F. V. Allon to be Capts. 

F. N. N. Roberts (late Flight-Lt. R.A. F. ) to be Lt. 

Lt. M. Elis resigns his commn. 


ROYAL AIR FORCE 
RESERVE OF OFFICERS 

Special Reserve: C. W. Kidd is granted a commission 
as Flying Officer. 

INDIAN MEDICAL SERVICE 

Lord Linlithgow, Viceroy-Designate of India, has 
appointed Major H. H. Elliot, M.B.E., M.C., F.R.C.S. Edin., 
I.M.S., to his personal staff. 

The promotion to the rank of Maj. of the undermentioned 
officers is confirmed: A. Tait, G. P. F. Bowers, J. S. Riddle, 
J. E. Grey, S. Smyth, M. H. Wace, R. L. Frost, J. C. 
Drummond, D. MacD. Fraser, J. F. Shepherd, K. S. 
Fitch, and S. C. H. Worseldine. 

J. M. F. Byrnes and W. J. Young to be Lts. (on prob.). 


There will be a selection of recruits early in April and 
thereafter at intervals of about three months. A memo- 
randum of conditions of service can be obtained from 
the secretary, Military Department, India Office, White- 
hall, London, S.W.1, and any who are interested in the 
matter should consult personal friends who are actually 
serving in the Indian Medical Service or apply for an 
interview with the medical adviser, India Office, White- 
hall, London, S.W.1. 


to be Bt.-Col. 


500 


THE LANCET] 


PAYING PATIENTS IN HOSPITALS 


PROBLEM OF GLOUCESTERSHIRE ROYAL 
INFIRMARY 


A SPECIAL meeting of the governors of the 
Gloucestershire Royal Infirmary was called a week or 
two ago to consider the conflicting interests of the 
workpeople’s contribution scheme and the medical 
staff. After a long discussion the following resolution, 
proposed by the chairman, Mr. Stamford Hutton, 
was adopted by 29 votes to 24 :— 

That it be an instruction to the weekly board to inves- 
tigate the best means of meeting the wishes of the medical 
staff with regard to (1) the limitation of persons attending 
= as out-patients to those whose means are insufficient to 
enable them to obtain as private patients the advice and 
treatment required ; (2) the setting up in connexion with 
the Infirmary of paying wards freed of any restrictions 
as to income—and to report thereon to the general 
committee. 

Speaking to this resolution, Mr. Hutton said that, 
while on the one hand the honorary medical staff 
had good grounds for complaint about hospital 
abuse, the committee in charge of the contributory 
scheme had an idea that the medical staff were 
seeking to exploit this scheme in their own interests. 
The staff were convinced that stricter supervision 
was needed in order to prevent members of the 
scheme from getting free treatment in the out-patient 
department when they could afford to go to private 
doctors. This was an accepted principle of the 
hospital; request was set out in the printed annual 
report that the hospital subscriber should inform 
himself of the circumstances of the patient whom he 
recommended for admission. No contributory scheme 
should be allowed to alter the basis upon which the 
institution was run—namely, for those who had not 
the ability to pay for their cure. While the hospital 
authorities did not make any charge for treatment 
they were entitled to recover overhead expenses. 
The medical staff contended, and Mr. Hutton said 
he agreed with them, that some limit ought to be 
placed upon the income of the contributors. This 
was done at: other institutions of the kind. On 
inquiry he found that of 50 hospitals with a similar 
scheme in 33 there was an income limit of £5 per 
week; 44 of the 50 made some inquiry into the 
means of contributors who applied for hospital care. 
The abuse of the out-patient department was, Mr. 
Hutton added, not restricted to contributors of the 
scheme. Turning to the question of paying wards, 
admission of private patients to these was limited ‘to 
those with incomes below £400 for a single man or 
woman, below £500 where there was a family. The 
medical staff asked to have the income limit done 
away with. Again, from inquiries he had made he 
was in a position to state that 39 of 53 hospitals in 
the provinces admitted private patients irrespective 
of their financial position. They had been reminded 
that the Infirmary had a waiting-list of 116; this 
was a matter for regret, but he felt sure that no 
reasonable increase in the number of beds. would 
diminish this list because the hospital spirit had 
become so prevalent among those who wanted to go 
into the ordinary wards that without a close scrutiny 
of income they would never be able to keep within 
the limits. Unless they abolished’ the income limit 
for paying patients Mr. Hutton felt they were not 
making medical practice sufficiently attractive to 
induce the best class of medical men to settle in the 


SPECIAL ARTICLES 


[FEB. 29, 1936 


district, and the standard would go down. Hospitals 
were getting more and more expensive and delicate 
machinery and appliances which required men who 
had been trained to use them. When the paying 
wards were set up in 1925 it was hoped that they 
would not interfere with nursing-homes, but that 
hope had not been verified. 

In his reply, Mr. W. C. Oxenham, chairman of 
the workpeople’s hospital committee, said there was 
some reason for the appointment of an almoner to 
see that consultations were not obtained by people 
who could afford to pay, but he was doubtful whether 
the doctors should receive a percentage of the con- 
tributions of the workpeople, at all events not 25 per 
cent., and he doubted whether the paying wards had 
seriously diminished the doctors’ incomes, as examina- 
tion of the figures showed that last year they received 
some 60 per cent. of the income from the wards. 
If the doctors were permitted to charge what fees 
they liked, could anyone, he said, see people of 
moderate means ever getting into the wards? The 
provision of nursing-homes for people with affluent 
means was still a business proposition. 

Speaking on behalf of the honorary medical staff, 
Dr. A. Alcock said that in his time the number of 
beds at the hospital had increased from 80 to some- 
thing like 200, which meant a great deal more work 
for the staff, and it could not be seriously contended 
that this big increase came from people who were 
destitute of means to pay. Times were surely not 
as bad as that. There was no doubt that the doctors’ 
private practice had declined because of the work- 
people’s contribution scheme. Is it fair or right, 
he said, to expect the doctor to treat for nothing a 
man earning £5 a week? Nursing-homes certainly 
were now not business enterprises. . 

After a lively discussion in which it was stated 
that, if the doctors’ proposals were accepted, collectors 
for the hospital scheme would be in an embarrassing 
position and scores of people would stop contributing, 
the chairman’s resolution was adopted. 


MEDICINE AND THE LAW 


Alleged Negligence in Hypodermic Injection 


THE Privy Council dismissed the appeal of a 
doctor last week in Caldeira v. Gray, where the 
Supreme Court of Trinidad, after a hearing which 
lasted several weeks, had awarded the patient 
£864 3s. 4d. damages for negligent treatment. The 
negligence was alleged to have occurred in hypodermic 
injections of quinine in the right buttock. It was 
said that the needle had been so unskilfully inserted 
as to injure the sciatic nerve. The plaintiff com- 
plained that, immediately after he got up from the 
bed on which he lay while the injection was made, 
he walked with a dropped right foot, and that the 
disability had continued ever since. There was 
a great volume of medical evidence taken in the 
Trinidad Court; it had been exhaustively analysed 
by the trial judge and the Privy Council did not 
attempt to go through it all again. Each side had 
given its own explanation of the injury. The patient 
said that either the needle pierced the sciatic nerve 
or else the injection was made so close to the nerve 
that the quinine permeated into the nerve; he had 
no symptoms of foot-drop before the injection. 
The trial judge accepted this explanation, observing 
that it was fair to infer that the injection caused, or 


THE LANCET] 


contributed to, the foot-drop. The doctor explained 
the injury by saying that the patient had suffered 
from latent alcoholic neuritis before the injection 
and that the alcoholic toxins in the patient’s system 
were lit up and precipitated by the shock of the 
injection. There was, however, no definite evidence 
of the existence of the latent alcoholic neuritis ; 
the patient was willing to confess that he enjoyed 
an occasional ‘“‘ spree,’ but no witness put the case 
for alcoholism any higher than that. The medical 
witnesses who gave evidence on behalf of the doctor 
during the Trinidad hearing could claim no actual 
experience of latent alcoholic neuritis precipitated 
by shock; they agreed that such a condition was 
rare and they were unable to cite a single authentic 
case which lent full support to the theory. Thus 
‘the defendant doctor’s explanation could be described 
by the trial judge and by the appellate tribunal as 
resting on mere speculation. It presupposed 
alcoholism in the patient and it required the concurrent 
existence of two conditions—namely, the existence 
of latent alcoholic neuritis and the flaring up of the 
neuritis upon so slight a shock as the injection would 
cause. The Privy Council considered that the 
concurrence of these two conditions was, on the 
evidence, highly improbable. It was argued for the 
doctor that an experienced practitioner could not 
have made the cardinal and elementary blunder 
attributed to him by the patient. Lord Alness, who 
delivered the judgment of the Privy Council, recalled 
that there were many instances of signalmen and 
engine-drivers of experience who on occasion neglected 
their duty. Their lapses illustrated the principle 
that familiarity might breed contempt and that an 
ordinary practice sometimes lacked the constant 
care which the circumstances demanded. Be that 
as it may, the judgment declared that the patient’s 
explanation of his disability, supported by the 
medical evidence which he adduced, had not been 
displaced by evidence on the other side. The case 
for the plaintiff was clear, simple, and straightforward ; 
the case for the defendant doctor was speculative, 
theoretic, and unconvincing. 

Although the Privy Council thus tended to express 
its own opinion upon the merits of the claim, the 
appeal was not a re-trial. The Trinidad Court had 
carefully and dispassionately weighed the two 
conflicting theories and had reached a clear conclusion 
of fact in favour of the patient. It is not the practice 
of the Judicial Committee of the Privy Council to 
reverse a conclusion of fact based upon adequate 
evidence. The principle is the same as that which 
was decisive not long ago in the House of Lords 
case of Powell v. Streatham Nursing Home. The 
trial court has an overwhelming advantage over the 
appellate tribunals in that it has seen and heard the 
parties and their witnesses. 


Professional Libel Action Settled 


Dr. A. M. Simpson’s libel action, claiming damages 
against the eight doctors constituting the medical 
committee of St. Paul’s Hospital, Endell-street, 
W.C., and a subcommittee of one of the departments 
of the hospital, was settled in Mr. Justice Macnaghten’s 
court last week. The plaintiff, for many years 
honorary surgeon at the hospital, had attended 
before a subcommittee set up by the committee of 
management to inquire into part of the hospital’s 
work. His comments and criticisms at this inquiry 
became known to other members of the staff. The 
defendants drew up replies to his criticisms before 
the committee had made any report. These replies 
imputed personal motives to the plaintiff. The 


MEDICINE AND THE LAW.—-AUSTRALASIA 


of the hospital. 


‘Permanent Post-Graduate Committee. 


‘University was essential. 


7 


[FEB. 29, 1936 501 


‘combination of his critics and the publication of 


the statements about his motives resulted in his 
not being re-elected to the position of senior surgeon 
Such was the account given by his 
counsel, Sir Patrick Hastings, in announcing the 
settlement of the case and the withdrawal of all 
imputations. Mr.Norman Birkett, for the defendants, 
handsomely agreed with what had been said, and the 
judge pronounced his benediction. If there must 


‘be libel actions between professional men, the best 


kind of libel action is’ one which is happily settled 
before witnesses are called. It is profitable to the 
bar if, when once briefs have been delivered, the 
presentment of the case in court can be concluded 
in a few minutes and in the easy atmosphere of 
mutual compliments. Would it not be profitable 
to the medical profession if there were some earlier 
method of composing differences with less expense 
and less publicity ? 


AUSTRALASIA 
(FROM OUR OWN CORRESPONDENT) 


POST-GRADUATE WORK IN NEW SOUTH WALES 


IMPORTANT changes have taken place during the 
last few months in the organisation of post-graduate 
work in New South Wales. Occasional courses for 
graduates have been held in Sydney since 1900 
by the University and by the New South Wales 
branch of the British Medical Association, which 
provided teaching and instruction for its members 
by means of lectures and clinical meetings. In 
Victoria, a lead had been given by the appointment 
of the Melbourne Permanent Post-Graduate Com- 
mittee, and in 1929 the New South Wales branch 
formed a standing committee of its council for the 
purpose of organising post-graduate work in New 
South Wales. This standing committee showed that 
wider representation and scope and the complete 
control of its own funds was important for the proper 
carrying out of its function. Accordingly, in 
September, 1932, the branch founded an autonomous 
body which was known as the New South Wales 
Under this 
committee, considerable advance was made and post- 
graduate instruction in medicine began to become 
regular and definite. After three years’ working it 
became apparent that still wider scope was re- 
quired and that a close association with Sydney 
After several conferences 
had taken place with the University, the senate, 
on Oct. 10th, 1935, adopted a new by-law which had 
been approved by the Governor, and the Executive 
Council, establishing a committee to be known as the 
New South Wales Post-graduate Committee in 
Medicine, and on Nov. 4th, 1935, the members of this 
new committee were appointed. The old committee 
went out of existence on Nov. 30th, 1935, and all its 
funds and functions, including any matter which 
that committee had undertaken or authorised, 
taken over by the new committee. The by-law 
of the University that constitutes this body provides 
for a fund for the promotion of post-graduate educa- 
tion, study, work, and research, and for the advance- 
ment of the art and science of medicine. The 
Committee consists of the chancellor, the deputy- 
chancellor, the vice-chancellor, and the dean of the 
faculty of medicine as ex-officio members, repre- 
sentative members appointed from the faculty of 
medicine, two from the New South Wales branch 
of the British Medical Association, and frdm the 
honorary medical staffs of a number of metropolitan 


502 THE LANCET] 


SCOTLAND.—IRELAND 


'FEB. 29, 1936 


hospitals. Except for the ex-officio members or a 


member representative of the faculty of medicine, 
no person can be a member of the Committee unless 
he is a member of the British Medical Association, 
and all must be active members of the body which 
they represent. 

After a review of the hospital position in Sydney, 
the Permanent Post-graduate Committee, during its 
last months, approached the Minister for Health 
in Sydney with a request that special accommodation 
should be provided for graduate teaching in Sydney. 
As a result of this, the Government has decided to 
reconstitute the Prince Henry Hospital, Sydney, as 
a post-graduate hospital. This hospital, which will 
have 1100 beds, has hitherto been completely under 
government control. This will cease and the board 
will be controlled by a committee consisting of a 
number of business and medical men, on which it is 
proposed to give representation to the University 
of Sydney, the Royal Australasian College of Surgeons, 
the Association of Physicians, and the New South 
Wales Government. A Bill for this purpose will be 
brought forward shortly by the Minister for Health. 


SCOTLAND 


(FROM OUR OWN CORRESPONDENT) 


THE ROYAL MEDICAL SOCIETY 

Dr. S. A. Kinnier Wilson was the guest of the 
evening at the annual dinner of the Royal Medical 
Society which was held in the hall of the Royal 
College of Surgeons of Edinburgh last week. Dr. 
A. M. McFarlan, the senior president, presided over 
a company of about 120, and the other presidents 
- were Dr. H. M. Adam, Dr. A. F. Barron, and Dr. 
R. T. Campbell. 

In proposing the toast of the guest of the evening, 
the chairman welcomed Dr. Kinnier Wilson as a former 
president of the society and paid a tribute to his 
many contributions to neurology. Dr. Kinnier 
Wilson, in his reply, said he would like to pass on a 
few lessons he had learned in the 33 years that had 
elapsed since he had occupied the presidential chair. 
One was ‘‘ Never show surprise ’’; another, “‘ Never 
say the same thing twice to a patient”; a third 
piece of advice he offered was, “‘ Never believe what 
the patient says the doctor said’’; and a fourth, 
‘“ Be decisive in your indecision.” If doctors did not 
know what a disease was they should know exactly 
what their reasons were for not knowing. A further 
piece of advice was: ‘‘ Never take a meal with your 
patients.” In proposing the toast of the Royal 
Medical Society, Dr. Wilson said that it was at the 
society's meetings that he first learned to stand on 
his feet, to face criticism, and to think medically ; 
it was there that he got his first glimpse of the real 
medical world. The society had a marvellous history 
of nearly 200 years; it was old, but ever new, as it 
was conducted by generations of new men every 
year. Those who had been active members in the 
past were proud to think that they were once part 
of that great wave, sweeping onwards. 

Dr. H. M. Adam, who replied to the toast, referred 
to the preparations which are being made for the 
celebration of the society’s bicentenary: next year. 
The bicentenary fund now amounts to £1500, and 
the Royal Colleges have demonstrated their friendship 
to the society by their generous contributions. He 
thanked the College of Surgeons for allowing the 
society to hold their dinner in the college hall, and 
drew attention to the fact that on one occasion, 
over a hundred years ago, the hall of the College of 


Surgeons was in such a dilapidated state that the 
members of the College were glad to have permission 
to use the hall of the Royal Medical Society. 


NEW GLASGOW CLINIC 


The Lansdowne Clinic for Functional Nervous 
Disorders at 400, Great Western-road, Glasgow, was 
inaugurated at a meeting held last week. The clinic 
is under the management of the directors of the 
Royal Mental Hospital and its function is to supple- 
ment the work carried out by the psychiatric clinics 
already working in Glasgow. Patients will be seen 
at the new out-patient clinic, by appointment, only on 
request of their family physician, for consultation or 
treatment, and will be allocated to a member of the 
medical staff who will arrange for any subsequent 
interviews that may be required, and who will have 
charge of the case throughout in coöperation with 
the family physician. It is hoped that the clinic will 
gradually develop into something much larger to 
meet the great need for the treatment of minor 
nervous disorders. Prof. D. K. Henderson, of 
Edinburgh University, emphasised the value of clinics 
such as these. He thought it would have a large 
social and economic value and should do much to 
relieve those who are nervously ill. Their chief 


work was preventive and it would often enable the 


breadwinner of a family to carry on his daily occu- 
pation with the aid of the treatment he received. 


IRELAND 
(FROM OUR OWN CORRESPONDENT) 


THE IRISH FREE STATE MEDICAL UNION 

THE first meeting of the central council of the 
Irish Free State Medical Union was held in Dublin 
on Feb. 20th, with Prof. T. G. Moorhead in the 
chair. The chief business of the meeting was to 
sign the memorandum and articles of association of 
the Union, and for the signatories to constitute them- 
selves the central council. According to the articles 
such of the subscribers to the memorandum as shall 
be members of the council of the Irish Medical 
Association or of the Irish committee of the British 
Medical Association, resident in the Irish Free State 
at the date of registration of the Union asa company, 
shall form the first central council. Such council 
will hold office until the termination of the annual 
general mecting of the Union to be held in 1936, 
and its members will be eligible for re-election. 
There were about thirty members present, and after 
the signing of the memorandum and articles a general 
discussion took place on the steps to be taken to 
render the Union effective. Dr. John P. Shanley was 
appointed hon. secretary of the Union and Mr. 
C. MacAuley and Dr. Robert J. Rowlette were elected 
joint hon. treasurers. 


A NEW FEVER HOSPITAL FOR DUBLIN 


It has been generally known for some time that 
the Hospitals Commission favoured the establish- 
ment of a new hospital for infectious diseases in or 
near Dublin, in which the existing Cork-street Fever 
Hospital would be merged. The recommendation 
of the Commission has been approved by the Minister 
for Local Government and Public Health, who last 
week introduced in the Dáil a Bill for the purpose 
of establishing such a hospital. It is proposed that 
the board of the hospital shall consist of 20 persons, 
of whom 7 shall be elected by the corporation. of the 
city of Dublin, 3 by the Dublin board of public 
health, 7 by the existing trustees of Cork-street 
Fever Hospital (and their successors, provision being 


' THE LANCET] 


- PUBLIC HEALTH 


(res. 29, 1936 503 


made for a continuing electorate), and 3 to be 
appointed by the Minister. It shall be the duty of 
the hospital to receive, as far as accommodation 
-permits, any patients suffering from infectious 
diseases sent on the order of the medical officers of 
health for the city and for the county of Dublin, 
their assistants, or any dispensary medical officer 
in the city or county of Dublin. Provision is made 
that the corporation of Dublin and the board of 
health shall make payments to the hospital board 
in respect of city and county patients respectively. 
Moreover, the corporation and the board of health 
shall make good any deficiencies in the establishment 
account of the hospital from time to time, their 


contributions being in proportion to the respective 
valuations of the city and the county of Dublin. 
The hospital board, when constituted, is, with all 
convenient speed, to prepare and submit to the 
Minister a scheme for the erection and establishment 
of a new fever hospital in or near Dublin, setting 
out the proposed site, the plans and specifications, 
and the estimated cost. Approval of the scheme 
lies with the Minister who also reserves the right to 
modify the scheme subsequent to approval. It is 
understood that the cost of building and equipping 
the hospital will be met by a grant by the Minister 
under Section 25 of the Public Hospitals Act, 1933, 
from the Sweepstake Funds. 


PUBLIC HEALTH 


THE SPECIAL AREAS 


THE report of the Commissioner for the Special 
Areas! deals primarily with economic conditions but 
merits consideration from its reference to certain 
aspects of public health. 

At the time of the crisis in the cotton trade in 
Lancashire during the American Civil War public 
money was found for and employment provided in 
schemes of sanitary improvenfent under a special 

Act—the Public Works (Manufacturing Districts) 
Act, 1863. To such works many of the Lancashire 
towns owe a definite impetus towards the ameliora- 
tion of the appalling sanitary environment which 
then prevailed. It is of interest to note the repetition 
of this experience during the present distress, and 
that the Commissioner has under his powers approved 
152 grants to local authorities for works of public 
utility totalling a sum of £1,870,872. Grants are 
mostly in respect of sewerage and water schemes but 
have also been made to maternity and child welfare 
centres, and as an illustration of recent trend it is 
significant to remark the emergence of hospital 
grants—e.g., £240,000 to Durham county council 
and £250,000 to Glamorgan county council towards 
the provision of new general hospitals. The assist- 
ance thus rendered is timely in view of the fact 
that the authorities in the special areas are confronted 
with the difficulty that while schemes for ameliora- 
tion of public services may be urgent, the pressure 
of unemployment has both reduced the rateable 
value and increased demands on the authority, as 
by the much enlarged scope of public assistance ; 
thus in County Durham in 1934 (estimated popula- 
tion 914,500) a penny rate produced £12,092, in 
Middlesex (estimated population 1,810,200) the 
produce was £67,788. 

. Food for thought is provided by the observations 
of the Commissioner on the outlook for the adolescent 
population: “‘ probably the most serious problem 
of the Special Areas is that presented by unemploy- 
ment among young men between 18 and 21.” Stress 
is laid on the social aspect of the passing into man- 
hood of youths debarred from useful occupation, 
living in an atmosphere of unemployment, and 

-accustomed from early years to maintenance by the 
State. The population of this age-group is given as 
11,000, of whom 7000 have been unemployed for 
more than three months, so that during the recent 
black years in these areas a multitude has passed 
forward handicapped by this depressing passage 
from youth to manhood. The Commissioner shows 
concern, however, not only with this moral, social, 
and psychological reaction but also with the physical 

1 Second Report of the Commissioner for the Special Areas 


(England and Wales), 1936. Cmd. 5090. London: 
Stationery Office. 2s. 


condition of this section of the community. He 
states ‘‘the percentage of rejections on medical 
grounds for juvenile transfer centres and for the 


men’s instructional centres is alarmingly high.” 


Reference to this question is to be found in the 
recent annual report on ‘“‘ The Health of the School 
Child,” and in the report by the Ministry of Health 
on conditions in Sunderland and the adjacent areas 
which stated ‘‘the condition of adolescent youths 
especially those aged 14 and 15 years is the least 
satisfactory feature of our findings.” Anyone 
acquainted with the special areas must be seriously 
concerned by the problem of the unemployed 
adolescent. | 

It is well that the Commissioner can report some 
encouraging features, and it is to be hoped that the 
return of these areas to brighter conditions may not 
be indefinitely delayed. Limbs from which the blood- 
supply is cut off cannot but react on the body | 
corporate. 


‘INFECTIOUS DISEASE 


IN ENGLAND AND WALES DURING THE WEEK ENDED 
FEB. 15TH, 1936 


Notifications.—The following cases of infectious 
disease were notified during the week: Small-pox, 
0; scarlet fever, 2173; diphtheria, 1203; enteric 
fever, 16; acute pneumonia (primary or influenzal), 
1308 ; puerperal fever, 34; puerperal pyrexia, 99 ; 
cerebro-spinal fever, 22; acute poliomyelitis, 2 ; 
acute polio-encephalitis, 1; encephalitis lethargica, 
4; continued fever, 1 (Rugby R.D.); dysentery, 42 ; 
ophthalmia neonatorum, 79. No case of cholera, 
plague, or typhus fever was notified during the week. 

The number of cases in the Infectious Hospitals of the London 
County Council on Feb. 21st was 4617, which included : Scarlet 
fever, 987; diphtheria, 1094 ; measles, 1194 ; whooping-cough, 
693 ; puerperal fever, 22 motbers (plus 15 babies) ; encephalitis 
lethargica, 281 : poliomyelitis, 3. At St. Margaret’s Hospital 
there were 22 babics (plus 11 mothers) with ophthalmia 
neonatorum. 

Deaths.—In_ 121 great towns, including London, 
there was no death from small-pox, 1 (1) from enteric 
fever, 58 (S) from measles, 5 (1) from scarlet fever, 


41 (13) from whooping-cough, 48 (7) from diphtheria, 


47 (8) from diarrhcea and enteritis under two years, 


and 97 (12) from influenza. The figures in parentheses 
are those for London itself. 

The mortality from influenza remains much the same, the 
total deaths for the last 11 weeks (working backwards) being 
97, 85, 98, 104, 89, 110, 110, 80, 67, 62, 45. The deaths this 
week are scatterd over 52 great towns, Birmingham reporting 
6, Portsmouth and Salford each 4, Willesden, Oxford, Bradford, 
Liverpool, Manchester, Rochdale, and Wallasey each 3; no 
other great town more than 2. Liverpool and Manchester 
each had 10 deaths from measles, Middlesbrough 4, Croydon, 
Salford, Sheffield, Warrington, and Bristol each 3. Whooping- 
cough caused 4 deaths at Birmingham, 3 each at Manchester 
and Salford. Deaths from diphtheria were reported from 
27 great towns: 4 from Liverpool, 3 each from Hull, West 
Hartlepool, and Plymouth. 


The number of stillbirths notified during the week 
was 253 (corresponding to a rate of 40 per 1000 total 
births), including 38 in London. 


504 THE LANCET] © 


[FEB. 29, 1936 


CORRESPONDENCE ' 


ARTIFICIAL RESPIRATION FOR THREE AND 
A HALF YEARS | 


To the Editor of Tur LANCET 


Sir,—I described an unusual case of prolonged 
artificial respiration in your issue of April 14th, 
1934, and I have now to report that the patient, a 
man who suffered from progressive muscular atrophy, 
died a few days ago at the age of 66. It may be 
recalled that respiratory paralysis began in 1932, and 
was at first intermittent, but continuous artificial 
respiration became necessary from June, 1932, until 
his death. An unorthodox manual method was in 
use for many months before Sir William Bragg 
introduced a.very successful device, using simple 
apparatus and the experimental method. Eventually 
a machine worked by the water-supply was specially 
designed and made by Mr. R. W. Paul. The first 
instrument was installed in October, 1933. An 
improved model was substituted a month or so later, 
and this was in use thereafter. One slight alteration 
in design was made in October, 1934, in order to 
improve the lubrication, but no fundamental change 
or repair became necessary, in spite of the continuous 
wear caused by the 700 gallons of water which each 
day passed through it. Fortunately there was no 
shortage of water in the district during the last two 
dry summers. On one occasion the water-supply 
was cut off without notice, on account of repairs to 
the main; and once the water-pipes froze. The 
original manual method was used in both emergencies, 
and the patient was never left alone for fear of such 
accidents. An alarm note, resembling that of a bird, 
could be uttered by the patient with tongue and 
teeth without breath, and it was arranged that this 
should be a danger-signal to be used if the machine 
stopped working and the attendant did not notice. 

The medical history after 1934 was almost as 
eventless as the scientific. No new symptoms arose 
until near the end, and the slight difficulty in 
swallowing became less. Dr. W. T. Mills, who was 
in charge of the case, and to whom I am indebted 
for the clinical details, treated occasional difficulty 
due to collections of mucus in the respiratory passages 
with atropine, and two respiratory infections with 
injections of ‘‘ pneumococcus immunogen combined.” 
Great care was taken with the skin, and no bedsores 
developed, in spite of the fact that the patient was 
moved very little, because there was only one 
position in which he was really comfortable. During 
the daily washing, which took 13-2 hours, the manual 
method of artificial respiration was employed, which 
gave the chest a relief from the wearing of the belt. 
The patient remained mentally active to the last, 
and both apparatus and illness ran so smooth a 


course that the chief feature of the case became an ` 


unforgettable revelation of how rich life could remain 
with an incapacitated body when the spirit was 
unconquered. During the last few days of the 
patient’s life he had a gastro-intestinal disorder, 
together with difficulty in opening his mouth and in 
swallowing. He died while he was asleep. 

The artificial respiration apparatus has become 
known as the Bragg-Paul Pulsator, and an elec- 
trically worked model has been described by Mr. Paul 
in the Proceedings of the Royal Society of Medicine 
(1935, xxviii., 436). Its manufacture has been taken 
up by a firm of safety engineers, Messrs. Siebe, 
Gorman and Co., of 187, Westminster Bridge-road, 
London S.W. This firm keeps one instrument which 


is available for hire in emergencies. It can be 
obtained by telephoning Waterloo 6071 by day or 
night, and arranging for transport. The machine 
has been used successfully for cases of temporary 
respiratory paralysis complicating diphtheria, and 
anterior poliomyelitis. It has been installed in the 
first-aid room of a large mining concern for cases of 
gas poisoning. A miniature model is on trial for 
selected cases of asphyxia neonatorum. 
I am, Sir, yours faithfully, 
PHYLLIS M. TooKEY KERRIDGE. 
University College, Gower-street, W.C., Feb. 24th. 


THE EMBLEY MEMORIAL LECTURE 
To the Editor of THE LANCET 


Sir,—You were good enough to refer in your issue 
of Feb. 22nd (p. 438) to the Embley memorial lecture 
which I delivered in Melbourne in September last, 
and to note that it has been published in the Medical 
Journal of Australia. I was gratified at the publica- 
tion of the lecture, but it was accompanied by an 
editorial expression „of opinion against which I 
have felt it necessary to protest. I would ask if 
that protest may appear in THE LANCET as it is 
quite possible that those readers who see the Medical 
Journal of Australia may read the denunciatory 
leading article there but not the lecture itself. The 
leading article closes with the following passage :— 


“ The results of the modern type of cerebral operation 
speak for themselves. If in the future surgeons are able 
to evolve newer methods of securing the necessary gentle 
handling of tissues, asepsis, hemostasis, and so forth, 
together with speed, Dr. Mennell’s wish will be gratified. 
This does not at present seem possible. Dr. Mennell 
comes from London as an anesthetist of world-wide 
reputation. His views on anesthetics and their adminis- 
tration will be listened to with respect. His utterances 
on cerebral surgery are to be deplored in a country where 
neuro-surgeons are trying to bring their art to the high 
level attained in other parts of the world. It is to be 
hoped that no serious attention will be paid to them.” 


In support of this contemptuous view the article 
says :— 

“ It can be dogmatically stated that the present so-called 
slow technique has achieved infinitely better results than 
were obtained by the older methods. To refuse to follow 
modern methods with a slavish attention to minute 
detail is to jeopardise the life of the patient. It has 
been computed that at present the death-rate for complete 
removal of cerebral tumours in Australia, even with the 
use of modern methods, is somewhere in the region of 
80 per cent. Cushing has for certain types of tumour 
brought his mortality down to as low as 7 per cent. What 
the death-rate with the old rapid methods was may be 
left to the imagination. ... When the operation was 
performed rapidly, it was the exception rather than the 
rule for the patient to recover.” 


Since writing the above I have seen the leading 
article in Tur LAnceT of Feb. 22nd entitled The 
Gentle Surgeon, and it appears to me apposite to the 
remarks made in my Embley lecture and for which 
I am criticised. Nobody can dispute what is said 
in your leading article about the surgery in the early 
part of this century, or that the advance in anws- 
thesia and the better understanding of shock have 
enabled surgeons to do without the extreme slashing 
speed formerly necessary. But surely the pendulum 
has swung too far, more surgeons relying on the better 
anesthesia for a too great deliberateness in their 
methods. Gentleness and care combined with unflurried 
speed are the essentials of good surgery. 


THE LANCET] 


In reply to the Medical Journal of Australia 
I have made the following protest which they will 
have received by now, and which I shall be much 
obligea if you will quote. 
I am, Sir, yours faithfully, 


Harley-stroet, W., Feb. 21st. Z. MENNELL. 


COPY OF LETTER SENT TO THE EDITOR OF THE 
Medical Journal of Australia 
Feb. 4th, 1936 


Sir,—Holding the views you have so clearly and 
forcibly expressed in your leader of Dec. 14th, I feel I 
must first thank you for your courtesy in giving a 
verbatim report of the Embley lecture I delivered in 
Melbourne in September, 1935. 

The slides, through an error, have been referred to 
incorrectly, but notwithstanding the well-known diff- 
culty of reproducing coloured slides, they remain clear 
enough for anyone reading the paper to realise the mistake. 

Your leader is another matter; I wrote the lecture 
with extreme care, and apart from my'‘personal views I 
am entitled without giving offence to give reasons why a 
change in anesthesia has become necessary in certain 
cases. No one can be more alive than I am to the fact 
that there are two schools of thought in intracranial 
surgery, but I am convinced that speed and gentleness 
are compatible. 

You speak first of all of thoracic surgery. Surely it 
must be admitted that in this work speed is essential 
whether the operation is done under a local or general 
anesthetic. The most recent lobectomy to which I gave 
an anesthetic was done in twenty minutes under a very 
light chloroform anesthesia, and the excellent result in 
this and in other cases in which I have been concerned 
makes me think that in the future the mortality of this 
very serious procedure may be lowered by a combination 
of speed and simple anesthesia. 

I can well understand that when you admit an Aus- 
tralian operative mortality of 80 per cent. for the removal 
of- cerebral tumours some change is desirable. Such a 
mortality is far higher than anything I have met during 
the thirty-two years I have been giving anesthetics for 
such cases. It is because I believe certain neurological 
surgeons have evolved “the necessary gentle handling 
of the tissues, asepsis, hemostasis, and so forth together 
with speed ” that “‘I cannot understand why it is neces- 
sary to be so slow ’”’ in making a bone flap, &c. Giving 
anzesthetics to such cases almost daily, and seeing them 
afterwards, makes it possible to form the opinion which 
I felt at liberty to express. I do so more readily as I have 
had the opportunity of seeing cerebral surgery in the new 
world and on the continent as well as in England. Are 
Dandy and Adson, whose skill is recognised throughout 
the world, slow operators? You will naturally reply to 
this more “‘vague and goneral statements.” I have 
figures of course that could be made to prove anything, 
as they would include many desperate cases and a great 
variety of tumours. 

Here are the figures of four sets of cases. 


1. Pituitary tumours operated on by the intracranial 
route in one year. Twenty-one consecutive cases in 1928 
without any untoward symptoms or death. Shortest 
time forty minutes ; longest seventy-five minutes. Neither 
the late Sir Percy Sargent, who was the surgeon, nor I 
could claim this a constant figure; but the facts are as 
stated. Anesthetic: intratracheal ether with pressure. 


2. Gliomata unselected and unclassified. The late Sir 
Percy Sargent’s records, analysed by Mr. Harvey Jackson, 
who has given me the following data. 

Two hundred and sixty successive cerebral gliomata— 
mortality 12-7 per cent. within forty-eight hours. 

This is case mortality and not operative mortality, 
which would be considerably lower. 


3. Hedonal anesthesia. A hundred and twelve cerebral 
tumours removed reported in the Transactions of the 
Royal Society of Medicine, Section of Anmwsthetics, 1922. 
No death from anesthetic within twenty-four hours. 


4. To illustrate work with which I am concerned in 
London (if one may venture to cite English experiences 


DUTIES AND RESPONSIBILITIES OF A SHIP’S SURGEON 


(res. 29, 1936 505 


in Sydney) I quote one of my last cases (surgeon, Mr. 
Julian Taylor). 


H. L. 38. Operation Jan. 31st, 1936, for left parietal 


endothclioma. Anæsthetic started 11, 20 'A. M. Large bone 
flap extending across midline. Tumour, weighing 82 grammes, 
removed. Part of the bone flap taken out which was invaded 
by the tumour, and then fixed in position. Wound closed and 
patient in bed 1 P.M. Condition good. Ansesthetic: Atropine, 
ss gst N.O and Qy,, ether i 
r A 2nd: Patient Sooria bie: Sitting up in bed eating 
00 

Patient 


To-day, Feb. 4th: Pulse 76, temperature 97:6°. 
sitting up apparcntly without abnormal symptoms. 

The use of local anesthesia and basal narcotics may 
be ‘the most usual practice in Australia, it is not here. 
A small quantity of ether added to continuous stream of 
gas-and-oxygen is believed to be best after an extensive 
trial of other methods. I hasten to add pulmonary 
complications do not occur. 

My first impression on reading your leader was surprise, 
but then it occurred to me how my old friend, Embley, 
would have risen to the occasion, and I only wish I had 
his facile pen and power of expression at my command. 

I am, Sir, yours faithfully, 
Z. MENNELL. 


‘‘MORBUS BRITANNICUS ” 
To the Editor of THE LANCET 


SIR, —Dr. Copeland reproaches me with attaching 
a new label to an old disease. It should be evident 
from my note that it was not at all my purpose to 
make new confusing labels to put in text-books, 
which are most of them surely too big already. I 
only wanted to call attention to the fact that at the 
Faroe Islands we observed so many cases of fire- 
man’s cramp, among British fishermen only, that we 
gave the illness a simple geographical name. I 
emphasised that it is a form of fireman’s cramp, and 
referred to Haldane’s researches into miner’s cramp, 
which Macintyre evidently also considers important 
in the pathogenesis of fireman’s cramp. That it is 
an acute vagotonia I for my part am inclined to 
doubt, first because similar symptoms are observed 
in ulcer-stenosis as gastric tetany, secondly because 
the amount of chlorine in the urine is plainly reduced. 
Examination of the blood should decide that. The 
observation that atropine relieves the symptoms in 
some cases I can confirm, but it does not rule out 
deficiency of salt or chlorine ions as causing the 
illness. The fact that a supply of chlorine ions 
intravenously or rectally can cure the illness at a 
stroke appears to me much more significant. 


I ain, Sir, yours faithfully, 
Klaksvig, Feroe, Feb. 14th. Sv. E. KOFOED. 


DUTIES AND RESPONSIBILITIES OF A 
SHIP’S SURGEON 


To the Editor of THE LANCET 


Srr,—After fifteen years ashore in general practice 
I entered on the duties and great responsibilities of 
a ship’s surgeon on a big liner plying between London 
and Japan. In common with a large number of my 
brethren ashore I thought that it would be a light 
task. I found, of course, that it is a specialised job 
which needs a considerable time to learn the way of. 
That by the way. I am hoping that this letter may 
draw the attention of the profession to those cases 
which are not suitable to be sent for a “‘ sea voyage.” 
I made the mistakes myself in practice and it is only 
since I have been at sea that I have realised what 
gross mistakes they are. 

Let me say that the resources of the modern liner 
are such, nowadays, that almost any treatment can 
be carried out on board provided that due notice is 
given of anything special that will be needed. Again, 


506 THE LANCET] 


it is often necessary for a given individual to be 
conveyed from one place to another irrespective of 
what he is suffering from. This can be easily arranged, 
but the surgeon should be notified in good time and 
certain conditions must be agreed to. It is not 
with such cases that I am dealing. It is with those 
patients for whom the doctor in charge prescribes a 
‘sea voyage.” I often think that this prescription 
is sometimes given to get them out of sight and out 
of mind. The particular types of cases I have in 
mind are :— 

l. Pulmonary cases with a cough.—From a physical 
point of view the rapid changes of temperature on a 
voyage such as this, together with the extreme 
humidity experienced after Port Said, are reasons 
enough to contra-indicate recommending such a case 
to take a sea trip. But think of the psychological 
aspect. Everything that happens on board is known 
all round the ship within a few hours; there are no 
secrets. What patient can refrain from discussing 
symptoms, especially a consumptive. The fact 
becomes known and the patient is ostracised, very 
kindly, but nevertheless ostracised. I have not dealt 
with the obvious danger to other passengers in such 
an enclosed space. 

2. Neurasthenia.—This is the favourite type to 
send to sea and the most unsuitable. The phrase 
includes all types, the most usual of which are 
(a) melancholic; (b) dipsomaniac; (e) the unstable 
type. 

(a) Melancholic.—The opportunities for suicide on 
board ship must be seen to be believed. There is to 
start with a long ship’s side with sea all around into 
which the would-be suicide can plunge. He has a 
cabin to himself in which he can lock himself and do 
what he pleases. By nature morose he establishes 
very few contacts with his fellow passengers and 
goes from bad to worse. The first thing the surgeon 
hears is that he has gone overboard. Apart from 
the fact that this costs the company a good deal of 
money, in stopping the ship and picking him up, it 
is good marks neither to the doctor who sent him on 
the voyage for his health nor to the ship’s surgeon 
who knew nothing about him. 

(b) The dipsomaniac.—This is an obvious case which 
should not be sent to sea. The opportunities for 
drinking on board are unlimited. The “chit” 
system makes it very difficult to check and control 
the amount of alcohol any given man consumes. 
And he can always get a drink from a friend. 

(c) The unstable type.—Until I came to sea I did 
not know that so many very odd people existed. 
I have had to deal with borderline cases and oddities 
of all kinds, and they have all given rise to a great 
deal of anxiety, chiefly from the danger and oppor- 
tunity of suicide but also owing to the resentment 
of other passengers. One lady of uncertain age 
caused alarm to women passengers by claiming 
relationship with a different Royal family each day. 
Another girl was an aggressive nymphomaniac. 
A man had the habit of wandering around the ship 
at night waking up complete strangers and demanding 
all manner of things from cigarettes to typewriters. 
This last, I found later, a man of good family, had 
been released from a mental nursing-home two days 
before the ship sailed and put on board by himself 
and without notification to anyone. 

3. The venereal case.—It will hardly be believed 
that on three occasions I have found, by chance, 
cases of acute gonorrhea, travelling in cabins with 
other passengers, who have been instructed by their 
doctors to douche themselves in one of the ship’s 
baths. Apart from the danger to his cabin mate, 


A DANGEROUS REMEDY 


[FEB. 29, 1936 


the fact that the bath will be used by eight or ten 
other passengers makes such instructions almost 
criminal, 

There are other unsuitable people who are sent to 
sea for their health, but the above are the most 
common. 

In conclusion let me say that any ship’s surgeon, 
at any rate in the bigger lines, will be always ready 
to codperate in any way he can to make the path 
of a patient easy and as pleasant as possible. If the 
doctor in charge of the intended passenger will 
take the surgeon into his confidence, let him have 
what notes are necessary for the proper under- 
standing of the case and suggestions for the con- 
tinuance of treatment, much more satisfactory results 
will ensue.—I am, Sir, yours faithfully, 

Feb. 24th. SHIP’S SURGEON. 


A DANGEROUS REMEDY 
To the Editor of THE LANCET 


Sır —The Manchester Guardian of Feb. 21st reports 
the case of a 14-year-old boy who was forced by his 
father to eat a cigarette as a cure for smoking. The 
father’s action appears to have received the approval 
of the court. 

You have previously published notes of certain 
cases of nicotine poisoning in which patients of 
mine have been seriously affected by absorption of 
pure nicotine through the skin. Such experience as 
I have in this type of poisoning leads me to send 
you an emphatic protest regarding the treatment of 
cases of juvenile smoking by the method related 
above. If this method should be adopted by other 
parents I think there will undoubtedly be fatalities 
and it is a pity that approval should have been 
given to what is obviously a most mistaken course. 

When a cigarette is smoked the nicotine is oxidised, 
but when it is eaten or when a decoction of tobacco 
is applied to the body there is grave risk of serious 
poisoning, and I trust that the attention of the 
authorities may be drawn to what is obviously a 
little realised but nevertheless serious risk. 

I am, Sir, yours faithfully, 


Nottingham, Feb. 24th. L. P. LOCKHART. 


THE OXYGEN: TENT SERVICE 
To the Editor of THE LANCET 


SIR, —An oxygen tent of the Guy’s Hospital pattern 
has been sent by the British Red Cross Society to 
each teaching hospital in London, so that a wide 
experience of this method of treatment may be 
gained. In this connexion we have been asked 
by the society to act as a small medical advisory 
committee. 

We desire to draw the attention of the profession 
to the facilities afforded by the Oxygen Tent Service, 
which is at present under our control. For over. two 
years arrangements have been made to send a tent 
to any part of the country and even abroad at the 
request of any medical man. A physicist, not 
medically qualified, accompanies the tent. The 
furthest distance a tent has travelled is to Gibraltar 
at the request of a well-known physician. Applications 
should be made to the secretary, Mr. T. W. Adams, 
A.Inst.P., and the address (for the present) is 25, Upper 
Wimpole-street, W. 1 (Tel.: Welbeck 1627). 


We are, Sir, yours faithfully, 


REGINALD HILTON, WILFRED J. PEARSON, 


E. P. POULTON. 
'London, W., Feb. 24th. 


THE LANCET] 


WHAT IS SCARLET FEVER FOR THE 
CLINICIAN ? 


To the Editor of Tur LANCET 


Sir,—In the admirable paper on this subject 
published in your last issue, Dr. F. G. Hobson says 
much that will be accepted by those who have had 
experience in throat infections and in scarlet fever— 
if for a little longer we may be allowed to use that 
term. It is refreshing to have a challenging article 
such as this, for the time is certainly ripe to take 
stock of and to readjust our attitude to streptococcal 
infection in general. Whether much will be gained 
by abandoning the term scarlet fever is, however, 
debatable. Even though it is the name only of a 
syndrome, and there are, as in all infectious syndromes, 
borderline and atypical cases, the term is useful. 
Scarlet fever is a convenient description of a type of 
streptococcal infection in a non-immune. That the 
field of streptococcal infection is wider than has been 
appreciated in the past is no reason why a well- 
mapped corner of it should lose its notice board. 

A fundamental point on which much more evidence 
is required is the statement that the liability to 
serious complications appears to be slightly greater 
= in cases without an erythema, or in other words, 
that erythema is a favourable sign. This surely is 
exceedingly doubtful. Only an exhaustive clinical 
study of non-erythematous streptococcal tonsillitis 
for the periods and under the conditions in which 
we observe scarlet fever could settle this. After 
all, the erythema is an indication of non-immunity. 
It is suggested that a non-immune is better off than 
a partial immune. If this be so, I do my staff a 
disservice when I immunise the Dick-positive reactors 
among them. Given the same streptococcus, is 
it safer to have scarlet fever than tonsillitis? I 
doubt it. And if erythema is a favourable sign, 
why should we give serum, one of the demonstrable 
effects of which, if given early and intravenously, 
is to abolish the rash. 

If we ask ‘‘ what is scarlet fever for the clinician ”’ 
we must also ask “what is, streptococcal infection 
for the bacteriologist.”” For some little time we 
have been plating the throat swabs of scarlet fever 
admissions on blood agar. The cases are typical of 
the prevailing mild scarlet fever of the district. 
The striking feature of these plates is the mixed 
streptococcal infection present. (§-hzemolytic strepto- 
coccal colonies may be scanty, fairly numerous, or 
numerous, but the other organisms which usually 
outnumber them are «-hxmolytic and non-hxemolytic 
streptococci with a few staphylococci. In one 
case no ß colonies were found, but repeat swabs 
were not obtained. The picture differs according 
to the blood plates used, the same swab sown on to 
(1) horse blood agar, (2) human blood (individual A) 
agar, and (3) human blood (individual B) agar showed : 
(1) good growth but no hemolytic streptococcal 
colonies; (2) good growth with one or two doubtful 
hxemolytic colonies; (3) good growth with numerous 
typical £®-hemolytic colonies. I mention these 
points to illustrate the complexity of working out 
throat infections and the need for a standard tech- 
nique if, as has been suggested, swabs are to be used 
as a public health measure. 

“ Scarlet fever’? or ‘streptococcal fever with 
erythema.” Such would appear to be Dr. Hobson’s 
choice. After all a disease is not a thing. There 
are no infective diseases, there are only organisms 
infecting hosts and producing no symptoins or varying 
symptoms. Dr. Hobson may call meningococcal 
fever a disease, but I might call it a rare complication 


WHAT IS SCARLET FEVER FOR THE CLINICIAN ? 


[FEB. 29, 1936 507 


following infection of the nasopharynx by the 
meningococcus. What’s in a name? Only a short 
description of a clinical syndrome and as such it is 
useful. Scarlet fever is a useful term. 

Dr. Hobson’s refreshing paper might well have been 
entitled What can Public Health do for Streptococcal 
Infection. It is a plea for something more than the 
abolition of a name. It calls for further study of 
these infections and a reconsideration of our policy 
towards them. We want our fever hospitals to 
do the most needed and most useful work possible 
and if there are better indications for the admission 
of streptococcal fever than the presence of a rash, 
let us use them. But what these indications are 
and how they can best be applied are wide problems 
on which much thought will be needed. Should all 
cases of tonsillitis and other streptococcal infections 
be notified? I can hear both general practitioners 
and medical officers of health, with an unusual 
unanimity, say Heaven forbid. This and many other 
questions are involved and Dr. Hobson’s paper should 
hasten their consideration. 

I am, Sir, yours faithfully, 
H. Mason LEETE. 

Hull City Hospital, Cottingham, Yorks, Feb. 24th. 


To the Editor of THE LANCET 


Sir,—The question which forms the title of Dr. 
Hobson’s excellent article is one which has been 
puzzling many practitioners for a long time. A 
paper discussing some of the points he raises was 
contributed by one of us (J. C. S.) to the Medical 
Officer of Jan. 18th last, and a complementary paper 
by the others (F. E. C. and J. M. W.) is in course of 
preparation. Meanwhile it may be appropriate to 
mention one or two of the observations we made 
during a milk-borne epidemic of scarlet fever, and 
the steps taken to control it. 

In the first place, the tendency of the early cases 
to show no rash bore out Dr. Hobson’s experience. 
Secondly, he may be interested to know that the 
Schultz-Charlton reaction, performed as a routine 
in all cases admitted to the isolation hospital (the 
majority of which were type 2), gave a positive 
result regardless of the type to which they belonged ; 
whilst one or two definite type 2 cases gave a definite 
negative result. Accordingly we regarded the test 
of no value and discarded it. 

In view of the number of cases of streptococcal 
tonsillitis there had been in the area for some years, 
and of experience with the epidemic, the following 
administrative measures were adopted. (1) Notice 
has been circulated to medical practitioners that the 
function of the isolation hospital is to deal with all 
cases which by reason of their infectivity cannot be 
admitted to a general hospital, but that admission 
is limited, as far as possible, to patients in the above 
category who are sufficiently ill to require hospital 
treatment or are so placed as to be an especial danger 
to public health. (2) Scarlatinal antitoxin and poly- 
valent antistreptococcal serum are available free 
of charge for administration at the patient’s own 
homes by their medical attendant in exactly the 
same way as diphtheria antitoxin. (3) The question 
whether a case is notifiable as scarlet fever is for the 
practitioner to determine; but during the epidemic 
practitioners were informed that notifications of 
streptococcal sore-throats, with or without a rash, 
would be accepted as scarlet fever ; and an increasing 
number of such cases were notified, thereby helping 
to control the outbreak. (4) The throats of all 
patients were swabbed on admission to the isolation 
hospital and also at their own homes by their own 


508 THE LANCET] 


doctors. The swabs were examined for hxmolytic 
streptococci, and if positive were typed. This was 
of value in tracing the source of infection and in 
preventing cross-infection on the isolation hospital. 

We note with interest Dr. Hobson’s suggestion 
that the typing of hemolytic streptococci might be 
of value clinically. So far as workers have shown 
up to the present, typing appears to be more applicable 
to the public health side of medicine—in tracing the 
source of infection, and in controlling epidemics and 
preventing cross-infection—than in clinical practice. 
Gunn, Griffith, and other observers have hitherto 
failed to trace a definite clinical picture associated with 
specific types, but it might appear that certain types 
under certain conditions are more virulent and give 
rise to more complications, whilst certain others 
seem to be relatively mild. 

We are, Sir, yours faithfully, 
J.C. SLEIGH, J. L. MiLLER Woop, 
Chelmsford, Feb. 25th. F. E. CAMPS. 


TREATMENT OF PSYCHOSES BY 
PROLONGED NARCOSIS 


To the Editor of Tue LANCET 


Sir,—In his interesting paper in your last issue 
Dr. D. N. Parfitt records that he used Somnifaine 
for prolonged narcosis 60 times with 3 fatalities. As 
this high mortality-rate (5 per cent.) might well 
dissuade others from carrying out this valuable 
form of treatment, I should like to point out that 
it is not in accord with our experience at Cardiff 
City Mental Hospital, where prolonged narcosis has 
been carried out in 240 psychotics and neurotics. 
When somnifaine alone was used we had 2 deaths 
in 86 treatments (2:3 per cent.); but since glucose 
and insulin have been used to combat toxic symptoms 
154 cases have been treated without a single fatality. 
A future publication will deal with possible causes 
of this discrepancy in mortality-rates, and here I 
will merely state that at Cardiff, with careful nursing 
in a darkened single room, it is rarely found necessary 
to give more than 4 c.cm. of somnifaine in the 24 
hours.—I am, Sir, yours faithfully, 

P. K. McCowan, 


Medical Superintendent, Cardiff City 


Feb. 21th. Mental Hospital. ` 


AN ADDRESS IN HARLEY STREET 
To the Editor of THE LANCET 


SIrR—A belief common among laymen is that 
doctors may not advertise; whether the ban is 
imposed by law or the rules of good form, whether 
it is de jure or de facto, does not interest the layman, 
nor does it matter for the purpose of this letter. 
The question is : what is ‘‘ advertising ” in the mean- 
ing of the ban on professional men? We know that 
in commercial practice the object of advertising in 
the broad sense is to draw attention to specific goods ; 
to create the impression in the minds of ‘potential 
purchasers of the genus of goods that there 1s none 
so choice as the species advertised. We know, too, 
that to all intents and purposes there is no restraint 
on commercial publicity, and that in this respect 
trade advertisers enjoy a measure of liberty which 
is almost immeasurable—such a measure of liberty 
as is probably without parallel in human things. 
It may be for good, it may be for bad, but on balance 
it is probably for good. 

Advertising in its popular meaning brings to mind 
posters on the hoardings, pamphlets distributed 
from house to house, and especially—the best means 
of all of bringing the commodities of life to the 


TREATMENT OF PSYCHOSES BY PROLONGED NARCOSIS 


[reB. 29, 1936 


notice of the public—the newspaper press. All these 
methods are denied to the professional man, and with 
the consequence that if he desires to draw attention 
to himself he must have resort to more subtle means. 
In the case of the doctor there are in common use 
the red lamp, the blue lamp, and the brass plate 
—it may be a personal subtlety to have the plate 
larger and more brightly polished than his neigh- 
bours’ plates, and. in some districts, clean curtains 
point out the. doctor's house. The lamps and plate 
are without reproach in the view of laymen and even 
commendable since there are times when a doctor 
is wanted in a hurry. 

There is another means of advertising open to 
the medical man which is not so subtle as he seems 
to believe; in fact it is becoming so obvious as to 
be damaging to a section of the profession and 
I doubt whether it is any longer misleading to the 
public. I say this as a layman and I may be wrong, 
but it seems to me, and the opinion is gaining ground, 
that the fame of “ Harley Street ’’—and by ‘‘ Harley 
Street’? I mean not merely that thoroughfare but 
also its environs—is being exploited for advertising 
purposes. There may be a danger to the profession 
and to the public in the use of an address merely for 
advertising purposes. It is even said that not a 
few charlatans are housed in the district and that 
the place is as overcrowded—an exaggeration of 
course—as some of the slums in the East End where 
several families live in the same room. It ought to 
be known to the public that “ Harley Street ’’ is not 
a degree but an address. 

I am, Sir, yours faithfully, 

Whitchall-place, S.W., Feb. 15th. F. C. GOODALL. 


THE TREATMENT OF VAGINAL DISCHARGE 
To the Editor of Tur LANCET 


Sır, —The annotation, A Remedy for Vaginal 
Infections, in your issue of Feb. 15th caused me some 
astonishment, since it appears to be in the nature of a 
good advertisement for a proprietary article Devegan. 
The whole question of vaginal discharge being such 
a very complicated and diflicult one, it seems to me 
a pity to publish an article of this nature which will 
inake many doctors think that at last a cure for 
vaginal discharge has been found. 

I think you will agree that vaginal discharge is 
most often due to a chronic endocervicitis, and that 
this will not be affected by any treatment applied 
to the vagina. As it is most important to make a 
complete and thorough gynecological examination 
before commencing treatment for vaginal discharge, 
I feel that it is unwise to recommend a purely vaginal 
treatment. My own experience of this condition is 
that a vaginal discharge caused by a localised vaginal 
infection is very rare; that the presence of the 
Trichomonas vaginalis is very rare; and that, at 
present, the case for the value of devegan is far from 
being proved. 

I am, Sir, yours faithfully, 
Bournemouth, Feb. 19th. S. GORDON LUKER. 


*.* We are glad to have Mr. Luker’s views and 
would welcome other expressions of opinion on the 
treatment of vaginal discharge. We do not agree 
with him, however, that it is improper to comment 
on proprietary preparations of known composition. 
Many of the most important remedies now in use 
(from salvarsan and aspirin downwards) were intro- 
duced under protected names, and though monopolies 
are in many ways undesirable they are a recognised 
condition of modern manufacture, and may be a valu- 
able stimulus to chemotherapeutic research.—ED. L. 


THE LANCET] 


RUSSELL’S VIPER VENOM 
To the Editor of THE LANCET 


Sm,—Our attention has been drawn to a disturbing 
statement, reported in the daily press, and attributed 
to Dr. Peck, of New York, to the effect that the use 
of snake venom as a hemostatic has been practically 
abandoned in the United States on account of the 
severe reactions produced. Since Dr. Peck is well 
known for his treatment of hemorrhagic states 
by the injection of moccasin venom, which frequently 
produces local reactions (THE LANCET, 1935, 1., 997), 
we believe that the statement refers to this procedure. 
Moreover, we are not aware that Russells viper 
venom has received a trial in America. In the many 
cases of hemorrhage treated at St. Bartholomew’s 
Hospital and elsewhere, by the local application of 
Russell’s viper venom, we have not observed any 


OBITUARY 


[FEB. 29, 1936 509 


reaction or local effect other than coagulation of the 
issuing blood. 

In view of the apparent confusion, it may be useful 
to summarise the venoms that have been employed 
therapeutically. Cobra venom has been used as an 
analgesic, particularly in cancer ; this and puff adder 
venom in the treatment of epilepsy; moccasin, 
venom has found an application in certain hæmor- 
rhagic conditions and skin diseases. All these are 
given by injection. Dilute solutions of Russell’s 
viper venom are only employed as hemostatic 
applications direct to bleeding surfaces. This venom 
is, in our opinion, the most effective local hzmostatic 
available.—We are, Sir, yours faithfully, 

R. G. MACFARLANE, 
BURGESS BARNETT. 


Pathological Department, oe Bartholomew’s 


ospital, E.C., Feb. 25th. 


OBITUARY 


PRIESTLEY LEECH, M.D. Lond., F.R.C.S. Eng. 
CONSULTING SURGEON, ROYAL HALIFAX INFIRMARY 


Dr. Priestley Leech, who died on Feb. 7th, had been 
in indifferent health for some months but had con- 
tinued in harness until a few weeks before his death. 
A native of Halifax he was educated at Owens 
College, Manchester, where he took honours in several 
scientific subjects. He qualified as M.R.C.S. Eng. in 
1885 and graduated M.B., B.S.Lond. in 1888, 
obtaining the F.R.C.S. Eng. in the following year. 
He was for a time house surgeon at the Warrington 
Infirmary but returned to commence general prac- 
tice in Halifax, and in 1890 was appointed honorary 
medical officer to the Royal Halifax Infirmary, an 
institution which he served until resignation in 1919 
when he was made honorary consulting medical 
officer. He was also the medical officer in charge 
of the venereal diseases clinic at the Infirmary. 


A colleague “ J. F. H.,” writes : “ Dr. Priestley Leech 
carried on a large general as well as a surgical practice, 
and for a long period he was the best known consultant 
over a wide area outside his own town. A voracious 
reader and a keen observer, he acquired a large 
practical experience so that his judgment was always 
sound and valued by his colleagues, and his patients 
had every reason to be grateful for his skilful and 
capable surgery. His reputation was more than 
local. For many years he contributed the article 
on General Surgery in the Medical Annual. He was 
an expert linguist and abstracted the items from 
the original. In spite of his very busy life he found 
time to undertake much work for the profession. 
He had been chairman of the local medical society, 
the Halifax division of the B.M.A., and of the Leeds 
and West Riding Medico-Chirurgical Society. During 
the war he did much valuable surgical work amongst the 
soldiers in his own hospital and at St. Luke’s hospital, 
Halifax. When his work would allow him a few hours 
of relaxation he indulged in his favourite sport of 
fishing, of which he was an enthusiast. His reminis- 
cences of fishing men and fishing dinners were always 
entertaining.” 


Dr. Leech was in his 74th year when he died, and 
leaves a widow and one son. He celebrated his 
golden wedding last year. 


ARTHUR JAMES ARCH, M.R.C.S. Eng. 


Dr. A. J. Arch, who died on Feb. 14th aged 58, 
was a well-known Coventry practitioner, holding a 


large number of public appointments. He was 
born in Coventry, the son of Mr. James Arch, who 
was for a long period clerk to the Coventry Board 
of Guardians, and received his medical education 
at Birmingham, qualifying as L.R.C.P. Lond., 
M.R.C.S. Eng. in 1904. He was one of the best 
known general practitioners in Birmingham, having 
an extensive general circle of patients, while he 
was closely identified with National Health Insurance 
administration, being a member of the Coventry 
Insurance Commbittee for 14 years and for a consider- 
able period vice-chairman of the Coventry Panel 
and Local Medical Committee. Dr. Arch was also 
public vaccinator when the duties of the Poor Law 
Guardians were taken over by the municipality, 
and until the time of his death was public vaccinator 
under the new authorities.: He had been a consider- 
able athlete in his younger days. 


ALEXANDER WAUGH, M.B. Glass. 

THE recent death at Prenton, Birkenhead, of 
Dr. Alexander Waugh, has removed a practitioner 
who for a considerable period occupied a prominent 
position in Skipton. He received his medical training 
in Edinburgh and Glasgow and graduated in medicine 
at the University of Glasgow in 1899. He now 
practised at Skipton where he had a large practice, 
being also medical officer to the infectious diseases 
hospital and poor-law officer to the Skipton sub- 
district. While at Skipton a serious small-pox 
epidemic occurred, and Waugh, who had already . 
shown keenness in regard to prevention and suppres- 
sion of infectious diseases, was so successful in the 
measures which he took that he was thanked by the 
urban council for his labours. He left Skipton in 
1909, his residence there being terminated by a 
breakdown in health leading to a sea-voyage. On 
his return he entered practice in Birkenhead. He 
did much good work at home during the war, and 
on the cessation of hostilities held for a period a 
position under the Ministry of Pensions. He was 
also medical examiner to many insurance companies 
and gave medical advice to various shipping com- 
panies. Dr. Waugh had been in bad health for the 
last ten years and was 72 years of age at the time 
of his death. ` 


ST. GEORGE’S-IN-THE-EAST HOSPITAL.—A new out- 
patient department at this hospital has been planned by 
the London County Council at a cost of £20,000. It will 
include two new receiving wards and an antenatal unit. 


510 THE LANCET] 


ENDEMIC YELLOW FEVER 
IN TOWN, VILLAGE, AND JUNGLE 


THERE has been a revolution in the last decade in 
ideas of the prevalence and origin of yellow fever, 
especially in South America. In 1926 the disease 
was thought to be confined to the north-east corner 
of Brazil, and it was believed that with anti-mosquito 
measures it was rapidly disappearing and could soon 
be eliminated. It was considered a disease limited 
to the cities and maritime parts of the east coast 
and to some extent to the shores of the Amazon. 
The only infecting agent of importance was then 
thought to be the Aédes (Stegomyia) egypti mosquito 
which was found only in the houses of an urban 
- population. To-day, however, it is known that 
yellow fever is widespread throughout the two-thirds 
of the continent north of Paraguay and east of the 
Andes. The more intensive the investigations, the 
more cases are discovered in places remote from 
cities and maritime transport, in the jungles and 
plains of the interior, with sporadic outbreaks in 
isolated settlements where no means of contact can 
be found. It is now known that the disease can be 
transmitted by a large variety of mosquitoes and in 
the complete absence of the stegomyia. Hope of 
controlling the disease solely by anti-mosquito 
measures has been abandoned and a new means of 
prevention has had to be devised. 


THE CAMPAIGN AGAINST THE DISEASE 


Dr.. F. L. Soper, of the International Health 
Division of the Rockefeller Foundation, outlined this 
revolution in the history of yellow fever in an address 
given at the London School of Hygiene and Tropical 
Medicine on Feb. 24th. Warfare against the disease 
had, he said, been successfully waged in South 
America since 1914, and from 1920 to 1924 it had 
disappeared from the equatorial zone. In 1927 there 
was a period of 11 months without a single notified 
case in the continent. The next year, however, it 
reappeared in Rio de Janeiro after an absence of 
20 years and again in north-east Brazil. In 1929 
it had once more spread along the coast and up the 
Amazon valley. There were isolated outbreaks in 
Colombia and Venezuela with no known focus of 
infection or possible contact with other infected 
places. The year 1930 saw a campaign of intensive 
anti-mosquito measures throughout the country, not 
only in the cities but in small towns and villages. 
These methods were still inadequate and it was 
decided to hunt for the mosquito in unsuspected 
places and for the disease in unsuspected persons. 
The very valuable ‘“viscerotomy service” was 
organised. Liver tissue, removed post mortem with 
the viscerotome from every person dying within 
ten days of the onset of any disease, was sent to the 
laboratory ; it was found that a proportion of the 
specimens had the lesions of yellow fever. The 
mouse-protection test! was first used on a large 
scale in 1931, and it was then discovered that over 
an area of two-thirds of the whole continent every 
community had a varying proportion of acquired 
immunity, showing that no part of that area was 


free from the disease, in spite of the absence of- 


A. egypti. Even young children had this immunity 
and it was most evident in Indians remote from any 


2 Yellow fever virus, fixed for mice, is inoculated intra- 
peritoneally into a mouse, together with the scrum to be tested. 
A simultaneous injection of starch solution into the brain 
localises the virus and if the serum lacks protective power 
(a negative result) the animal dies of yellow fever encephalitis, 


ENDEMIC YELLOW FEVER 


[FEB. 29, 1936 


possible known source of infection. This discovery 
made some investigators sceptical of the value of 
the test. 

During the next three years there were several 
isolated outbreaks, one among troops in Bolivia 
that were being acclimatised in preparation for the 
Chaco war, but their significance was not remarked, 
though they had taken all by surprise. In 1935 the 
investigators were startled by a large outbreak far 
beyond their expectations in an area hundreds of 
miles from any contagious focus, believed to be free 
from yellow fever and investigated only to complete 
the survey. The mouse-protection tests had given 
a proportion of positives of only 1-6 per cent., and yet, 
soon afterwards, evidence was found that there must 
have been thousands of cases of the disease spread over 
an area of more than 100,000 square miles. The disease 
did not come into the cities, of which there were 
several of. a population of 30,000-40,000, but the 
outbreak still continues. 


JUNGLE YELLOW FEVER 


These events led to the discovery of a second typ 
of the disease known as jungle yellow fever, to 
distinguish it from that due to the stegomyia. 
This was prevalent in the remote districts and was. 
believed to be traceable to infected wild monkeys, 
though there were no A. egyptt for hundreds of 
miles. The diseases were, however, identical in all 
other respects, not only clinically but also in their 
response to cross-immunity and monkey trans- 
mission tests and in the pathological lesions produced. 
The disease, it was true, was at present sporadic 
but there was no reason why the cities might not 
become heavily infected from immigrants. The 
stegomyia type was confined to the houses, whereas 
the jungle fever was found only in those who lived 
in close proximity to uncut forest. In fact, in many 
parts it was known to the people as “‘ fiancé’s fever ” 
for it infected young men who had left the com- 
munity to prepare a home further afield. Graphs 
of the age-incidence were very illuminating in con- 
trasting the two types of the disease. The stegomyial 
yellow fever in rural districts had its greatest 
incidence in the early years of life, whereas the jungle 
type occurred in the young adults group, that is to 
say, in those that worked in the field and away from 
their homes. In towns, stegomyial fever showed the 
early peak found in the rural districts, but also a 
second peak in early adults, similar to that of the 
jungle disease. This second curve was due to immigra- 
tion from the country of non-immune people who 
quickly fell a prey to the A. æœægypti. It was also 
notable that the disease was one that proved fatal 
to children, the greatest incidence being under 
5 years and the next greatest between 5 and 
9 years. 

Dr. Soper showed a number of photographs of the 
type of settlement in which a large proportion or 
all of the people had an acquired immunity. The 
disease was never present where there was no 
adjacent uncut jungle, but even small areas of forest in 
open prairie country were virulent sources of infection. 
That the wild monkeys were responsible had been 
proved, for in some investigations 20 per cent. of 
the monkeys killed in the jungle were found to be 
infected with yellow fever. This source of infec- 
tion would never be eradicated but he believed 
that the new preventive measures against the 
stegomyia mosquito in the towns would prevent 
epidemics. It had been discovered that if the 
breeding-index—i.e., the proportion of houses in the 
town harbouring the mosquito—was reduced to 


THE LANCET] 


below 2 to 3 per cent. and maintained there, the 
probability of infection was remote. Every town 
had now a periodic examination at least every 
quarter. If A. ægypti was discovered, every house 
was searched for possible breeding-places, adult 
mosquitoes were captured, and exposed water was 
covered with petroleum. In this way even the large 
cities were able entirely to eliminate the mosquito 
for several weeks, before one was found, introduced 
from another place. The viscerotomy service was 
still continued in every district, and it was the duty 
of a responsible layman if necessary to provide the 
specimens. There was also a close codperation 
between the health services of the different sea-ports, 
and information was exchanged which was of even 
greater importance than the incidence of the mosquito 
or disease in each individual city. 


THE PROBLEM IN AFRICA 


In the discussion that followed the address, 
reference was made to the spread of yellow fever in 
Africa. Dr. Soper did not believe that because 
certain areas such as the Sudan were at present 
free from ‘infection there would be no epidemic in 
the future; on the contrary, the experience of 
South America had shown that after apparently 


PARLIAMENTARY 


NOTES ON CURRENT TOPICS 


Juvenile Training in Schools 


In the House of Commons on Feb. 19th Mr. C. S. 
TAYLOR moved : 


That this House is of opinion that a greater degree of 
technical and physical training should be given to juveniles 
before leaving school, so that they may be better fitted 
for the changing conditions of industrial and economic 
progress. 


He said that to work well one must be fit. He felt 
the necessity for developing in the schools a system 
of physical training. A standard syllabus approved 
by the Ministry of Health or Board of Education and 
admniniatered by qualified instructors would help to 
produce the bodily fitness which was so desirable. 
Unqualified instructors might do an immense amount 
of damage; unsuitable exercises might have a very 
detrimental effect on the health of the children. It 
was up to the Government now to press upon the 
local education authorities the need for expanding 
physical training. It was time for the Government 
to make a further appeal to local authorities to 
provide holiday and school camps for the youth of 
the country. These camps would supplement the 
physical efficiency which they all desired. He also 
asked, must the State rely on public charity for the 
provision of school playing fields? Building was 
going on to such an extent that all the available 
open spaces round our great cities would be occupied 
unless the Government took steps to remedy this 
great defect. 

Mr. CRAVEN-ELLIS seconded the motion. 

Mr. MORGAN said he was not too easy about the 
glib talk about the Army of physical organisers. He 
would impress upon the Board of Education this 
point: physical education was something much 
more than ‘“ physical jerks.” To put it in a nutshell, 
physical training without medical supervision and 
advice might be very harmful. Mr. Malcolm Stewart, 
Commissioner for the Special Areas, in his report, 
referred to children suffering from malnutrition 
and children with a tendency to tuberculosis. In 
such cases a set form of physical exercises would be 
the worst possible thing for the child. With the 
demand for greater opportunities for physical training 


PARLIAMENTARY INTELLIGENCE 


(FEB. 29, 1936 511 


absolute freedom there might be widespread out- 
breaks. He felt sure that there was jungle yellow 
fever throughout a large area as far east as the 
Great Rift Valley ; in fact in a recent journey there 
he himself had found cases of this type in Uganda. 
Kenya was free because of the nature of the country 
and its vegetation, but as far as he knew there was 
no eastern limit to possible infection in the 
Sudan. The spread of motor traffic would bring 
civilisation ; that brings clothing, and clothing implies 
washing, and washing, water; but in a dry country 
all the water was domestic and therefore measures 
against the A. egypti were essential and it would 
not be difficult to eradicate the species even in the 
land that gave it its name. The breeding-index 
should be lowered to the safe limit in every town 
in and near the endemic regions; these measures 
were assisted by the fact that dengue fever was also 
transmitted by A. ægypti and that it had been 
successfully treated. Dr. Soper thought that even the 
most stringent precautions in air transport would 
not of themselves guarantee immunity; the other 
preventive measures were essential. The whole 
question of the prevalence in Africa of the jungle 
type of yellow fever had not yet become clear and 
more research was necessary. 


INTELLIGENCE 


he was in the greatest sympathy, but he did not 
think they should go mad about it. Do not let it 
be said that they were training a nation of mechanical 
robots finely developed from the neck downwards. 
ie i existed for something higher and better than 

at. 

Mr. MARKLEW said that the first essential of 
physical fitness was proper nourishment of the body 
and a sufficiency of the right kind of food. Let hon. 
Members turn their attention to measures whereb 
parents might provide their children with such food. 
If the elementary needs which were indispensable 
for physical health were satisfied young children 
would show how to keep themselves fit by indulgence 
in that healthy play in which children did not need 
a great deal of instruction. 

Viscountess ASTOR said that the most important 
of all the subjects before the country to-day was the 
number of children in the elementary schools who 
were physically unfit because they were under- 
nourished or mal-nourished. She was all for fitness, 
and did not even mind the children being drilled. : 
There were 95,000 children in the elementary schools 


who were unfit, but they had found a way out. 


She hoped that they were soon going to see a tremen- 
dous development in open-air nursery schools. 
That was the real proper way to deal with this 
question. 

Mr. OLIVER STANLEY, President of the Board of 


‘Education, replying to the debate, said that'one of 


the most important requests which his department 
made to local authorities in the circular on physical 
training was the importance of organisation. They 
did not rely on charity for playgrounds and playing 
fields for their schools. For a long time local authori- 
ties and the State had spent large sums on their 
provision. Nor was it fair to overlook the amount 
of actual physical instruction which was given in 
schools or the amount of time devoted to games. 
out of school hours at the expense of the teachers’ 
time and trouble. He hoped that the circular which 
the Board of Education had issued would have the 
effect of stimulating what was already a largely 
growing interest in physical education, not only 
games, but training as well. He was sure that the 
fact that the House would unanimously assent to 
the motion would be helpful in the campaign in which 
all of them were interested. 

_ After further debate the motion was agreed to. 


512 THE LANCET] 


PARLIAMENTARY INTELLIGENCE 


[reB. 29, 1936 


The Milk Bill 


On Feb. 20th, in the House of Commons, Mr. 
ELLIOT, Minister of Agriculture, moved the second 
reading of the Milk (Extension of Temporary Pro- 
visions) Bill. He said that the debate on the financial 
resolution had dealt with the question of nutrition. 
He fully sympathised with that, but the really impor- 
tant fact was that the industry must be kept going. 
The milk must exist before it could be distributed. 
They must also remember that the dairy industry 
did not consist merely of milk production, but also 
that of butter and cheese—which were, after all, 
nutritious, valuable and protective foodstuffs, full 
of vitamins. If, as had been suggested, the £2,500,000 
subsidy given to butter and cheese manufacture 
were used for subsidising the liquid milk market, 
that would not solve their problems, it would allow 
of a reduction of only one quarter of one farthing 
per cent. in the price of liquid milk; and who would 
say that such a reduction would lead to an enormous 
expansion in consumption ? It had also been stated 
that one of the reasons for the lack of success of the 
milk scheme was that milk for schools was taken 
into account in computing unemployment allowances, 
and that consequently parents preferred to maintain 
their allowances and not to have the free or cheap 
milk in the schools. He was informed that that was 
not so. In calculating unemployment allowances 
the Unemployment Assistance Board ignored entirely 
the provision of free milk for school-children, and 
also the provision of milk at a reduced price. The 
poor-law division of the Ministry of Health stated 
that it was practically certain that the public assist- 
ance committees did not take cheap milk into account 
in assessing poor relief. Allowing for the fact that 
the milk-in-schools scheme was operating in the 
great majority of the large urban schools it was 
probable that about 92 per cent. of the children 
attending public elementary schools were in schools 
where the scheme was in operation. The fact that 
less than half the children were taking milk was not 
primarily due to the absence of facilities but to other 
factors. This emphasised the desirability of having 
a further period for test and experience, so that they 
might find out what all the factors were, and thereby 
be in a better position to deal with them when the 
Government brought forward their long-term legis- 
lation. 

Provision of milk for children during week-ends 
and holidays was already made in the milk-in- 
schools scheme. ‘The Board of Education proposed 
in the next half-yearly returns from the schools to 
ask whether such arrangements were actually made. 
As to the improvement in the cleanliness of the 
milk supplied, the right hon. gentleman said that 


in December last over 25 per cent. of the milk had. 


been brought up to the standard of Grade A or 
Accredited Milk. In the week ending Feb. 1lth 
there were over 15,000 accredited producers in 
England and Wales, and they were producing one- 
third of all the milk sold under wholesale contract 
for liquid consumption. ) 

The motion which Mr. Alexander was going to 
move on behalf of the Labour Opposition referred 
to the desirability of making milk products available 
at a price within the compass of the lowest income. 
The policy of the Government had not only been 
directed towards that end but had secured that end. 
Without Government assistance there would have 
been a widespread crash in the dairy and liquid milk 
industry. During the two years since the House 
voted this subsidy over 1,000,000 tons of butter and 
nearly 500,000 tons of cheese had been consumed in 
this country. If we had bought the butter eaten 
in the last two years at 1929 prices it would have 
cost £100,000,000 more. How small in comparison 
was the rebate which has been given to the producers 
in this country. At 1925 prices it would have cost 
£116,000,000 more. Since 1925, and even since 
1929, great strides had been made towards the 
provision of ample supplies within the reach of all, 


These calculations were unfamiliar and no doubt 
would attract attention. They were fundamentally 
the justification for bringing forward this Bill As 
regards malnutrition, he thought that there was a 
widespread evil of that sort, but he did not think 
that any dietetic authority would challenge the 
proposition that a greater proportion of this nation 
than of almost any other nation in the world was 
adequately nourished, that that proportion had 
risen in recent years, and that the nourishment of 
this country had improved and was improving more 
rapidly in recent years than it had done in the long 
periods before. Every speech made by Ministers on 
the 1934 Act had stressed the importance, from the 
point of view not only of agriculture but of national 
health, of the increased consumption of liquid milk, 
and the milk-in-schools scheme has been a gub- 
stantial contribution to that end. They all wanted 
to see the public drinking more milk. That was the 
main object of this Bill. The problem could not be 
insoluble and must not be insoluble. 


Mr, ALEXANDER moved the following amendment : 


That, in the opinion of this House, it is necessary for 
the improvement of the national physique and for dealing 
with the widespread evil of malnutrition that the con- 
sumption of liquid milk should be increased and 
encouraged by the provision of ample supplies at a price 
within the compass of the lowest incomes, and this 
House therefore declines to assent to the Second Reading 
of a Bill which merely continues a State subsidy without 
making provision for the effective reorganisation of milk 
production or for the establishment of an efficient system 
of distribution, whereby the public need, and particularly 
the need of children, expectant mothers, the sick and 
infirm, may be adequately met. 


To anyone concerned with social improvement, 
he said, it seemed a great anomaly that there should 
be hundreds and even thousands of families who 
were unable to get anything approaching an adequate 
supply of liquid milk, while at the same time milk 
was being sold at a loss for manufacture at a price 
so low as 34d. per gallon. If the Minister admitted 
the need for a subsidy there was surely a case for 
widening the extent of the subsidy. They were 
now supplying milk to schools at 3d. per third-of-a- 
pint bottle, instead of ld. as formerly, and yet on 
the Minister’s figures nearly half the school-children 
were still without milk. He (Mr. Alexander) did not 
believe that any of the reasons given were as impor- 
tant as that of poverty. He hoped that the Minister 
would not take the propaganda of the Milk Board 
on the improvement in the cleanliness of the milk 
supply as being the whole of the truth. He thought 
that it was beginning to regularise what had already 
been introduced for a long time by the important 
retail and pasteurising organisations in the country. 
As to the cleaning-up of herds, he believed that a 
much bigger and a more intensive and scientific 
scheme was required if they were to get rid of a 
state of affairs in which 40 per cent. of the herds 
were reacting to the tuberculin test. There was no 
doubt that the present price level was too high. 
The producer needed to be gingered up into more 
efficient production and a more efficient method of 
distribution was also necessary. If they were to 
have a really efficient distribution of clean, healthy 
bottled milk to all the population, and not merely 
to sections of it, they must have a real national 
basis of organised distribution. 

After further debate, the amendment was nega- 
tived by 201 votes to 121 and the Bill was then read 
a second time. 


In the House of Lords on Feb. 20th the National 
Pension Fund for Nurses Bill was read a second 
time, 


On Tuesday, Feb. 25th, in the House of Commons 
the Milk (Extension of Temporary Provisions) Bill 
passed through Committee. © 


THE LANCET] 


PARLIAMENTARY INTELLIGENCE 


[FEB. 29, 1936 513 


HOUSE OF COMMONS 
WEDNESDAY, FEB. 19TH 
Lymph Supplies for Public Vaccination in Scotland 


Mr. Groves asked the Secretary of State for Scotland 
the name of the firm of lymph manufacturers from whom 
his department obtained supplies of lymph for vaccination 
purposes; whether the firm in question held a licence to 
manufacture lymph under the Therapeutic Substances 
Act, 1925; and whether he would consider the desira- 
bility of obtaining lymph in future from the English 
Government lymph establishment instead of from private 
manufacturers.—Sir GODFREY COLLINS replied: The 
Department of Health obtain their lymph from the Jenner 
Institute for Calf Lymph, Limited. This firm holds both 
an importing and a manufacturing licence, under the 
Therapeutic Substances Act, 1925. The department 
have found that the keeping qualities of the lymph made 
by the firm mentioned are peculiarly suited to Scottish 
needs, and I see no reason therefore to make any change. 


Malaria Epidemic in Ceylon 


. Liieut.-Commander FLETCHER asked the Secretary of 
State for the Colonies the total number of deaths in 
Ceylon from malaria between November, 1934, and April, 
1935; if he was satisfied that adequate supplies of quinine 
were available during the whole of this period; and if 
the report of Colonel Gill on the subject of the malaria 
epidemic in Ceylon would be published.—Mr. THOMAS 
replied : During the epidemic it was not possible to secure 
accurate statistics as to the causes of all the deaths that 
occurred. Malaria was probably a contributory cause in 
the case of many deaths attributed to other diseases. 
I am afraid that I cannot give a more accurate figure 
. than that contained in my reply on Feb. 12th, which 
indicated the excess of deaths over the normal figure 
during the epidemic period. Colonel Gill reported that 
there was never any shortage of quinine. His report 
has been published as a sessional paper in Ceylon, and I 
shall be glad to place a copy in the library of the House. 


Small-pox and Vaccination of Children 


Mr. Broap asked the Minister of Health how many 
deaths of children under five years had been registered 
from small-pox; and how many had been registered as 
being caused by, or associated with, vaccination since 
Jan. Ist, 1908, when the present conscience clause came 
into force.—Sir KinesteEy Woop replied: The total 
numbers for the period from Jan. Ist, 1908, to Dec. 31st, 
1935, are 96 and 216 respectively. 


Municipal Maternity Homes in Lancashire 


Mr. Gorpon Macponatp asked the Minister of Health 
the number of municipal maternity homes in the adminis- 
trative county of Lancashire, including the boroughs, in 
each of the last five years for which figures were available.— 
Sir KinestEy Woop replied: According to returns 
furnished to my department by the local authorities, the 
number of municipal maternity homes in the adminis- 
trative county of Lancashire, including the non-county 
boroughs, was 5 in each of the years 1930 to 1934. 


Midwives in Lancashire 


` Mr. Gorpon MACDONALD asked the Minister of Health 
the number of practising midwives in the administrative 
county of Lancashire, including the boroughs, in each of 
the last five years for which figures were available.—Sir 
KINGSLEY Woop replied: According to returns furnished 
to my department by the local authorities, the numbers 
of practising midwives in the administrative county of 
Lancashire, including the non-county boroughs, have been 
as follow :— 


Year Midwives.| Year. Midwives. 
1930 .. 603 1933 .. 625 
1931 601 1934. 656 
1932 610 


Births in Lancashire Municipal Maternity Homes 


Mr. Gorpon MacponaLpD asked the Minister of Health 
the number of births in the municipal maternity homes 
in the administrative county of Lancashire, including 


the boroughs, during each of the last five years for which 
figures were available—Sir Kuyestey Woop replied: 
According to returns furnished to my department by 
the local authorities, the numbers of births in the muni- 
cipal maternity homes in the administrative county of 
pe e including non-county boroughs, were as 
ollow : 


Year. Births. Year. Births.. 
1930 .. ns .. 816 1933 ~. 922 
1931 778 1934 975 
1932 865 


Anesthetics Used in Surgical Operations 


Mr. Groves asked the Home Secretary what anesthetic 
was used by Dr. Adli Samaan at University College, 
London, in the case the report on which was published 
in the Journal of Physiology, August 22nd, 1935, under 
the title The Effect of Pituitary, Posterior Lobe.—Mr. 
GEOFFREY LLOYD, Under Secretary, Home Office, replied : 
I am informed that the operations described in the paper 
to which the hon. Member refers were, as stated in the 
footnote on page 37, performed by Dr. G. W. Theobald, 
and that they were performed under full anesthesia after 
a preliminary injection of morphine, the anesthetics being 
chloroform and ether. 


THURSDAY, FEB. 20TH 
Colliery Employee and Pneumoconiosis 


Mr. HopxKIN asked the Home Secretary if he was aware 
that Sidney Norton, recently employed at the Great 
Mountain Colliery, Tumble, had been certified as suffering 
from pneumoconiosis in the third stage; that Norton 
had worked for the last 14 years on the screens but did 
not come under the Silicosis Order and would therefore 
not receive compensation ; and would he consider amend- 
ing the above order to include men who worked in or 
about the mine.—Sir Jonn Simon replied: This case has 
not, I understand, been before the Medical Board, and I 
have no information in regard to it. The Home Office 
is not in possession of any evidence that work on the 
coal screens gives rise to silicosis, but if the hon. Member 
will send me particulars of the case, including the medical 
certificate, I will consider them and, if necessary, inquire 
further into the matter. 

Mr. E. J. WaLrrams: Will the Home Secretary give 
attention to the whole question, as there is great dis- 
satisfaction in all areas that these respiratory diseases 
are leading to this particular form of disability ? 

- Sir J. SIMON : As a matter of fact I have had the matter 
very much under my attention in connexion with various 
cases, but I was only aware of this particular matter 
when I saw the question. 

Mr. Wrams: Is the right hon. gentleman aware of 
the case recently decided in the High Court, and if so will 
he further consider revising the Order ? 

Sir J. Simon : It was to the Court of Appeal that the 
decision was referred. 

Mr. Wituiams: To the House of Lords. 

Sir J. Srmon: No, not the House of Lords. The 
matter has recently been before the Home Office and gone 
into very fully with the representatives of the men. 


Publication of Offensive Evidence in the Courts 


Mr. Day asked the Home Secretary whether he would 
consider introducing legislation to amend the present 
procedure in the courts so as to provide that all evidence 
of a shocking or offensive character in cases of alleged 
murder or other serious felonies should be taken in camera. 
—Sir Joun Simon replied: No, Sir. I do not consider 
that it would be in the public interest to amend the law 
in the sense suggested. If the hon. Member has in mind 
the control of newspaper reports, I doubt if legislative 
restrictions could properly go beyond the provisions on 
the subject in the Judicial Proceedings (Regulation of 
Reports) Act, 1926. 

- Mr. Day: Does not the right hon. gentleman consider 
that the publication of some of the details in these cases 
has a bad influence upon younger minds ? 

Sir J. Stwon: I think that the hon. gentleman had 
better look at the section in the Judicial Proceedings 
Act, 1926, which will cover a great deal he has in mind. 


514 THE LANCET] 


Expressions of Opinions by Coroners and Juries 


Sir Jonn Hastam asked the Home Secretary whether, 
in view of the recent case when a coroner and the coroner’s 
jury inquiring into the death of a footballer censured 
the conduct of a football referee, and in view of other 
such cases, he would introduce legislation to prevent 
coroners or their juries expressing any such opinions or 
taking any action other than to ascertain the cause of 
death of the deceased.—Sir JoHN Smon replied : The recent 
report of the Departmental Committee on Coroners 
contains recommendations on the subject matter of my 
hon. friend’s question, and this report is at present under 
consideration. 

Sir J. Hastam: May I ask whether from his unrivalled 
experience as a lawyer and in his present office the right 
hon. gentleman does not think it is desirable that some- 
thing should be done so that people are not condemned 
by a coroner in public in their absence, and also that a 
coroner’s jury should not be allowed to express an opinion 
when the accused has never been invited to attend the 
inquiry ? 

Sir J. Simon : The report of the Committee on Coroners 
discusses this matter, and these considerations are fully 
set out. 
= Mr. Rrrson: Is the right hon. gentleman aware that 
a jury was only stopped from giving their verdict by a 
very clever handling on the part of the police; that some 
of us were there on that occasion, and before he condemns 
the coroner will he ask for further evidence ? 

No further answer was given. 


Maternal Mortality 


Mr. GEORGE GRIFFITHS asked the Minister of Health 
the number of deaths from and arising out of childbirth 
for the years ended Dec. 3lst, 1932, 1933, 1934, and 
1935.—Sir KrnasLEy Woop replied: The following are 
the number of deaths registered in England and Wales. 
A.=Classified to pregnancy and childbearing. B.=Not 
so classified but returned as associated with those con- 
ditions. 


A. B. 
1932 2587. panies 713 
1933 2618 ooscoiia 828 
1934 2748 eases 747 
1935 Not yet available. 


Hospitals and Ambulance Services 


Sir Percy HARRIS asked the Minister of Health whether 
his attention had been called to the recent case that 
came before the Stepney coroner of a woman having to 
wheel the dead body of her child through the streets to 
the London Hospital for a post-mortem examination 
because the hospital was not able to provide an ambulance ; 
and whether he would endeavour to see that there was 
closer coöperation between the private hospitals and the 
municipal ambulance to prevent incidents of this character. 
—Sir KinastEy Woop replied: I have seen a newspaper 
report of this case and am making inquiries. I will com- 
municate with the hon. Member when I am more fully 
informed of the circumstances. 


Insanitary Slum Dwellings in Bethnal Green 


Sir Percy Harris asked the Minister of Health whether 
his attention had been called to a lot of bad slum courts 
in Bethnal Green which had been the subject of a survey 
by the Bethnal Green Housing Association, especially to 
Busby-square, where the total population appeared to 
be 53 persons in 1 three-room and 10 two-room houses, 
the area of the site being 2686 square feet, including the 
yard, &c.—i.e., one-sixteenth of an acre; whether he 
was aware that the lavatory arrangements were in a 
most unsatisfactory condition; whether he could find 
out if anything could be done to provide alternative 
accommodation for the people living under these condi- 
tions: and whether, when that was available, the court 
could be cleared.—Sir KingstEy Woop replied: My atten- 
tion has been called to this matter. The London County 
Council and the Bethnal Green borough council are 
engaged in dealing in close coöperation with slum areas 
in the borough. I understand that the area referred to 
will be dealt with as soon as practicable. 


PARLIAMENTARY INTELLIGENCE 


[FEB. 29, 1936 


Sir P. Harris: Does not the right hon. gentleman 
realise that this is a very special cases and that it should 
have priority over other case that are not so urgent, 
because of the appalling conditions prevailing ? 

Sir K. Woop : I have no doubt that the London County 
Council and the Bethnal Green borough council have 
this matter in hand. 


Milk Designation Order 


Mr. Tuomas Wruuiams asked the Minister of Health 
whether his attention had been called to the recent criti- 
cisms of the new Milk Designation Order; and would he 
undertake to re-examine the question, with a view to 
helping the campaign for pure milk instead of deteriorating 
the standard already attained.—Sir KineastEyY Woop 
replied: Various representations have been made to me 
on the draft Milk (Special Designations) Order, and they 
will have my fullest consideration before the Order is 
finally settled. 


Voluntary Hospitals and General Nursing Council 
Rules 
Mr. BouLTON asked the Minister of Health if he was 
able to give an undertaking that the boards of manage- 
ment of the principal voluntary hospitals of the country 
should be consulted before any action was taken to amend 
Rule No. 4 (1) of the Nurses Registration Act, 1919, or 
before it became law.—Sir KincstEy Woop replied: I 
do not think it necessary to adopt the course suggested 
by my hon. friend. The proposed new Rule 4 (1) (a) of 
the General Nursing Council, to which I presume he is 
referring, has been published in the press, and it is open 
to any interested party who objects to the rule to make 
representations to me before I approve it under the Act. 
I may add that the voluntary hospitals are represented 
on the General Nursing Council. 


Prevention of Silicosis 


Mr. Horxr asked the Secretary for Mines if he was 
aware that a number of men from 25 to 35 years of age were 
being certified as suffering from silicosis in the anthracite 
district of South Wales; and what practical steps were 
being taken to deal with the prevention of this disease.— 
Captain CrooKSHANK replied: The answer to the: first 
part of the question is Yes. As regards the second part, 
I would refer the hon. Member to my reply to his question 
of Feb. 13th. 


Diabetic Patients and Motor-car Driving 


Mr. Groves asked the Minister of Transport, in view 
of the fact that from time to time drivers of motor-cars 
were prosecuted on the ground of being in charge of a 
motor-car while under the influence of drink, and in 
defence it was stated that their condition was due to the 
effect of insulin dosage, whether he would make it a 
condition for granting a licence to a diabetic under insulin 
treatment that he should state this in the declaration as 
to physical fitness required when applying for a driving 
licence.—Mr. Hore-BELIsHA replied: On the facts 
placed before me, I do not think that I should have 


. sufficient ground for taking the course recommended by 


the hon. gentleman. 


MONDAY, FEB. 24TH 
Protective Measures against Air Attack 


Captain MacnaMaRA asked the Home Secretary, in 
view of the fact that the Army, the Royal Air Force, the 
police, ambulance and hospital services, decontamination 
squads, &c., were administered by the War Office, Air 
Ministry, Home Office, and Ministry of Health, often 
working through local authorities, had any arrangements 
been made by districts for all such services to be under 
the actual command of one officer in the event of an air 
attack on this country; if so, was such an officer given 
facilities for the codérdinated training of these services in 
peace time; and who was the official responsible at 
present in any district for ordering a black-out in the 
event of a sudden air attack.—Mr. G. Lioyp, Under- 
Secretary, Home Office, replied: Subject to general 
guidance from the Air Raids Precautions Department of 
the Home Office, the responsibility. for working out and 


THE LANOET| 


MEDICAL NEWS 


[reB. 29, 1936 515 


codrdinating necessary measures of precaution against the 
emergency of air attack rests with the various local 
authorities. The question of the form of executive 
organisation to be adopted in the event of war is under 
consideration. With regard to the last part of the 
question, it would fall to the Secretary of State for the 
Home Department in time of war to issue any general 
orders that might be necessary for the regulation and 
restriction of lighting. It would be the duty of the 
chief officer of police in each district to make the necessary 
arrangements for ‘giving effect to any such orders. 


TUESDAY, FEB. 25TH — 
- Free Meals for School-children in Greenock 


Mr. Davipson asked the Secretary of State for Scotland - 
the total number of school-children in Greenock receiving 
free meals as necessitous cases.—Colonel COLVILLE, 
Under-Secretary of State for Scotland, replied: The 
number of children receiving free meals on the 20th of 
this month was 163. In addition, about 4000 receive 
free milk under a scheme BPPrOYeS under the provisions 
of the Milk Act, 1934. 


MEDICAL NEWS 


University of Cambridge 
On Feb. 22nd the following degrees were conferred :— 
M.D.—W. S. C. Copeman, G. D. Kersley, Frank Goldby, and 
E. S. Stern. 
M.B., B.Chir.—E. J. Currant, B. H. Page, and J. B. C. 
Murdoch. 
M.B.—W. I. Bain, J. H. Walters, and G. O. Brooks. 
B.Chir.—A. F. Bryson and P. G. Scott. 


University of London 

The university chair of dietetics tenable at St. Thomas’s 
Hospital medical school is to be transferred to University 
College Hospital medical school for five years. 

Mr. H. L. Eason has been reappointed representative 
of the University on the General Medical Council. 

On March 2nd, at 5 p.m., at University College, Gower- 
street, W.C., Dr. Charles Reid will give the first of four 
Monday lectures on the endocrine organs in relation to 
metabolism. 


Society of Apothecaries of London 
At recent examinations the following candidates were 
successful :— 


Surgery.—H. Bentovim and H. Burrows, Univ. of Manch. > 
and O. A. L. Goode, Univ. of Leeds. 
Medicine.—H. a Koretz, Univ. of Manch. 
Forensic Medicine.—H. A. Koretz, Univ. of Manch. 
Midwifery.—H. we Bhuttacharji, Univ. Coll. Hosp.; J. A. G. 
Gulliford, V Welsh National School of Medicine ; ; and J. F. 


O'Malley, Guy’s HOSP 
H. Burrows and O. A. L. Goode, having completed the final 


examination, are ented the diploma of the society entitling 
them to practise medicine, surgery, and midwifery. 


Royal College of Surgeons of England 

On Monday, March 2nd, Mr. C. E. Shattock will open 
the spring course of museum demonstrations at the Royal 
College of Surgeons by showing specimens illustrating 
cysts. On the following three Fridays Dr. A. J. E. Cave 
will deal with the anatomy of cervical rib and of certain 
vertebral joints and the significance of the facial muscu- 
lature. Dr. L. W. Proger will demonstrate tumours of 
the kidney on Monday, March 16th, and on March 23rd 
new additions to the museum. The demonstrations will 
be held in the College, Lincoln’s Inn-fields, London, W.C., 
at 5 P.M., and they are open to advanced students and 
medical practitioners. 


University of Glasgow 

It is announced that the number of students to be 
admitted to the first-year courses in medicine in October, 
1936, will be limited and that forms of application for 
permission to commence the study of medicine, which 
may now be obtained from the registrar, must be returned 
by applicants not later than July Ist, 1936. 

On the recommendation of the faculty of medicine 
the senate has resolved to add the subject of tropical 
diseases to the list of special departments from which a 
candidate may elect to be examined for the M.D. degree, 


Post-graduate Course in Paris 

A fortnight’s course on the medical and fyarslogibal 
treatment of digestive and nutritional disorders will begin 
on May 4th at the Hôpital Necker under the direction 
of Prof. Maurice Villaret. May 17th to 19th will be 
spent at Vichy where the last two lectures of the course 

will be given. Further information may be had from the 
Laboratoire d’Hydrologie et de Climatologie théra- 
peutiques, Faculté de Médecine, Paris, 


British Institute of Philosophy 

An address entitled Vice and Illusion will be given by 
Prof. Gilbert Murray on Tuesday, March 10th, at 8.15 P.M., 
at University College, Gower-street, London, W.C. Cards 
of admission may be had from the director of studies at 
University Hall, 14, Gordon-square, W.C.1. 


Royal Sanitary Institute 

A meeting of this institute will be held in the town 
hall, Ipswich, on Saturday, March 14th, at 2.30 P.M., 
when Mr. E. McLauchlan will open a discussion on the 
disposal of house refuse by controlled tipping, and Dr. 
A. M. N. Pringle a discussion on baths and bath water. 


Public Food Service in Russia 

At 8 p.m. on Thursday, March 12th, at the houe of the 
Royal Society of Arts, 18, J ohn-street, Adelphi, Mr. 
F. Le Gros Clark, hon. secretary of the Committee Against 
Malnutrition, will lecture on Men, Medicine, and Food 
in the Soviet Union. Tickets may be had from the 
committee at 19c, Eagle-street, London, W.C. 1.. 


Microchemical Club 

The third annual general meeting of ,this club will be 
held in the department of plant physiology at the Imperial 
College of Science and Technology, South Kensington, 
on Saturday, March 14th, at 11 a.m. The programme 
will include a lecture by Mr. C. Ainsworth Mitchell, 
D.Sc., on the microchemical examination of inks and 
handwriting. 


Course in Psychological Medicine 

The second part of the course of instruction for a 
diploma in psychological medicine, which has been 
arranged by the London County Council and is being 
held at the Maudsley Hospital, Denmark Hill, S.E., 
starts on March 2nd and will continue till May 25th. 
Further information may be had from Dr. F. Golla, hon. 
director of the medical school at the Maudsley Hospital. 


Sir Charles Hastings Lecture 

Prof. Winifred Cullis and Dr. R. Cove-Smith will 
deliver the eighth Sir Charles Hastings lecture at the house 
of the British Medical Association, Tavistock-square, 
London, W.C., on Tuesday, March 10th, at 8P.m. Their 
subject will be Keeping Fit. Tickets may be had from 
the financial secretary of the B.M.A. 


Demonstrations of Contraceptive Technique 

On Thursday, March 5th, at 2.30 P.M., a practical domon- 
stration of the technique of the use of a variety of contra- 
ceptive methods will be given by Mrs. Marie Stopes, D.Sc., 
and Dr. Evelyn Fisher at the clinic of the Society for 
Constructive Birth Control. Medical practitioners and 
senior students should apply for tickets to the hon. 
secretary of the society at the clinic, 108, Whitfield-street, 
London, W. 1. 


A Debate on Euthanasia 

At a meeting of the Law Students’ Debating Society 
held in London on Feb. 18th Dr. C. Killick Millard, as a 
visitor, proposed ‘‘ that in the interests of humanity it is 
desirable that voluntary euthanasia should be legalised, 
subject to adequate safeguards, for persons who are 
suffering from incurable, fatal and painful disease.’’ 
Mr. A. L. Ungoed Thomas opposed the motion, and after 
discussion it was carried by one vote, 


516 THE LANCET] 


State Medical Faculty of Bengal 


This faculty has instituted a fellowship examin ition (to 
be taken in medicine or surgery) for candidates who seek a 
post-graduate qualification equivalent in status to a univer- 
sity doctorate. Further particulars may be had from the 
secretary of the faculty at Grosvenor House, Calcutta. 


Eugenics Society 


At a meeting of this society to be held on Tuesday, 
March 17th, at 5.15 P.M., at the rooms of the Linnean 
Society, Burlington House, Piccadilly, London, W., 
Mr. D. Caradog Jones will speak on Eugenics and the 
Merseyside Enquiry. Mr. A. Bradford Hill, D.Sc., is to 
be in the chair, 


British Postgraduate Medical School 


On Mondays, at 2.30 P.M., beginning on March 2nd, 
Dr. Gordon Holmes, F.R.S., will give five lectures on 
cerebro-spinal syphilis, and on Fridays, at 5 P.M., beginning 
on March 20th, Sir James Walton will give six lectures on 
surgical aspects of dyspepsia. A course of 13 lectures 
on recent advances in obstetrics and infant hygiene 
(of which particulars will be found weekly in our Medical 
Diary) will be opened on Monday also, when Dr. Leonard 
Colebrook will discuss puerperal sepsis. Four lectures 
on the hygiene of the new-born child will be delivered by 
Dr. Alan Moncrieff from March 27th to April 24th. Further 
particulars of all these courses may be had from the 
Dean of the School, Ducane-road, London, W. 12. 


A Conference on Climatophysiology 


The first All-Union Conference on Climatophysiology 
and Climatotherapy has recently been held in Moscow. 
“The problem of climate,” said Prof. I. P. Razenkov, 
assistant director of the All-Union Institute of Experi- 
mental Medicine, in his opening specch, “‘ is a vital problem 
of modern medicine. And in our country, with the great 
variety of climate in its different regions, these problems 
are of particular importance.” A report by Prof. N. E. 
Marshak was devoted to the climatophysiological problems 
associated with the rapid industrial growth of the Soviet 
Union and the development and peopling of its border- 
lands, and also with the extensive use of climate in the 
prevention and cure of disease. The other communica- 
tions presented to the Congress included observations on 
the climatic treatment of tuberculosis and of renal 
diseases, on physiological data obtained by the 1935 
Pamir expedition, on climatotherapeutic research in 
Georgia, and on tho effect of climatic conditions on 
treatment with ultra-violet rays. 


Joint Tuberculosis Council 


After discussing a number of present-day problems, 
including the new milk designations and the risk run in 
nursing tuberculous cases, the council lunched together 
on Feb. 22nd at the Hotel Russell, under the 
genial chairmanship of Dr. G. Lissant Cox. In replying 
for the guests, Dr. Arthur MacNalty said that the idea 
of having a council of all those interested was a great step 
forward in a national antituberculosis scheme. It was 
Dr. Ernest Ward’s great idea and he was happy himself 
to have been the first representative of the Ministry of 
Health on the council, which had led to a better under- 
standing of the aims and uses of the sanatorium-hospital 
and the place of after-care. The village settlement, he 
said, fully demonstrated the value of such work. Sir 
Henry Gauvain, in proposing The Council, excused 
himself from speaking to tho toast in the phrase “ we 
know we're all very good fellows and we needn’t rub 
it in,” and then told entertaining stories of his recent 
journey round the world. Dr. Ward, roplying, recalled a 
M.O.H.’s remark to him, ‘ Your work is easier than mine ; 
it is static,’ and thus stimulated sought new fields of 
activity. The tuberculosis-rate was falling (not, it was 
true, as fast as in Italy), but had intensive pneumothorax 
treatment led to any acceleration in the fall? Some 
10 per cent. of cases were infected from a known source ; 
where did the remaining 90 per cent. get infected ? In 
some cases where treatment was refused (but radiography 
permitted) he had watched the disease fade away ; could 
the reason for this be discovered ? Dr. C. O. Hawthorne 
proposed the health of the chairman. 


MEDICAL NEWS.—APPOINTMENTS 


‘London 


[FEB. 29, 1936 


THE King has granted permission to Colonel Philip 
Henry Mitchiner, T.D., M.S., surgeon to St. Thomas’s 
Hospital, London, to wear the insignia of the second class 
of the Order of St. Sava, conferred on him by the King 
of Yugoslavia in recognition of his services. 


Woolwich War Memorial Hospital 


More accommodation is badly needed at this hospital, 
for the number of cases in every department was greater 
in 1935 than in 1934. There was a specially large increase 
in the number of out-patient attendances. 


Ophthalmological Congress 


The second Internationale Kongress fir Irisdiagnostik, 
which was postponed last year, will be held on May 28th 


‘and 29th in Nuremberg. Further information may be 


had from J. Steen, Leubnitzerstr. 2, Dresden, A 24. 


Chadwick Public Lectures 


On Thursday, March 19th, at the Royal United Service 
Institution, Whitehall, London, S.W., at 5.30 r.m., Dr. 
Arthur MacNalty will give a public lecture under the 
auspices of this trust. He will speak on epidemic polio- 
myelitis and Sir James Crichton Browne, F.R.S., will be 
in the chair. On April 2nd, at 8.15 P.M., Mr. Lionel 
Pearson will speak on modern hospital construction at 
the Royal Institute of British Architects, 66, Portland- 
place, W. The lectures are open to all, and further 
particulars may be had from Mrs. Aubrey Richardson, 
O.B.E., at the offices of the trust, 204, Abbey House, 
Westminster, 


Lectures on Women’s Health 


A series of lectures on this subject will be delivered 
under the auspices of the Roval Institute of Public Health 
and the Institute of Hygiene at 28, Portland-place, 
London, W., on Wednesdays, from March 4th to April 8th, 
at 3.30 p.m. The lecturers will be Mr. Aubrey Goodwin 
(the health of the married woman), Prof. Winifred Cullis 
(women in industry), Dr. G. W. Theobald (some effects 
of emancipation on the health of married women), Dr. 
J. F. Halls Dally (psychological influences on the circula- 
tion), Dr. R. Fortescue Fox (arthritis in women), and 
Prof. James Young (sociological problems affecting 
women’s health). The lectures are open to all who are 
interested in health problems. 


Appointments 


BRINTON, D., B.M. Oxon., M.R.C.P. Lond.. has been appointed 
Neurologist to the Croydon General Hospital. 

CASE, R. M., M.B. Birm., Resident Medical Officer at the 
Leicester General Hospital. 

ELLUS, R. W. B., M.D. Camb., M.R.C.P. Lond., Physician to the 
Infants Hospital, Vincent-square, London. ° 

Evans, ©. D., M.B. Camb., Hon. Medical Registrar at the 
Royal United Hospital, Bath. 

GILPIN, A., M.D., M.R.C.P. Lond., Assistant Physician to the 
Croydon General Hospital. 

HARRIS, CHARLES, M.D., FLR.C.P. Lond., Physician to the 
Infants Hospital, Vincent-square, London. 

Last, S. L., M.D. Berlin, L.R.C.s. Edin., D.P.M. Eng., Second 
Assistant Medical Otlicer at the Mental Hospital, Berry 
Wood, Northampton. 

Moore, JoOckELYN, M.B. Lond., F.R.C.S. Eng., M.C.O.G., 
Assistant Pbysician for Diseases of Women to the London 
Homeopathic Hospital. 

ROBERTS, L. V., M.B. Edin., Resident Medical Officer at the 
Leicester General Hospital. 

BOE ee i M.B. Camb., Hon. Anesthetist to Charing Cross 
dospital. 

ROSENKRANZ, K., M.D. Freiburg. L.R.C.P. Edin., Assistant 
Radiologist at the Elizabeth Garrett Anderson Hospital. 

WIMTTAKER, DUNCAN, M.R.C.S. Eng., Junior Assistant Physi- 
cian at the Bethlem Royal Hospital. 

Skin Hospital.—The following appointments 
announced :— 

DUCKWORTH, GEOFFREY, M.R.C.P. Lond., Hon. Physician ; 
Murray, J. F., M.B. Irel., Hon. Assistant Physician ; and 
Dunn, J. H., M.D. Belf., M.R.C.P. Lond., Registrar. 

Soulhend General Hospital.—The following appointments are 
announced :— 

Evans, WILLIAM, M.D., F.R.C.P. Lond., Hon. Physician ; 

WHEELER, Sir WILLIAM, M.D. Dub., F.R.C.S. Irel., Hon. 
Surgeon 3 

O’REILLY, J. N., B.M. Oxon., M.R.C.P. Lond., Hon. Physician 

in Diseases of Children ; 

BaRLow, D. S., M.S. Lond., F.R.C.S. Eng., General Surgeon ; 

Bonn, L. T., M.B. Camb., Pathologist; and 

STROM-OLSEN, R., M.D. Wales, D.P.M.. Hon. Psychiatrist. 

Certifying Surgeons under the Factory and Workshop Acts? 
Dr. J. O. MCDONAGH (Stanley District, Porth) and Dr. N- 
ANDERMAN (Lynton District, Devon). 


are 


THE LANCET] 


Medical Diary 


Information to be included in this column should reach us 
in proper form on Tuesday, and cannot appear if it reaches 
us later than the first post on Wednesday morning. 


SOCIETIES 


ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W. 

TUESDAY, March 3rd. 

. Pathology. 8.15 for 8.30 P.M. (National Institute for 
Medical aerate Mount Vernon, N.W.) P. P. 
Laidlaw : A Group of Filtrable Organisins. 2. An 
Anaerobic hicthod for Plates. W. J. Elford and M. 
Schlesinger: 3. Purified Preparations of Bacterio- 
phage. F. F. Tang: 4. Filamentous Forms of Pleuro- 
pneumonia. C. H. Andrewes: 5. Malignant Trans- 
formation of Virus-induced Papiloma of the Rabbit. 
6. Immunisation of Mice against Influenza Virus. 
S. E. B. Balfour Jones: 7. Rat Leprosy in Hamsters. 
J. E. Barnard: 8. Microscopic Appearances of Some 
Viruses. P. Bruce White: 9. Polysaccharides from 
Cholera Vibrios. J. R. ‘Perdrau 10. Australian 
X- disease. A. S. Parkes and S. Zuckerman: 11. 
Changes in the Primate Prostate Caused by Œstrone 
and their Suppression by Male Hormone. 


Orthopedics. 8.30 P.M. Mr. George Perkins and Mr. R. 
W atson Jones : Fractures in the Region of the Shoulder- 
joint. 
WEDNESDAY. 


History of Medicine. 5 P.M. Prof. Millais Culpin: The 
History of Psychology in Medicine. 
Surgery. 8.30 P.M. Mr. Ian Aird, Mr. G. C. Knight, 


Mr. David Slome, and Mr. R. St. Leger Brockman : 
Intestinal Strangulation. 
THURSDAY. 
Tropical Diseases and Parasitology. 8 P.M., Special 
Meeting. 8.30 P.M., Colonel S. P. James: Clini 


and Parasitological Observations Applicable to the 
Study of Malaria Epidemics. 
FRIDAY. - 
Otology. 10.30 A.M. (Cases at 9.30 A.M.) Dr. G. Kelemen 
(Budapest) and Dr. E. A. Blake Pritchard: Disturb- 
ances of Function of the Ear following Injury. 
5 (Cases at 4 P.M.) Dr. 


Laryngology 2 P.M. Brown 


a fae Kelemen, Mr. V. E. Negus and Mr. 
yeaa: Non-inalignant Obstruction of the 
orne 
Anæsthetics. 8.30 P.M., Clinical Meeting. 


MEDICAL SOCIETY OF LONDON, 11, Chandos-street, W. 
MONDAY, March 2nd.—9 P.M., Dr. P. H. Manson-Bahr: 
3 The Differential Diagnosis of Discases of the Colon 
(Dysentery and Colitis) and their Complications, with 
ey. Reference to Treatment (last Lettsomian 
ecture 
WEST LONDON MEDICO-CHIRURGICAL SOCIETY. 
FRIDAY, March 6th.—8.45 P.M. (West London Hospital), 
Clinical and Pathological Mecting. (Cases at 8 P.M.) 
, SOCIETY OF CHEMICAL INDUSTRY (London Section). 
MONDAY, March 2nd.—8 P.M. (Burlington House, Picca- 
dilly, W.), Dr. T. A. Henry: 
Malaria. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 


ROYAL COLLEGE OF PHYSICIANS, Pall Mall Kast, S.W. 
TUESDAY, March 3rd.—5 P.M., Dr. B. L. Middleton : 
Industrial Pulmonary Disease due to the Inbalation 
of Dust, with Special Reference to Silicosis (last Milroy 
lecture). 
THURSDAY.—5 P.M., Dr. R. A. McCance : Medical Problems 
in Mineral Metabolism (first Goulstonian lecture). 
ROYAL COLLEGE OF SURGEONS OF ENGLAND, Lincoln’s 
Inn-fields, W.C. 
Monvpay, March 2nd.—5 P.M., Mr. C. E. Shattock: Speci- 
mens Illustrating Cysts. 
FRIDAY.—5 P.M., Dr. A. J. E. Cave: 
Cervical Rib (Musewn demonstrations), 
UNIVERSITY OF LONDON, 
Monvpay, March 2nd.—s P.M. (University College, Gower- 
street, W.C.), Dr. Charles Reid: The Endocrine 
Organs in Relation to Metabolism (first of four lectures). 
TUESDAY.—5 P.M., Dr. R. Kuczynski: Recent Population 
* Trends (first of three lectures). 
INSTITUTE OF HYGIENE, 28, Portland-place, W. 
WEDNESDAY, March 4th. any 30 P.M., Mr. Aubrey Goodwin: 
The Health of the Married Woman. 


BRITISH, POSTGRADUATE MEDICAL 


road, W 
March 2nd.—2.30 P.M., Dr. 


SCHOOL, Ducane- 


Gordon Holmes, 
F.R.S.: Cerebro- -Spinal Syphilis (first of five lectures). 
3.30 P.M., Dr. Leonard Colebrook : Puerperal Sepsis. 

WEDNESDAY. are 30 P.M., Mr. Eardley Holand: Hamor- 
rhage of Late Pregnaucy. 


WIEST LONDON HOSPITAL POST- GRADUATE COLLEGE, 
Hammersmith, W.6 

MONDAY, March ‘2und.—10 A.M., Skin clinic. 11 A.M., 
Surgical wards. 2 P.M., Gynecological and surgical 
wards, gy nwcological and eye clinics. 

TUESDAY. 210 A.M., Medical wards. 1l 
wards. 2 P.M., Throat. clinic. 

WEDNESDAY.—10 A.M., Children’s ward and clinic. 
Medical wards. 2 P.M., Eye clinic, 
operations. 


MONDAY, 


A.M., Surgical 


11 AM., 
gynecological 


MEDICAL DIARY 


The Chemotherapy of .- 


The Anatomy of . 


[reB. 29, 1936 517 


THURSDAY.—10 A.M., Neurological and gyneecological 
clinics. Noon, Fracture clinic. P.M., Eye and genito- 
urinary clinics. 4 P.M., Venereal diseases. 

FriIpDAY.—10 A.M., Medical wards and skin clinic. Noon, 
Lecture on treatment. 2 P.M., Throat clinic. 4.15 P.M., 
Mr. Vlasto: Hsemorrhage from the Upper Respiratory 


Tract. 

SATURDAY.—10 A.M., Children’s and. surgical clinics, 
Medical wards. 

Daily, 2 P.M., Operations, Medical and Surgical Clinics. 

The lectures at 4.15 P.M. are open to all medical practi- 


tioners without fee. 
seat aa FOR SICK CHILDREN, Great Otmondssttest, 


WEDNESDAY, March 4th.—2 P.M., Dr. B. E. Schlesinger: 
Croup. 3 P.M., Dr. D. N. Nabarro: Purity of Milk- 


supply. ; 
Out- patent clinics daily at 10 a.M. and ward visits at 
NATIONAL’ HOSPITAL, Queen-square, W.C. 


MONDAY, March 2nd.—3.30 P.M. . Dr. Kinnier Wilson : 
Some Heredo-familial Diseases (IV.) ‘Cerebellar 
spinal, 

TUESDAY.—3.30 P.M., Mr. Julian Taylor: Spinal Com- 
pression. 

WEDNESDAY.—3.30 P.M. . Dr. Kinnier Wilson: Clinical 
Demonstration. 


THURSDAY.—3.30 P.M., Mr. Leslie Paton: Optic Atrophy. 

FRIDAY.—3.30 P.M., Dr. Purdon Martin : Disseminated 
Sclerosis. 

Out-patient clinic daily at 2 P.M. 

NATIONAL HOSPITAL FOR DISEASES OF THE HEART, 
Westmoreland-street, W. 

TUESDAY, March 3rd.—5.30 P.M., Dr. J. M. H. Campbell: 
The Use of Quinidine in Fibrillati on. 

HAMPSTEAD GENERAL AND NORTH-WEST LONDON 
HOSPITAL, N.W. 

WEDNESDAY, March 4th.—4 P.M., Dr. Ralph Noble: Some 

Psychological Principles in General Medicine. 
ST. JOHN CLINIC, Ranelagh-road, S.W. 

FRIDAY, March 6th.—4.30 P. M., Mr. H. J. Taylor, Ph.D. : The 
Physical Basis of Electric Treatments, including 
Diathermy and Ultra-short Waves. 

SOUTH-WEST LONDON POST-GRADUATE ASSOCIATION. 

WEDNESDAY, March 4th.—4 P.M. (St. James’s Hospital, 
Ouseley-road, S.W.), Mr. V. Z Cope: Demonstration 
of Surgical Cases. 

FELLOWSHIP OF MEDICINE AND POST- GRADUATE 
MEDICAL ASSOCIATION, 1, Wimpole-street, W. 

MONDAY, March 2nd, to SATURDAY, March 7th.—INFANTS 
HOSPITAL, Vincent- -square, S.W. Mon., Wed., and 
Fri., at 8 P.M., primary F.R.C.S. course in anatomy 
and physiology.—NATIONAL TEMPERANCE HOSPITAL, 
Hampstead-road, N.W. Tues., 8.30 P.M., Mr. Hamilton 
Bailey : Testicle and Prostate. Thurs., 8.30 P.M., 
Mr. T. Meyrick Thomas: Breast (M.R.C.P. clinical 
course at 8 P.M.).—W EST END HOSPITAL FOR NERVOUS 
DISEASES, Welbeck-street and Regent’s Park.—After- 
noon M.R.C.P. course in neurology and psycho- 
pathalogy.—BROMPTON HOSPITAL, S. W.—Week-end 
course in chest diseases.—Courses are open only to 
members of the Fellowship. 

MANCHESTER ROYAL INFIRMARY. l 

TUESDAY, March 3rd.—4.15 P.M., Mr. P. R. Wrigley: 
Chronic Abdominal Pain. 

FriIDAY.—4.15 P.M., Mr. A. Graham Bryce: 
of Surgical Cases. 

ANCOATS HOSPITAL, Manchester. 

THURSDAY, March dth.—4.15 P.M., 
Fractures of the Spine. 

LEEDS GENERAL INFIRMARY. 

TUESDAY, March 3rd.—3.30 P.M., Mr. Armitage : (1) Injec- 
tion Therapy in the Treatment of Hemorrhoids and 
o ose Veins. (2) Demonstration of Some Surgical 

ases 
LEEDS PUBLIC DISPENSARY. 

TUESDAY, March 4th.—4 P.M., Dr. IH. G. Garland: Neuritis 

—the Common Causes, Prognosis, and Treatment. 
UNIVERSITY OF DURHAM. 

SUNDAY, March 8th.—10.30 A.M. (Newcastle General Hos- 

pital), Dr. W. G. A. Swan: Selected Medical Cases. 
GLASGOW POST-GRADUATE MEDICAL ASSOCIATION. 

WEDNESDAY, March 4th.—4.15 P.M. (Western Infirmary), 

Dr. John Gracie: Nepbritis. 


Demonstration 


Mr. E. S. Brentnall : 


CONGRESS OF COMPARATIVE MEDICINE.—The third 
International Congress of Comparative Medicine will 
take place in Athens from April 15th to 18th under 
the presidency of Prof. W. Bensis. The last meeting 
of the congress will be held at Epidaurus. Twenty-eight 
nations, including Great Britain, will be officially repre- 
sented, and a British committee is being formed under 
the chairmanship of Lord Dawson. The official repre- 
sentatives of the British Government are: Mr. F. P. 
Brooks, F.R.S., Dr. N. Hamilton Fairley, and Prof. 
F. C. Minett, and those contributing to the proceedings 
will include Lieut.-Colonel H. E. Short. Further informa- 


tion can be had from. the secretary of the British 


committee, Dr. 
London, W.1.: 


A. P. Cawadias, 52, Wimpole-street, 


518 THE LANCET] 


[FEB. 29, 1936 


NOTES, COMMENTS, AND ABSTRACTS 


PASTEURISING PLANTS 


THE apparent failure of pasteurisation of milk 
between 145° and 150° F. for 30 minutes to destroy 
tubercle bacilli has been recorded by various investi- 
gators. Since others have obtained consistently 
negative results when examining milk from efficiently 
designed and operated pasteurising plants under 
the same conditions of time and temperature, it 
seems likely that failure to destroy the tubercle 
bacilli is an indication of a bad design or inexpert 
operation of the apparatus. In order to test this 
hypothesis A. W. Scott and N. C. Wright have 
examined 19 holding plants in 4 Scottish cities. The 
outcome of their investigations is set out in a special 
report to the Hannah Dairy Research Institute.? 
Some of the conclusions reached are summarised 
below. 

Filtration.— Milk is usually weighed at a platform 
and then transferred into a receiving tank after 

assing through a coarse filter designed to remove 
arge particles. Such filters should not be constructed 
of copper for fear of tainting the milk. The receiving 
tank should be sufficiently large in relation to the 
capacity of the rest of the plant to ensure a steady, 
unbroken supply of milk into the heating apparatus 
throughout the run. Milk is generally circulated by 
means of force pumps. Pumps having a long suction 
lead are undesirable owing to the danger of air leaks 
developing at joints and consequent contamination 
of milk from the air. Nor is it desirable to pass milk 
-through a pump after pasteurisation owing to the 
danger of contamination from the working parts 
of the machine. Milk should flow by gravity through 
the cooling and bottling apparatus. Careful filtra- 
tion or clarification of milk prior to pasteurisation 
is most necessary. For this purpose cloth filters or 
centrifugal separators may be used. There is no 
agreement as to which constitutes the more satis- 
factory type, but whichever method of cleansing is 
used it should be carried out at as low a temperature 
as possible so as not to interfere with the cream-line 
of the resulting product. | 

Milk may be pre-heated to the requisite tempera- 
ture and then passed into holding tanks, or it may 
receive all the heating in the holder. Four types of 
heating apparatus were examined—viz., kettle heaters, 
plate heaters, tubular heaters, and batch pasteurisers. 
The first three types depend upon the rapid passage 
of a thin layer of milk through a narrow space with 
suitably heated walls. In the batch pasteuriser a 
vat of milk is heated by a steam jacket, circulation 
being assisted by rotary paddles, or by rotating 
heated coils. The heating of the walls in the first 
three types—i.e., the pre-heaters—is effected by a 
system of jacketing with hot water or with steam, 
If circulating hot water is used, and provided the 
temperature of the water is thermostatically con- 
trolled, these types of pre-heaters raise the milk to 
an extremely constant temperature. Where tanks 
are heated directly automatic thermographs should 
be installed. 

As regards holding tanks to which milk is passed 
following ‘‘ pre-heating,” their object is to retain 
the milk at a temperature between 145° and 150° F. 
for a minimum of 30 minutes. A single tank is 
‘generally used for this purpose which is jacketed 
with steam or hot water. Provided that the correct 
temperature is maintained in the main bulk of the 
milk throughout the run, survival of tubercle bacilli 
can generally be explained by the existence of dead 
spaces, faults in the inlet or outlet valves, poor 
mixing, or excessive foam formation. A dead space 
-is a portion of the milk where circulation is suppressed 
and which does not reach the required temperature. 
Such spaces are generally associated with leads to 
the valves and can be avoided by fitting such valves 


3 Medical Research Council, Special Report Series No. 189. 
3? Hannah Dairy Research Institute, 1935, Bull. No. 6, pp. 72. 


flush with the sides of the tank. The valves them- 
selves should not leak; or any milk which leaks 
must be allowed to run to waste. Adequate stirring 
of the milk is necessary, but foam formation must 
be avoided, whilst measures should be taken to 
avoid contaminating milk with grease or dirt from 
the bearings of the stirring paddles. Where foam is 
formed tubercle bacilli and thermophilic organisms 
may escape destruction through not being sufficiently 
heated in the protecting foam; formation of this 
foam can be avoided by a suitable design of the inlet 
valve and the stirring apparatus, or else the space 
above the milk in the holder must be adequately 
heated,’ in which case foam formation ceases to 
matter. It was found that thermometers and thermo- 
graphs used in the various plants showed striking 
errors of reading, which emphasises the need for 
frequent checking of such instruments against 
standard thermometers. In order to ensure constant 
temperatures all heating processes should be thermo- 
statically controlled, whilst the holder tank should 
be fitted with a thermograph and a direct reading 
maximum and minimum thermometer. As regards 
the duration of heating, it is emphasised that the 
regulations demand that all milk shall be held at 
the required temperature for a minimum period of 
30 minutes exclusive of the time taken to fill and to 
empty the holder. 

Two types of cooling apparatus were studied, the 
one where milk trickles over the surface of corru- 
gated plates cooled by a brine jacket and is exposed 
to the atmosphere, the other in which the milk is 
cooled internally. Both types cooled the milk satis- 
factorily, and the contact between the atmosphere 
and the milk in the first type had less influence upon 
the bacterial content of the finished product than 
might have been expected. The important considera- 
tion is the adequate cleansing of the apparatus. To 
avoid contamination of milk with organisms patho- 
genic to human beings an internal cooling system 
is desirable. As regards the bottling apparatus, the 
design of the apparatus is of secondary importance 
compared to the necessity of adequate cleansing. 
An obvious corollary to this poni is that the apparatus, 
and in particular the delivery valves, should be 
designed with a view to easy cleansing. This remark 
applies to every piece of apparatus and every pipe 
through which the milk is passed. 

In judging the suitability of milk received for 
pasteurisation, attention should be paid not only to 
the pre-pasteurisation bacterial count, since that is 
frequently an unfair index of the conditions under 
which the milk has been produced, but also to the 
post-pasteurisation count of heat resistant organisms. 
The former count is largely influenced by weather 
conditions, but the thermophilic organisms come 
from dust and from badly sterilised apparatus, so 
that a high count of these organisms indicate strongly 
that the hygiene of production has been bad. 


It is suggested that the dairy firms would do well 
to carry out routine bacterial examinations of milk 
after every stage of pasteurisation, for such a pro- 
cedure would give a reliable check of the efficiency 
with which the apparatus was functioning. Further- 
more, routine examinations should be ey an 
outside authority in order to create a stand b 
which the efficiency of pasteurisation may be judged, 
and in order to give independent evidence of the 
efficiency of operation of any particular plant. Also 
it would serve to deter plant operators from becoming 
careless. In addition to bacterial counts, an estima- 
tion of the coli content of milk is a useful index of 
efficiency of pasteurisation. But quite irrespective 
of such tests the adequacy of plants must finally 
be judged by their ability or otherwise to destroy 
tubercle bacilli, since that is the primary function 
of pasteurisation. It is of interest to note that 
Scott and Wright found that out of 332 samples of 
milk taken from 3 plants run in a slipshod manner, 


Ma se, e ees et 


THE LANCET] 


3-3 per cent. contained tubercle bacilli. Out of. 
340 samples taken from 4 efficiently operated plants, 
none were found to contain this organism. 


PHYSIOLOGY FOR SCHOOLBOYS 


. A SMALL book,! to which Sir Humphry Rolleston 
and Dr. J. R. Rees have written complimentary 
forewords, embodies a course of seven lectures 
primarily intended for public schoolboys. The 
first four lectures deal with the digestive, circulatory, 
respiratory, and skeletal systems. Consideration 
of the nervous system is divided between the fourth 
and fifth lectures and the latter also includes the 
urogenital system. The sixth lecture summarises 
what has gone before and the seventh lecture, 
reserved for those of leaving-age, discusses venereal 
disease. The facts are accurate and the treatment 
not too profound. The style is attractively simple 
and intimate. Dr. Barber perhaps dwells too much 
on the dangers of constipation and, in a laudable 
anxiety not to stress sex unduly, has possibly erred 
on the other side. Some concrete amplification as 
to how the sex-impulse is to be sublimated before 
marriage is economically possible might not have 
been out of place. This little work should be in 
the hands of all schoolmasters, parents, and school 
medical officers. With certain modifications, it 
should be equally useful to headmistresses and those 
who have charge of the adolescent girl. 


A VISIT TO THE G.P.O. 


IN no business is efficiency as necesar for the 

comfort and smooth running of private and business 
life as it is in the General Post Office. How this high 
standard is maintained was shown when the Post- 
master-General entertained the London University 
Medical Graduates Society on Feb. 2lst in the 
King George V. Hall of the Central Telegraph Offce. 
After welcoming the guests, he invited them to 
visit what he claimed to be the largest and most 
efficient business organisation in the country. To 
the medical profession, he said, the health service 
under Dr. H. H. Bashford would be of particular 
interest, especially on account of the complete and 
accurate records kept of the staff of over 240,000, 
of all ages from 16 to 60. The recent great advances 
in the Post Office routine kept abreast of the times 
in response to the need of the general public for 
simplicity and of the modern business world for 
speed and efficiency. Examples were, on the one hand, 
the sixpenny telegram and the single night charge for 
all telephone calls throughout the country; and, 
on the other, the development of continental and 
trans-atlantic telephony, the ‘‘ telex ’’ system where 
typescript would be transmitted and received in the 
same way as conversation in the ordinary telephone, 
and, for the press, picture telegraphy. Mr. W. 
McAdam Eccles, in expressing the thanks of the 
company, claimed to be one of the first in Harley- 
street to use the telephone, and he described its 
value at that time in a surgical emergency in the 
country. 

The guests were then divided into groups to visit 
the chief departments of the Post Office. One party 
was conveyed to Mount Pleasant, the headquarters 
of the inland sorting office and of the unique under- 
ground postal railway. A second group stayed in 
the Central Telegraph Office, which also housed the 
medical department and the new air-conditioned 
King George V. Hall, used for exhibitions, broad- 
casting, lectures, and cinema displays. The apparatus 
and transmission of picture and ordinary telegraphy 
were demonstrated, aswell as the use of underground 
tubes, of which there are 75 miles under the London 
streets connecting the main post offices and business 
houses, and of the telephone, both of which have 
done much to accelerate telegraphy. The two 
remaining parties were shown the overseas mail 


1ı School Education in Hygiene and Sex. By G. O. Barber, 
M.B., B.Chir., .C.S., L.R.C.P., Medical -Officer, Felsted 
School. Cambridge: W. Heffer and Sons, Ltd. 1936. 


71. 28. 6d 


‘NOTES, COMMENTS, AND ABSTRACTS 


[rEB. 29, 1936 519 


department and the international telephone exchange ; 
telephonic communication took place during the 
time of the visit with places as far apart as Cape 
Town, Sydney, Bombay, New York, and the 
Aquitania in mid Atlantic. 


' A HOME FOR TUBERCULOUS NURSES 


Miss K. L. Borne, Matron of Papworth Village 
Settlement, Cambridge, writes: ‘‘ Papworth proposes 
to build a special home for the benefit and prolonged 
after-care of nurses who have contracted tuberculosis 
in the course of their duties. This scheme ought to 
meet with the approval of members of the medical 
profession who know how difficult. it is to advise 
an ex-sanatorium nurse regarding her future and her 
means of livelihood. At Papworth work will be 
available, either as a nurse or in some other suitable 
occupation. Since 1930 we have found it possible 
to employ many ex-patient nurses in the wards or 
in the Papworth Industries. We have discovered 
that, given shorter hours and sanatorium conditions, 
under medical supervision, such patients have become 
partially, some wholly, self-supporting. It is to 
give a larger number of nurses this same opportunity 
that I am venturing to ask assistance from the 
medical profession in the form of a small contribution 
towards the cost of building this house for 40 
ex-sanatorium nurses, or a donation to the Endow- 
ment Fund. If every member of the medical profession 
would send me 5s. we could, I think, pay for the 
house and still have something over towards endow- 
ing a few beds for nurses who are no longer able to 
work at all, and whose future is grey. The house 
has been designed by Mr. H. H. Dunn, F.R.I.B.A., 
our honorary architect, and will be built by the 
Papworth Industries, thus providing employment for 
other ex-patients at Papworth. Its site will be 
near our Nurses’ Home, in beautiful surroundings, 
with a garden, and will contain 40 bedrooms and 
dining- and sitting-rooms. The cost is expected to be 
less than £20,000.” : 


PHYSIOLOGY OF LACTATION 


THE physiology of milk secretion in the cow is 
being studied by Prof. H. D. Kay, of the National 
Institute for Research in Dairying, and his co- 
workers, and some of the findings were communi- 
cated to the Royal Society last Thursday. A new 
technique has been devised for obtaining arterial 
blood without serious disturbance to the animal, 
and with this method it has been ascertained that: 
(1) the fat of cow’s milk is derived mainly from the 
non-phospholipin fatty acids of the blood ;: (2) the 
phosphorus compounds of the milk (including casein) 
derive their phosphate from the inorganic phosphate 
of the blood plasma; (3) relatively large quantities 
(up to 30 per cent.) of the blood-sugar are removed 
from the blood on passage through the mammary 
gland, the amount of sugar taken out of unit volume 
of blood being related to the level of sugar in the 
arterial blood and (probably) to the volume of 
milk secreted ; and (4) the number of volumes of 
blood required to produce one volume of milk is 
of the same order whether calculated from the fatty 
acid changes, inorganic phosphate changes, or sugar 
changes between arterial and venous blood. A rapid 
circulation of blood—probably at the rate of 300- 
400 volumes for each volume of milk secreted — takes 
place through the mammary tissue. i 

The suggestion has been made that one of the 
factors controlling the quantity and quality. of the 
milk secreted is the arterial blood-sugar level. This 
can be raised and kept above the normal levelin the 
cow by thyroid feeding or thyroxine administration, 
and under proper conditions, it is found, thyroxine 
produces a considerable increase in milk volume and 
in milk fat percentage and also in the percentage 
of non-fatty solids in the milk. After cessation of 
thyroxine treatment, tbe rate of milk secretion rapidly 
falls and may go below the normal rate that would 
be expected from the slope of the lactation curve. 
Thyroxine does not, however, prevent the normal 


520 THE LANCET] 


VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS 


[FEB. 29, 1936 


progress of the diminution of functional activity of 
the mammary gland (which normally takes place 
after the peak of the lactation cycle): the ‘‘ thyroxine 
curve ” is parallel with the “normal ” one but at a 
considerably higher level. 

During these investigations the phosphatase con- 
tent of the milk (but not of the blood plasma) of the 
thyroxine-treated animals showed a striking decrease, 
which was more than restored when thyroxine adminis- 
tration was stopped. The phosphatase of the milk, it 
is concluded, is not derived directly from that of 
the blood. 


Messrs. Down Bros., LTD. (London, S.E. 1), have 
been awarded the medal of the exhibition held at 
Cairo last month in connexion with the tenth Inter- 
national Congress of Surgery. They displayed 
surgical instruments and theatre equipment. 


V acancies 


For further information refer to the advertisement columns 
ao aT Hospital, Connaught-road, E.—Res. M.O. At rate 


Aylesbury, Bucks, Mental Hospital, Stone.—Sen. Asst. M.O. 
£600. Also two Jun. Asst. M.O.’s. Each £350. 

Bath Royal United Hosptal.— H.S. At rate of £150. 

Belfast, Royal Maternity llospital.—Res. H.S. At rate of £100. 

e E a National Sanatorium.—Jun. H.P. At rate 
o è 

Sirmid City.—Asst. M.O. for Maternity and Child Welfare. 
£ 

Birmingham, Queen’s Hospital.—Res. Surg. Reg. £125. Also 
sen. Res. Anæsthetist. £70—£100 

Brighton, Royal Sussex County Hospital, and Hove General 
Hospital.—Ton. Physiotberapeutist. "Also Hon. Med. Reg. 

Bristol University.—Asst. Clin. Path. £375 

Cardiff. Welsh National Memorial A sanotilionc=AL Ds 
Adelina Patti o Oats At rate of £150. 

Chadderton, »&e. £500. 

Chester, County Mental ‘Hospital. —Jun. Asst. M.O. £350. 

Cily of London Hospital for Diseases of the Heart and Lungs, 
Victoria Park, '.—Phvsician to In- -paticnts. 

Colonial Medical Service.—Twenty-five Vacancies. Each £600- 

Dewshury and District General Hospital.—Second H.S. £150. 

Dreadnought Hospital, Greenwich, S.44.—H.P. and H.S. Each 


at rate of £110. 
DN Oe Sanatorium, Newcastle.—Asst. Med. Supt. 
30 


Dudley, Guest Hospital.—U.S. £200. 

Dumilee Corporation.—P.H. Dept. Asst. M.O.H. £600. 

Edinburgh, National Association for the Prevention of Tubercu- 
losis.—Seceretary-General. £600. 

Exeter, Royal Devon and Exelcr Hospital.—mf.S. to Ear, Nose, 
and Throat Dept. At rate of £150. 

Gloucestershire Royal Infirmary.—U.s. to Ear, Nose, and Throat 
Dept. At rate of £150. 

. Golden-square Throat, Nose, and Ear Hospital, W.—H.S. £100. 

Gordon Hospital for Rectal Diseases, Vauxhall Bridge-road, S.W. 
Res. H.S. At rate of £150. 

Guod koyal Surrey County Hospital.—H.S. Also H.P. and 

O. Ench at rate of £150. 

Hamneda General and N.W. London Hospital, Haverstock Till, 
N.W .—Cas. M.O. for Out-patient Dept. At rate of £100. 

Harrogate and District General Hospital.—H.P. and Cas. O. 
Also H.S. Each at rate of £150. 

Hertford County Hospital.—Hon. Clin. Asst. 

Hospital for Sick Children, Great Ormond-street, W.C.— Res. H.P. 
and Res. H.S. Each at rate of £100. 

Hospital for Tropical Diseases, Gordon-street, W.C.—H.P. At 
rate of £120. 

Hove General Hospital.—Hon. 


for 


Medical Otfcer. 


Huddersfield Royal Infirmary.—Cas O. £200. Also H.S. At 
rate of £150. is 

Kensington Royal Borough.—Asst. M.O. £500. 

Kesteven County Council.—M.O.H. £1000. 

Lancashire County Council.—Asst. Med. Supt. for High Carley 
Sanatorium. £450. Also Jun. Asst. M.O. for Wrightington 
Hospital. £200. 


Leamington Spa, Warneford General Tlospital.—Res. I.S. to 
Cas. and Spec. Depts. <At rate of £150. 

Leicester Royal infirmary.—Res. Anesthetist. At rate of £150. 
Cas. H.S., and H.P.’s. Each at rate of £125. Also 
Jun. Cas. O. At rate of £100. 

Tokero City Infectious Diseases Tlospitals.—Asst. Res. M.O. 
£2 ( 


Bernot Iospilal for Consumplion and Diseases of the Chest, 
Mount Pleasant.—Res. M.O. £150. 
Liverpool, Ministry of eas ck Hlospital, Mossley Hill.— 

Visiting Surgeon. £30 
London County Council, as District M.O. At rate of £290. 
London Homeopathic Hospital, Great Ormond-streel, W.C. — 
H.P. At rate of £100, 
Macclesfield General [nfirmary.—Second H.S. At rate of £150. 
Maidstone, County Pathological Laboratory.—Asst. Pathologist. 
£700, 
Maidstone, West Kent General Flospital.—II.P. £175. 
Manchester, Crunpsall Hospital and Institution.—Jun. Asst. 
M.O. At rate of £200. 


Manchester Royal Children’s Hospital, Gartside-street.—Two 
Asst. M.O.’s. Each at rate of £150. 

Manchester Royal Eye Hospital.—Jun. H.S. £120. 

see T uy Injfirmary.—Jun. Asst. M.O. for Radiological 

e £39 

Manchester, St. Mary’s Hospital.—Four H.S.’s. Each at rate 

Manchester, Withington Hospital and Institution.—Asst. M.O. 
for Tuberculosis Wards. At rate of £300. 

Melton, Suffolk, St. Audry’s Hospi. ae heer Asst. M.O. £350. 

Middlese.c County Council.—Asst. M.O. £600. 

Northampton General Hospital.—H.P., H.S.’s, also Cas. O. Each 
at rate of £150. 

Norwich, Norfolk and Norwich Hospital.— Res. Surg., O. £250. 
Also Res. Orthopeedic O. £200. 

Nottingham General Hospital.—H.8. for Fracture and Ortho- 

Depts. £300. Also H.S. to Ear, Nose, and Throat 

. At rate of £150. 

Plymouth City General Hospital.—Jun. Asst. M.O. £250. 

Preston, Sharoe Green Hospital.—Sen. and Jun. Asst. Res. 

.O.’s. At rate of £200 and £100 respectively. 

Prince of Wales’s General Hospital, N.— Hon. Med. and Surg. 
Regs. Each £100. 

Princess Elizabeth of Y ork Hospital for Children, Shadwell, E.— 
H.P. At rate of £125. 

Princess Louise Kensington Hospital for Children, St. Quintin- 
avenue, IV.—H.S. At rate of £100. 

Reading County Borough.—Asst. M.O.H. and Asst. School M.O. 


Rochdale, Birch Hill Hospital.—Jun. Res. M.O. At rate of £200. 


Rochdale I nfirmary and Dispensary.—Second H.S. £150. 
Romford Isolation Hospital.—Res. Asst. M.O. £350. 
Rotherham Hospital.—Cas. H.S. £150. 

Royal Eye Hospital, St. George’s-circus, S.E.—Part-time Patho- 
logist and part-time Bacteriologist. Each £100. Also 
Sen. H.S. and two Asst. H.S.’s. At rate of £150 and £100 
respectively. 


Royal Masonic Hospital, Ravenscourt Park, W.—Res. Surg. O. 
At rate of £250. 

Royal National Orthopadic Hospital, 234, Great Portland-street, 
W.—H.S. At rate of £150 

St. John’s Hospital, Lewisham, S.E.—Hon. Anesthetist to Ear, 
Nose, and Throat Dept. 

St. Peter’s Hospital for Stone, &c., Henrietta-street, WW.C.—H.S. 
At rate of £75. 


Salford Koyal Hospital. —H.P., H.S., and Cas. H.S. Each at 
rate of £125. Also Hon. Asst. Gynecologist. 

Scarborough Hospital and Dispensary.—Two H.S.’s. Each £175. 

Sheffield, eat Hospital for Women.—Res. M.O. Also two 


H.S.’ At rate of £150 and £100 respectively. 
Shoreham- DSE, Southlands Hospital.—Part-time Radiologist. 


£100. 

South Shields, Ingham Infirmary.—Jun. H.S. £150. 

Stoke-on-Trent, North Slaffordshire Royal Infirmary.— Radium 
Otħcer. £500. 

Sunderland Royal Infirmary.—H.S. £120. 

Tancred’s Studentships.—Three. Each £100. 

Warrington Infirmary and Dispensary.—Third Resident. At 
rate of £150. 

West London Hospital, Hammersmith-road, 1W—H.P. and H.S. 
to Spee. Depts. Also Res. Cas. O. Each at rate of £100. 
Non. Res. Cas. O. £250, 

Wolverhampton, Royal Hospital.—H.S. for Orthopaedic and 
Fracture Dept. At rate of £100. 

Woodside Hospital, Muswell Iil, N.—Sen. Asst. Phys. £600. 


The Chief Inspector of Factories announces a vacancy for a 
Certifying Factory Surgeon at Broughton, Hants. 


Births, Marriages, and Deaths 


BIRTHS 


Bacu.—On Feb. 18th, 1936, at 20, Devonshire-place, W.1, 
to Matine (néo Thompson), wife of Francis Bach, M.D., of 
49, Wimpole-street, W.1—a son. 

CHAMBERS.—On Feb. 16th, at Ealing Common, W., the wife 
of Dr. J. R. Chambers, of a daughter. 

MockLerR.—On Feb. 18th, at Welbeck-street, W., the wife of 


Surg. Lt.-Comdr. E. J. Mockler, M.B. N.U.I., Royal 
Navy, of a son. 
MARRIAGES 
ENRAGHT—SHFEPHERD.—On Feb. 20th, William Enraght, 


M.R.C.S. Eng., Croydon-road, S.E., to Jessie Gray, youngest 
daughter of the late Mr. and Mrs. T. A. Shepherd. 

REECE—PETRIK.—On Feb. 15th, at St. James’s, Piccadilly, 
Richard Harold Reece, M.A. Camb., M.R.C.S., to Janet 
Anderson Petrie, B.Sc., only daughter of Mr. and Mrs. 
John A. Petrie of Glasgow. 


DEATHS 
DuNLOor.—On Feb. 19th, at Norbrook, Knock, Co. Down, 
Joseph Everard Dunlop, M.D. R.U.I. 


PRUEN.—On Feb. 19th, Septimus Tristram Pruen, M.D. Durh., 
of Cheltenham. aged 76. 

UNDERHILL.— On Feb. ae at Vancouver, Frederic Theodore 
Underhill, F.R.C.S. Idin., son of the late Dr. William Lees 
Underhill, Tipton. Stattordshire. 

WILSON.—On Feb. 19th, James Alexander Wilson, O.B.E., 
M.D. Glasg., of Cambuslang, Lanarkshire. 


N.B.—A fee of Ts. 6d. is charged for the insertion of Notices of 
Births, \Mlarriages, and Deaths. 


‘THE LANOET] 


i | [marnon 7, 1936 


ADDRESSES AND ORIGINAL ARTICLES 


SOME OBSERVATIONS ON 
PEPTIC ULCER * 


By DANIEL T. Davies, M.D. Wales, F.R.C.P. Lond. 


ASSISTANT PHYSICIAN TO THE ROYAL FREE HOSPITAL, 
LONDON 


PEPTIC ulcer is in some respects a modern disorder, 
for it is unknown in the primitive uncivilised races, 
and equally unknown in the animal kingdom. It 
attacks the young adult rather than the old, the thin 
rather than the fat, and males more frequently than 
females. It is a common source of ill-health in city 
dwellers, and more often in those who carry responsi- 
bilities and their attendant anxieties. Moreover, 
there is a constitutional type which is prone to develop 
the disorder, the doer rather than the dreamer, the 
active in body and mind rather than the lethargic 
and more contented. It is not surprising, therefore, 
that its incidence is on the increase. The Registrar- 
General’s statistics show that the number of deaths 
from ulcer has risen steadily during the past ten 
years (Table I.), and since the mortality is relatively 
low, we can assume that the number actually 
suffering from the disorder is also steadily rising. 


TABLE I 
Deaths due to Peptic Ulcer in England and Wales (1921-31) 


= 1921. | 1923. | 1925. | 1927 | 1929 1931 
Males 1693 | 2106 | 2454 | 2973 | 3053 | 3214 
Females.. | 963 | 906 | 998 | 997 | 1028 | 1021 
Total . 2656 | 3012 | 3452 | 3970 | 4081 | 4235 


Experimental and Pathological Data 


Before proceeding to the more clinical aspect of 
this problem, brief reference should be made to work 
which has been done on animals. For many years 
attempts to produce a “chronic’’ ulcer met with no 
success, but during recent years this has been accom- 
plished, largely through the work of American 
experimental surgeons, notably Mann,! Ivy,? Matthews 
and Dragstedt,*? and Morton.4 Mann and Wiliam- 
son 5 were the first to develop a technique of diverting 
the alkaline duodenal juices and demonstrate that 
an ulcer would form in the intestine distal to the 
anastomosis, although it appears that Exalto è in 
1911 was the pioneer. 

If the intestine is anastomosed to the stomach, 
and the duodenum with its alkaline juices allowed to 
drain into the lower part of the intestine, an ulcer 
readily forms at the site where the gastric juice first 
impinges on the intestinal mucosa. It develops with 
great rapidity, for according to Mann and Bollman 7 
penetration of the mucosa only needs a few hours 
and perforation into the abdominal cavity can occur 
within the first 48 hours. The typical “chronic ” 
ulcer forms within 3-4 weeks, and histologically this 
is identical with that seen in man. Furthermore, its 
presence, like that of the human ulcer, is heralded 
by such events as perforation or melæna. 

Not only does this experimental ulcer form readily, 
but it-equally readily disappears. Provided the acid 
juice is made to impinge on an adjoining part of the 


* The Bradshaw lecture for 1935, delivered before the Royal 
Colega of Physicians of London on Nov. 5th. 


intestinal mucosa, the origina] ulcer begins to heal, 
and within 30 days healing is often complete. Mann 
draws attention to the delicacy of the repair tissue, 
and the ease with which it can be broken down again 
by coarse food 
or an acid juice. 
The mucosa 
readily regener- 
ates, but if the 
muscle has been 
involved in the 
ulcerative pro - 
cess it is replaced 
by scar tissue 
only. 

Matthews and 
Dragstedt’s 
technique? is 
particularly 
instructive in 
demonstrating 
the essential 
action of the 
gastric juice 
(Fig. 1) By 
suturing the 
jejunum or 
ileum on to a 
gastric pouch, and thereby allowing the intestinal 
mucosa to be bathed with a highly concentrated 
acid juice, ulcers could be produced with regu- 
larity—‘‘a striking example of the susceptibility 
of an organism’s living tissues to the irritant action 
of its own pure active gastric juice.” It was 
also demonstrated by these workers that if the gastric 
juice was deliberately retained in this pouch by 
plugging the stoma, an ulcer formed in the pouch 
itself. The implantation of a portion of intestinal 
wall into the stomach does not result in ulcer forma- 
tion (Dragstedt and Vaughan §), but if a small gastric 
pouch is implanted into the intestine, ulcer formation 
is the rule. In the latter experiment the intestinal 
mucosa is exposed to the pure active juice undiluted 
with food, while in the former experiment the gastric 
juice is already diluted and buffered by food and 
saliva and its action weakened in consequence. 

These experiments prove that under certain condi- 
tions normal gastric juice is by itself capable of 
producing a chronic ulcer in the intestine. The 
commonest seat of ulcer in man is the first part of 
the duodenum, and here, as Mann and Bollman state, 
‘is the site where the onrushes of acidity produced 
in the fundus are met, diluted, neutralised and 
buffered for acceptance by the intestine.” Under 
normal conditions the acidity of the duodenal contents 
fluctuates between a pH of 2 and 7, but the jejunal 
contents maintain a steadier reaction between a 
pH of 6:2 and 8:2 (Wu, quoted by Mann and Bollman’). 
When the jejunum is anastomosed to the stomach the 
jejunal contents are then found to fluctuate between 
a reaction of pH 1°7 and 8°33, under which condition 
we know that jejunal ulceration would be possible. 
Corroborative evidence of the importance of acid 
in ulcer development is the observation, again made 
by Mann, that repeated administration of acid does 
eventually result in an ulcer of the stomach itself. 

Methods to produce partial pyloric stenosis have 
been shown to result in increased acidity,!°™ and 
Bolton 12 in 1909 demonstrated the slow healing of 
traumatic ulcers under such conditions. Not only 

x 


Stomach 


~Stomach 
pouch 


- FIG. 1.—Matthews and Dragstedt’s 
experiment. -` 
G.B. = gall-bladder. 


:522 THE LANCET] 


does the acidity rise in partial pyloric stenosis, 
experimentally produced, but the spontaneous 
perforation of a duodenal ulcer has been recorded 
as a sequel to this (Elman and Eckert!*; Ham- 


burger and 

Cortical Stimuli Friedman!‘), 

Elman and 

Elect.Stim. Pituitrin Eckert refer 
66 2 

“a PARASYMPATHETIC-4~ to the “in- 


flammatory ”’ 


CENTRE 
reaction 
Midbrain which occurs 
in the duo- 
denum under 
Medulla Sieh: Growin: 
stances — a 
Vagus direct result 
of the in- 


creased acid- 
ity—a re- 
action which 
has its 
counterpart 
in the “ duo- 
denitis ° de- 
scribed clinic- 
ally as a pre- 
cursor to 
VEE ulcer. 

From these observations we are quite justified in 
concluding that the experimentally produced chronic 
peptic ulcer is dependent on an acid gastric juice 
for its development, and that an acid juice, provided 
it is undiluted, is sufficient for the development of the 
ulcer in the intestine. When we recall that the 
commonest seat of ulcer is in the duodenum, this 
‘knowledge derived from animal experiments becomes 
highly significant. We also learn that the ulcer 
forms with rapidity and likewise is rapid in healing. 
Whatever view is held regarding the etiology of 
ulcer in man, due cognizance must be given to this 
eroding action of the gastric juice. Is it possible 
that clinical ulcers as readily heal and break down 
again? The coexistence of achlorhydria and ulcer 
would certainly be difficult to explain, and any treat- 

e 3 . ment which 
does not allow 
for adequate 
neutralisation 
of the acid 
juice would 
not enjoy ex- 
perimental 
support. 


Gastric Branches 


Hyperperistalsis 


Hypersecretion 
Gastric Erosions 


Haemorrhages 


FIG. 2.—Diagrammatic representation of 
- nervous pathways (after Cushing), 


THE NERVOUS 
FACTOR 


Some three 
years ago Har- 
vey Cushing,!5 
in a masterly 
article, referred 
to the influ- 
ence of the ner- 
vous system on 
gastric func- 
tion. Much 
that was valu- 
able was resus- 
citated and 
further experi- 
mental work 
initiated. | 


FIG. 4.—Large ulcer crater in a man of 64 | 
with an eight weeks’ history. 


DR. DANIEL DAVIES: PEPTIC ULCER 


[maron 7, 1936 


That gastric changes can be caused by nervous 
lesions was first pointed out by Rokitansky?® in 
1846, and from then onwards isolated observations 
of organic brain lesions associated with gastric 
hemorrhage and ulceration have been recorded. 
In 1875 Brown-Séquard 17 showed that injury to 
the base of the brain produced gastric erosions. The 
association of subtentorial hemorrhage and brain 
injury at birth with gastric hemorrhage was also 
noted and commented upon. Cushing’s interest 
in the subject was aroused by the death of three 
patients from perforated ulcer after operation for 
a brain tumour. Some time before this Beattie" 
had shown that electrical stimulation of the nuclei 
in the region of the third ventricle leads to increased 
gastric peristalsis and hypersecretion ; with continued 
stimulation gastric erosions could be produced. 
Severance of the vagi abolishes these effects, and 
identical effects are produced by direct stimulation 
of the vagus (McCrea, 
McSwiney, and Stop- 
ford,!® 1927 ; Beattie 
and Sheehan,?° 1934). 

Stimulation of the 
brain-stem in any 
part, from this centre 
in the region of the 
third ventricle down 
along the vagal tracts 
to the vagal nucleus, 
will produce the same 
motor and secretory 
changes in the 
stomach (Fig. 2) 
Cushing recalls that 
this centre is in the 
vicinity of Cannon’s 
seat of the emotions, 


é it must of 

and T ‘nfl d FIG. 3.—Diagram of stomach 
course be iniluence showing location of ulcers in 
by higher centres. author’s series. 


Is this pathway 

unduly stimulated under certain circumstances! 
For example, do emotional upsets result in hyper- 
secretion and hyperperistalsis in the man _ who 
complains of epigastric discomfort under tension, 
and who ultimately develops an ulcer? Can we 
show in our clinical experience any such relation- 
ship between the nervous system and the produc- 
tion of a peptic ulcer? Is the onset of symptoms, 
either initially or in recurrences, related to some 
primary disturbance first experienced in the nervous 
system? If the nervous system plays a primary 
part in initiating symptoms, we should meet with 
such a group of symptoms before the development of 
the ulcer, and there should be a high incidence of 
emotional upsets in recurrences. o 


Scope of Present Inquiry 


In this lecture I shall try to show that clinical 
experience is in many respects in accord with the 
experimental and pathological findings | have outlined. 
Do not clinical “ulcers” form readily and- heal 
readily, and is there not good evidence to confirm the 
essential action of an acid gastric juice ? Moreover, 
is there not an “ulcer”? type in which symptoms 
frequently follow an emotional upset, and in which 
relaxation brings relief not only to the mind but 
also to gastric function ? | 

During the last five years I have personally observed 
and followed 377 patients showing a “‘ chronic” 


ulcer. They have been seen frequently, and periodic 


THE LANCET] . ` DR. DANIEL DAVIES: PEPTIC ULCER [maRrcH 7, 1936 523 


radiological examination has been 
carried out. The gastric secretion has 
also been repeatedly studied in a large 
number. The material is set out in 
Table II. :— 


TABLE II 


Cases under Review 


Male. Female. 
Gastric ulcers .. e. 145 .. 75 .. 70 


Duodenal ulcers e.. 206 .. 137 .. 69 

Gastrio and duodenal 
ulcers.. i5 bas 11 .. 6 .. 5 
Post-operative ulcers.. 15 .. 14 .. 1 
377 .. 232 .. 145 


The proportion of females is somewhat 


. ‘ss ey. 12.x.32 21.x.32 11.xi.32 
high, and this is in all probability due a 
, ; FIG. 5.—A lesser-curve ulcer in a male aged 30.. The second film shows 
to the preponderance of female patients the healing process a week later, with the disappearance of the crater 
at the Royal Free Hospital. | at the end of a month in the third film. Ambulatory treatment. 


. The Site of Ulceration curve of the stomach amounted to 94 per cent. This 
It is well established that the seat of the ordinary distribution is important—as Hurst 2! has emphasised; 


peptic ulcer is either in the first part of the duodenum and as Holmes and Hampton 2? have recently pointed 
or on the lesser 


curve of the 
stomach; it is 
seldom found in 
other parts of the 
stomach. In my 
series, as can be 
seen from Fig. 3, 
only 12 (3-4 per 
cent.) were on the 
posterior wall, 
and 13 (35 per 
cent.) in the pre- 
pyloric area. Of 
the 145 gastric 
ulcers 120 were 
on the lesser 


10.ii.33 27.11.33 27.ii1.33 24.V.33 


ee and only FIG. 6.—A large lesser-curve ulcer in a woman of 42, who also showed an anemia (Hb 40 per cent). 
16 of these in Considerable diminution in size of crater is seen in 24 weeks, and no trace of abnormality could be 
the upper third; demonstrated in 6 weeks. Note the improvement in gastric tone observed in the final film (3 months). 


the middle third 

claiming 103. Only 1 was situated at the cardia. Those out—in the differentiation between ulcer and cancer. 
in the first part of the duodenum or on the lesser Carcinoma of the stomach is usually a pyloric lesion, 
whereas only about 3 per cent. of benign ulcers are 
in the prepyloric area. It is well, therefore, to treat 
these prepyloric lesions as potential cancer, and, 
as Hurst maintains, operation on them is the wiser 
plan. er 

Rapidity of Formation of Ulcer 


While histories of dyspepsia for ten years or more 
are common, some patients give only a history of 
a few weeks but nevertheless show a well-defined 
crater. The size of the ulcer crater is certainly not 
proportionate to the length of dyspepsia. Occasionally 
one has a chance of gauging the time of appearance 
of an ulcer, as in one of my patients, a man of 64, 
who had had dyspepsia for four weeks. A barium 
meal examination disclosed no ulcer crater; nor 
was anything abnormal seen at a second examination 
at the fifth week. At the eighth week, however, 
a large crater was plainly demonstrable (Fig. 4). 
In another case a large crater on the lesser curve 
was found in a man of 68 with only three weeks’ 
dyspepsia. . 

Table III. shows the duration of symptoms in 
my series. 

It will be seen that as many as 76 (23 per cent.) 
gave histories of less than three months’ duration, 


 16.iii.34 27.iv.34 
FIG. 7.— Ulcer of lesser curve in a woman aged 50, with com- Skee ; . 
plete disappearance in five weeks, Ambulatory treatment. and it is unlikely that in all these persons the ulcer 


524 THE LANCET} 


15.xi.33 19. xii.33 


DR. DANIEL DAVIES : 


10.i.34 


PEPTIC ULCER [MARCH 7, 1936 


26.1.34 26.11.34 


FIG. 8.—A large lesser-curve ulcer in a woman aged 49, showing restitution to normal in 13 weeks. Ambulatory treatment. 


crater preceded the symptoms. Remissions extend 
over a number of years, and the patient may enjoy 
freedom even without treatment for a considerable 
period. Unfortunately little is known of the radio- 


TABLE III 
Duration of Symptoms 


— eee 12 mths.| 2 yrs. | 4 yrs. | 6 yrs. |6 yrs. + 
Gastric ulcer) 44 | 24 | 20 | 11 | 19 | 23 | 
Duodenal ,, 32 38 26 | 31 24 55 

Total ..| 76 | 62 46 | 42 | 43 | 78 


logical state in spontaneous remissions, but it is 
possible that a large number of ulcers do heal only 
to break down again in a recurrence. l 

Much interest is being shown towards cases in 
which the patient has the symptoms of peptic ulcer, 
relieved by taking alkalis, yet no ulcer can be found. 
During the past five years I have collected 8 cases 
of this kind, in which barium meal examination was 
repeatedly negative over 2-4 years, but in which 
an ulcer crater eventually developed. While it would 
be true to say that these persons had suffered 
dyspepsia for a long period, the development of an 
actual ulcer was much more recent. For example, 
one of them, a woman of 33, had suffered periodic 
dyspepsia for ten years, and barium meals in 1931, 
1932, and 1933 had disclosed no gastric or duodenal 
lesion; yet in 1935 a lesser curve ulcer became 
apparent. 

The length of symptoms is therefore not necessarily 
an index of the chronicity of an ulcer. It may be 
that the actual ulcer crater develops in man more 
rapidly than we have been led to believe, and that 
it is not correct to regard the patient who has suffered 
from dyspepsia for ten years as having had an ulcer 
of the same duration. Is it not possible that the 
ulcer comes and goes, heals and breaks down again, 
instead of being a ‘‘ chronic ” indolent lesion persisting 
for years ? 


The Healing of the Ulcer Crater 


From time to time much criticism has been levelled 
against the radiological interpretation of healing of 
the ulcer crater. It has been suggested that the 
size of the crater as seen radiographically is largely 
the result of surrounding cedema, and that medical 
measures merely dispel the swelling. There is some 
truth in this criticism; but on the other hand, a 
lesser curve ulcer can be fairly sharply outlined, 


and its diminution in size followed at frequent 
intervals without any difficulty until it disappears. 
Nicholas and Moncrieff showed the disappearance of 
the crater under treatment.2® Symptoms are dispelled 
within a few days of adequate treatment, but 
I have been equally impressed with the rapidity 
with which repair proceeds and the crater diminishes 
in size. Considerable improvement is seen in 10-)4 
days, and in some favourable cases all trace of 
abnormality has disappeared in 28 days. 

Of my lesser-curve ulcer patients 95 were followed 
sufficiently regularly to provide some information 
as to the time of ulcer disappearance (Table IV.). 


TABLE IV 
Time of Disappearance of Ulcer Crater (Lesser Curve) 
Weeks 3 4 6 8 12 16 24 
10 .. 16 10 .. 23 .. 23.44. 6 i 


It can be seen that 82 were clear in three months 
and 59 in two months, and these figures gain 
significance from the fact that only a small minority— 


RE 


22.x.34 
FIG. 9.—Ulcer of lesser curve, with an hour-glass stomach, 


24.viii.34 


ina woman of 55. Foun penance oF ulcer crater in two 
months but persistence o e hour-glass deformity. 
Ambulatory treatment j : 


THE LANCET | 


DR. DANIEL DAVIES: PEPTIC ULCER 


[maRcH 7,1936 525 


18—received hospital treatment, the 
bulk being treated while still at their 
work. Individual examples of this rapid 
healing can be seen in Figs. 5-8. In 
addition to the disappearance of the 
crater, the gastric tone improves and 
the shape of the stomach becomes more 
normal. - 

A mechanical abnormality, in the form 
of an hour-glass stomach, is not a bar to 
the temporary healing of the crater, 
although such a mechanical defect should 
be corrected by surgical means without 
delay, even if it does not give rise to 
symptoms, for the ground is prepared 
for further ulceration and recurrences are 
likely (Fig. 9). 

I am unable to demonstrate such 
significant changes in duodenal ulcer, 
for some deformity of the cap usually 
persists in all but the very small craters. 
There is, however, an obvious improve- 
ment in the films which initially show 
gastric delay and retention. An improvement in tone 
is observed, and this improvement may persist for 
years; the delay in emptying is corrected and the 
signs of early ‘‘ pyloric stenosis”’ disappear. Indeed, 
the response to treatment is often astonishing as is 
illustrated by the following case :— 


A woman of 68 showed the radiographic appearances 
of early pyloric stenosis in 1932, in that there was gastric 
delay, a dilated stomach, and a duodenal deformity. 
Her weight was 8 st. I had intended, after a pre- 
liminary course of lavage and medical treatment, to 
advise a gastro-enterostomy, but her improvement was 
maintained, and it has so far been unnecessary to con- 
sider operation. The radiogram taken in 1935, three 
years later, shows a better tone, and the stomach now 
empties in normal time. Her weight has also increased 
from 8 st. to 11 st. 2 lb. 


It behoves us, therefore, to distinguish between 
actual obstruction and retention; and although 
radiography is a sure guide in advanced cases, a 
preliminary course of medical treatment is necessary 
to distinguish cases in which there is more gastric 
retention than actual obstruction from those in Which 
surgery is essential for relief. This has been well 
brought out by Emery and Monroe.?4 

The only absolute proof of complete healing is that 
obtained by actual inspection of the stomach at 
operation, and this is rarely possible. The following 
details are instructive. 


9.ii1.34 6.iv.34 


gave a history of only 5 weeks. 
end of 3 months the crater is considerably smaller. 
normal state. Gain in weight from 5st. 9 lb. to 8 st. 6 Ib. 


(A) 12.iv.33 


FIG. 10.—An ulcer crater on the lesser curve in a man aged 45. 
diagram does not indicate the real size of the crater, for its upper part was 


occupied by a large gas bubble. 
size of the crater in the sixth week. 
8 weeks later, but no gastric lesion could be traced by the surgeon. 
ented aa shows a return of the crater in 10 months’ time. 
reatment. 


13.vi.34 


FIG. 11.—A huge crater arising from the lesser curve in a woman aged 62, who showed considerable emaciation (5 st. 9 1b.), but 


(B) 2.vi.33 (C) 8.1.34 


The first 


The second film shows a lessening in 
An acute appendicitis Zevaoned 

e 
Ambulatory 


A man of 48 gave a history of six weeks’ dyspepsia. 
On one occasion five years previously he had suffered 
from indigestion, but he had remained well in the interval. 
An ulcer crater was demonstrated on the lesser curve 
of the stomach (Fig. 104). A second examination after 
six weeks showed much diminution in the size of the 
ulcer crater (Fig. 10 B), but no further proof of his response 
was available until eight weeks later when he was sud- 
denly seized with severe abdominal pain and admitted 
to another hospital as an abdominal emergency. A 
diagnosis of a perforated ulcer was most probable, but 
to the surgeon’s surprise no lesion could be found in the 
stomach, and the cause of the emergency proved to be 
an acutely inflamed appendix. Such evidence of healing 
is seldom obtainable. It must be added that he lapsed 
from treatment and returned to me in ten months with 
a recurrence of his symptoms and the ulcer crater (Fig. 10 c). 


Anxiety and tension seem to delay the healing 
process, and complete rest in bed is occasionally 
required before symptoms can be dispelled and before 
any impression can be made on the size of the crater. 
If there is mental unrest the use of sedatives to 
produce relaxation is desirable. 


One of my female patients showed considerable tension 
and nervousness, and the healing of the large crater was 
not realised until treatment had lasted ten months. 
The history was five weeks, but much weight had been 
lost and the general condition was very poor. No demon- 


strable change in the size of the crater followed upon a 
‘month’s treatment, but some diminution was apparent 
in three months and again five months, although ten 


23.1.35 9.vili.35 


The second film (taken prone) shows no improvement after a month’s treatment, but at the 
The last film, 18 months from the commencement of treatment, shows a 


4 


526 THE LANCET] 


DR. F. C. O. VALENTINE : STAPHYLOCOCCAL TOXIN 


[marcu 7, 1936 


months elapsed before the crater actually disappeared 
(Fig. 11). After two years there is no recurrence; the 
patient is symptom-free and her weight has increased 
from 5 st. 9 lb. to 8 st. 6 Ib. 

In spite of the utmost attention the ulcer crater 
occasionally persists, and I have records of six lesser- 
curve lesions which did not respond to treatment. 
In one of these cases two admissions to a medical 
ward failed to dispel the crater and surgery was 
required. The details of this group are given in 
Table V. 

TABLE V 


Persistence of Ulcer Crater 


Duration of | 


andsex.| 48€- | symptoms. Remarks. 
1. M. 50 15 years. Active ulcer at operation. 
2. F. 34 1 year. Fatal hematemesis, sixth month. 
3. F. 34 3 years. Active ulcer ; mid-gastric fibrosis. 
4. F. 40 2 p Sixth month, active ulcer. 
5. F. 54 1 month. | Large crater sixth month; brain 
tumour. 
6. F. 56 2 years. Active ulcer at operation. 


Position of Ulcer.—Lesser curve in each case. 


In the second case hemorrhage occurred in the 
sixth month and proved fatal. If a crater shows 
no sign of healing within three months surgical 
interference should be advised, and my failure to 
act on this principle undoubtedly resulted in this 
tragedy. No apparent explanation is available 
for the lack of response in the other patients, except 
No. 5. 

The patient was a female, aged 54, who had had hemat- 
emesis after some mild indigestion. After six weeks a 
barium meal showed a lesser-curve ulcer, which was still 
present in twelve weeks’ time. This was regarded as 
unusual, and exhortation for more thorough treatment 
was made. Further radiography in the sixth month showed 
a crater larger than on the two previous occasions. At 
this time the patient complained for the first time of 
giddiness and weakness in the right upper limb. The 
weakness of the arm progressed and the signs of a tumour 
compressing the upper cervical cord advanced rapidly. 
An attempt to locate and remove this tumour was unsuc- 
cessful, and a tumour arising from the bulb was seen 
producing a pressure cone compressing the bulb and 
upper cervical cord. The nature of the tumour is uncer- 
tain, for it was degenerate when an autopsy was per- 
formed. The stomach was the seat of multiple erosions 
as well as a large ulcer crater which first caused symptoms. 
While I cannot definitely state that the two lesions had 
any bearing upon one another, it is possible that the 
tumour did irritate the vagal nucleiin the medulla and that 
this repeated stimulation resulted in gastric erosions and 
hemorrhage and a chronic ulcer which resisted treatment. 

With the exception of these six cases we find 
undoubted radiological evidence of healing in more 
than 100 lesser-curve ulcers. This response to 
treatment occurred while the majority of the patients 
remained at their work, a fact which further supports 
the statement that ulcers heal readily. On the other 
hand, a crater which persists in spite of medical 
attention should certainly be looked upon with 
suspicion, and if at the end of three months it is still 
seen with X rays, operation should be considered. 

So far, then, we have found nothing at variance 
with the experimental observations, and we can 
safely conclude that the vast majority of ulcers 
readily heal on medical measures. 


(To be concluded) 


REFERENCES 


1. Mann, F. C.: Surg. Clin. N. America, 1925, v., 753. 

2. Ivy, A.C.,and Fauley, G. B.: Amer. Jr. Surg., 1931, xi., 531. 

3. Matthews, W. B., and Dragstedt, L. R.: Surg., Gyn., and 
Obst., 1932, lv., 265. 


(Continued at foot of next column) 


FURTHER OBSERVATIONS 
ON THE ROLE OF THE TOXIN IN 
STAPHYLOCOCCAL INFECTION 


By F. C. O. VALENTINE, M.B. Camb., M.R.C.P. Lond. 


ASSISTANT DIRECTOR OF THE HALE CLINICAL LABORATORIES 
LONDON HOSPITAL 


IN a previous paper! on staphylococcal toxin 
evidence was brought forward showing that certain 
strains of cocci are capable of producing a true 
leucocidin which destroys the phagocytes of human 
and rabbit blood and which is distinct from the 
er TRDg and necrosing factor also present in the 

xin. 

The Medical Research Council recently promoted 
an inquiry, to which a contribution was made at 
the London Hospital, into the value of toxoid injec- 
tions in the treatment of staphylococcal infection. 
This supplied an excellent opportunity for con- 
tinuing the work on leucocidin and its significance. 
The present paper describes methods of making 
toxin and of estimating the leucocidin in toxin and 
the antileucocidin in serum, and provides fresh 
evidence indicating that a-hemolysin and leucocidin 
are distinct entities. Finally the methods described 
are employed in connexion with human material in 
an attempt to determine the rôles of the two toxins 
in human disease, attention being chiefly concentrated 
on the leucocidin. 


The Investigation 
PREPARATION OF TOXIN 


The medium employed has been soft meat—infusion 
agar at pH 7°6, containing 0°5 per cent. agar. 


Medicine bottles make convenient vessels for the 
purpose; if they are filled about one-quarter full no 
medium escapes when they are laid flat on their sides, 
in which position the agar is allowed to set. They are 
then inoculated by a Pasteur pipette from a fresh broth 
culture, excess of fluid after spreading being removed as 
much as possible. The bottles, still horizontal, are placed 


( Continued from previous column) 


. Mann, F. C., and Bollman, J. L.: Jour. Amer. Med. Assoc., 
5 Dat ee ree . 
. Dragstedt, L. R., an aughan, A. M.: Arch. of Surg., 
1924, viii., 791. i 
- Mann, F. C., and Bollman, J. L.: Jour. Amer. Med. Assoc., 
10. I 1930, ZY is ller, E. H 
. ivy, A. C., Droegemueller, E. H., and Myer, J. L.: Arch. 
Internal Med., 1927, xl., 434. 7 oa 
11. Webster, D. R., and Armorn, J. C.: Canad. Med. Assoc. 
Jour., 1932, xxvii., 240. 
12. Bolton, C.: Proc. Roy. Soc. B., 1909, lxxxii., 233. 
13. puni R., and Eckert, C. T.: Arch. of Surg., 1934, XNİX., 


14. Hamburger, W. W., and Friedman, J. C.: Arch. Inter 
Med., 1914, xiv., 722. ma 

15. Cushing, H.: Surg., Gyn., and Obst., 1932, Iv., 1. 

16. Rokitansky, C.: Quoted by Cushing from Handbuch der 
path. Anat., 1841, p. 1846. 

17. Brown-Sequard, C. E. : Progrés méd., 1876, iv., 136. 

18. Beattie, J.: Canad. Med. Assoc. Jour., 1932, xxvi., 278. 

19. McCrea, E. D., MeSwiney, B. A., and Stopford. J. S. RB.: 
Quart. Jour. Exp. Physiol., 1927-28, xviii., 301. 

20. Beattie, J., and Sheehan, D.: Jour. of Physiol., 1934 
Ixxxi., 218. : 

21. Hurst, A. F., and Stewart, M. J.: Gastric and Duodenal 
Ulcer, London, 1929. 

22. Holmes, G. W., and Hampton, A. O.: 
Med., 1933, ceviii., 971. 

23. Nicholas, F. G., and Moncrieff, A. A.: 
1927, i., 999 

24. Emery, E. S., and Monroe, R. T.: 
1935, lv., 271. 


New Eng. Jour. 
Brit. Med. Jour., 
Arch. Internal Meu., 


THE LANCET] 


in a desiccator from which the air is exhausted on the 
water-pump until the manometer reads about 600 mm. 
when it is replaced by a mixture containing 80 per cent. 
O, and 20 per cent. CO,. The vessel is then incubated 
for 24 hours only. 

Next morning the bottles are removed and are placed 
upright which causes the agar to fall to the bottom. 
A little shaking breaks’ it up so that it can be poured into 
filter paper in a Buchner funnel where it is sucked dry 
on the water-pump. At this point it is advisable to test 
the reaction of the filtrate and if it is inclined to be alkaline 
acidify until the colour with phenolsulphonephthalein 
is orange (about pH 7). The filtrate is then passed through 
a Berkefeld candle to sterilise it; a Seitz filter may be 
used but seldom removes all the cocci at the first filtration 
and a second filtration removes much of the leucocidin. 

It has seemed to be important to use a medium with 
enough agar to present a reasonably firm surface for 
inoculation, but for the purpose of filtration through paper 
the softer the agar is the better. The optimum strength 
is about 0-5 per cent. agar and shaking should be avoided 
until after incubation. 


The method of preparation used seems to permit 
the production of abundant leucocidin and of a fair 
but certainly not maximal hemolysin. In the course 
of the present work it has been found that leucocidin 
is less stable than a-hemolysin, the titre diminishing 
fairly rapidly, especially in the presence of free oxygen. 
But for the purpose of serum-toxin titrations it has 
been found desirable to use a comparatively large 
test dose of toxin, and in these circumstances toxins 
can be used for two or three months if kept sealed 
in a refrigerator. 

Recently, however, I have found that filtration, 
whether through Seitz or candle filter, removes a 
variable quantity of the toxin. This effect, as might 
be expected, is greatest when the original concen- 
tration of toxin is low, and may be almost negligible 
with a strong toxin. It may therefore happen that 
a preparation which was originally strongly hemo- 
lytic but feebly leucocidal may be found after filtra- 
tion to be still strongly hemolytic but without any 
demonstrable leucocidin. 

The staphylococcal strains which have been used 
for the production of toxin were originally main- 
tained in the refrigerator in blood broth, but it was 
found that this method was unsatisfactory for pre- 
serving their toxigenicity. Latterly Worth’s medium 
has been used with better results, but there is still 
evidence of a gradual diminution in toxigenic power 
particularly affecting leucocidin production. 


TESTING SERUM AND TOXIN 

1. Hemolysin.—It has now been established by 
Glenny and Stevens? following the work of Bigger, 
Boland, and O’Meara,® and Bigger,* that staphylo- 
coccal toxin may contain two separate hzmolytic 
factors, « and §. Since there is no evidence indi- 
cating that the 6-toxin is of importance in human 
infection, the «-toxin only has been taken into account 
in the present work; and it has been assumed that 
the ability of the a-toxin to lyse rabbit red cells, to 
cause necrosis of living tissue, and to kill rabbits 
on intravenous injection is due to the presence 
of one factor which may be designated and estimated 
as g-hemolysin. ! 

The antihemolysin content of all human and 
other sera tested in the course of the present work 
was estimated against the standard toxin B.8750 
supplied by the Wellcome Laboratories, and this in 
its turn was always controlled against their K-serum 
B.8760, which is stated to contain per c.cm. 150 
international units of antihemolysin. In this paper 
all figures for antihemolysin are given in terms of 
the international unit. 7 l 


DR. F. Ç. O. VALENTINE : STAPHYLOCOCCAL TOXIN 


[maRoH 7, 1936 527 


The hæmolytic activity of toxins has been esti- 
mated against K-serum and will be expressed as the 
L.H. dose—i.e., the smallest volume of toxin still 


. hemolytic for 1 per cent. rabbit cells after mixing 


with 1 unit of antitoxin. 


2. Leucocidin.—No unit of antileucocidin has as 
yet been established nor is the existence of a specific 
leucocidin universally recognised. It is necessary 
therefore to describe how leucocidin and antileuco- 
cidin may be demonstrated and estimated. 


For this purpose the washed cells of human blood have 
been used as a routine, the blood being first taken into 
2 per cent. citrate in normal saline. It is advisable to 
reserve a few cubic centimetres of blood in a dry tube so 
that a supply of homologous serum is available. a 

For the test small tubes of 8 or 9 mm. internal diameter 
have been used. In serum-toxin titrations each tube 
receives Q-lc.cm. toxin dilution and 0-Ic.cm. serum 
dilution, one of which is standard. These are mixed 
and allowed to stand for 5-15 minutes at room 
temperature. ` 0-1 c.cm. of washed concentrated cells 
is added and the tube again shaken and incubated 
for one hour. 0-1 c.cm. of homologous serum may 
then be added; this improves the quality of films 
made from the mixture and also prevents any further action 
of the toxin. The tubes are then re-shaken and a film is 
spread from each by platinum-loop, a method which has 
been found to cause less damage to the cells than spreading 
with another slide. Films are finally stained with 
Leishman. For estimating the titre of leucocidin in the 
absence of antibody the latter is replaced by saline. 

After a little experience of the method the films are best 
examined under the § in. objective with a x 10 or x 14 
eyepiece. The “ bird’s-eye ” view thus obtained is invalu- 
able for comparing different films while individual cells 
can be checked with the high power. The titre of a toxin 
is indicated by the highest dilution from which the 
Leishman film shows no recognisable polymorphonuclear 
neutrophils. The titre of a serum is given by the highest 
dilution in which recognisable neutrophils persist. The 
latter titration is therefore open to the objection that for 
the demonstration of the end-point a sufficient excess 
of toxin must remain to destroy all the phagocytes which 
are present. But it has been found that even in ‘“‘ normal ”’ 
human serum the amount of antileucocidin is sufficiently 
large and variable to permit the use of a very large test 
dose of toxin, roughly 16 times the amount of fresh toxin 
needed to destroy the same number of leucocytes in the 
absence of all antitoxin. In these circumstances titrations 
with 100 per cent. differences are sufficiently accurate and 
give a clear end-point. 

For the titration of immune horse-serum greater accuracy 
is desirable and can be obtained. It is then important that 
the toxin should be quite fresh so that a small excess may 
be demonstrable. It is also practicable to double the 
volumes of serum and toxin dilutions in each tube 
(to 0-2 c.cem. of each) while leaving the volume of cells at 
O-le.cm. In this way successful titrations with 25 per 
cent. differences have been made. 


It happened that for the first tests made on human 
serum in the course of the present work, a batch of 
toxin was used which was neutralised by its own 
volume of K-serum diluted 1 in 100 but not by 1 in 
200. It was also found that the smallest amount of 
antileucocidin commonly present in normal human 
serum was equivalent to K-serum 1 in 100. This 
amount is therefore suggested as a useful anti- 
leucocidin unit, although in this paper all figures 
are given in terms of K-serum. 

Toxins are standardised by finding the lowest 
dilution which is inactive after mixing with an 
equal volume of K-serum diluted 1 in 100. Since 
100 per cent. differences have been employed in all 
titrations throughout the present work, it has been 
sufficient to find the highest dilution of a toxin which 
is still active after mixing with an equal volume of 
K-serum diluted 1 in 200. The toxin could then 


528 


be used in this dilution for the titration of unknown 
serum, being always controlled against K-serum in 
the critical dilutions of 1 in 100 and 1 in 200. For 
more accurate estimations smaller. differences are 
necessary and, as has been indicated above, can be 
used. 

The antileucocidin here discussed appears as a 
true antibody to be found in the serum of horses and 
rabbits following the injection of leucocidal toxin. 
It also occurs in the serum of patients in the course 
of staphylococcal infection. Tests which have been 
made on horse serum indicate that the antileucocidin 
content may be concentrated in the pseudoglobulin 
fraction with the antihemolysin. 


THE LANCET] DR. F. C. O. VALENTINE 


THE LACK OF RELATIONSHIP BETWEEN &-HÆMOLYSIN 
AND LEUCOCIDIN AND BETWEEN THEIR ANTIBODIES 


The experiment shown in Table I. compares the 
activity of two filtrates and shows that the ability 
of a staphylococcal strain to produce g-hemolysin is 
unrelated to its ability. to produce leucocidin. One 


TABLE I 


Filtrate dilutions. 


. | Saline 
Fil i mpa 
trate. serum. a o = 2 S a] 2 > 
"m A et ee Se ey SS 
W.46 H +H +H +H + 
4 K 00 H +| +E +E +E — za 
» |Saline.L —|L — 
» (8/200 iL —iL — 
C il. | +E +E +E E EE — 
K/200 |H — ints 
» ¡Saline pean) (oe ae ee +L +b +L — 
» (|K/200 ~IL +L +L — 


W.46=Wood 46. 
H + complete hemolysis of 1 per cent. rabbit cells. 
L += complete destruction of human neutrophils. 


of these toxins was produced by the well-known strain 
Wood 46, and the other, toxin C, by a coccus isolated 
from a large carbuncle. 

If filtrate Wood 46 contains 16 times the amount of 
hemolysin present in filtrate C, and the latter con- 
tains at least 250 times the leucocidin present in 
Wood 46, it would seem that «-hemolysin and leuco- 
cidin must be distinct. 

That antihemolysin and antileucocidin also vary 
independently of each other is illustrated by the 
example of a horse immunised at the Lister Institute 
by Dr. McClean. This horse had previously been 
immunised against g-hemolysin and its serum, at 
the beginning of the experiment here described, 
contained approximately 150 units antihemolysin 
and 0°5 K antileucocidin. After immunisation with 
a toxin prepared in this laboratory, containing a 
moderate o-hemolysin and fairly strong leucocidin, 
the serum titres were approximately 100 units anti- 
hemolysin and 4 K antileucocidin, the former having 
fallen slightly while the latter increased eightfold. 


EFFECT OF TOXIN ON THE RABBIT LEUCOCYTE 


If rabbit’s blood is substituted for human in the 
leucocidin titration of a filtrate which contains a 
feeble «-hsmolysin but powerful leucocidin, the result 
will be comparable to that obtained by the use of 
human cells; the phagocytes will be destroyed by 
dilutions of toxin which leave the red cell untouched. 
The rabbit neutrophil, in fact, appears to be some- 
what more susceptible to leucocidin than is the 
human cell. 

But if a filtrate strong in «-hemolysin but almost 
wholly lacking in leucocidin, such as is produced by 


: STAPHYLOCOCCAL TOXIN 


[manon 7, 1936 


strain Wood 46, is tested against both human and 
rabbit blood, the results of the two titrations will 
be strikingly different. With the human cells in 
very low dilutions of the toxin there may or may 
not be some degree of hemolysis or of damage to the 
leucocytes or both. This destructive effect has usually 
disappeared in dilutions as low as 1 in 4, and it is 
impossible to decide whether it is due to a slight 
susceptibility of the leucocytes to «-hemolysin, to 


a trace of true leucocidin, or to other factors, possibly 


non-specific, present in undiluted filtrates. With 
rabbit blood hemolysis, of course, occurs, but this 
is accompanied quantitatively by destruction of the 
leucocytes. There seems to be no reason to attribute 
this phenomenon merely to .the . accompanying 
hemolysis, since in the case of human cells hemo- 
lysis is not necessarily accompanied by any destruc- 
tion of the leucocytes. It would rather seem that 
the rabbit leucocyte, like the rabbit red cell, is 
destroyed by a-hemolysin against which human cells, 
both red and white, are relatively, if not absolutely, 
resistant. 

The appearance of a rabbit leucocyte destroyed 
by a-hzemolysin is different, as a rule, from that of 
a human or rabbit cell destroyed by true leucocidin. 
In the latter case the cell, in an effective concentra- 
tion of leucocidin, takes up a spherical form, the 
granules being arranged mainly at the circumference ; 
in the presence of an excess of toxin the cell bursts 
and the granules are set free, and this appears to 
occur invariably in the making of a dried film once the 
cell has become spherical. But the rabbit neutrophil, 
killed by a-hemolysin, appears to be less fragile and 
commonly retains the granules, clustered in one part 
of the cell, even in a dried film. 

It seems possible that this difference in the morpho- 
logy of the rabbit neutrophil, according as it is killed 
by a-hemolysin or true leucocidin, may account for 
the existing uncertainty as to staphylococcal leucocidin, 
whether it is to be regarded as distinct from, or 
identical with, «-hemolysin. It is possible that the 
different methods available for the demonstration 


of leucocidin may yield essentially different 
results. Thus the Neisser-Wechsberg test is based 


on the fact that a live leucocyte consumes oxygen 
and will therefore decolorise methylene-blue and 
that a dead cell will not. But there is no reason to 
assume that the granules or other substances released 
from a cell destroyed by true leucocidin should not 
still be capable, for a time, of absorbing oxygen. 
Further work is clearly necessary on the subject, 
but it may be pointed out that tests such as the 
Neisser-Wechsberg provide less direct evidence of the 
condition of cells than does the microscope and have 
the further disadvantage that they involve the use 
of animal and not human cells. 


THE ANTITOXINS IN NORMAL HUMAN SERUM 


Many human sera have now been tested for 
staphylococcal antitoxin by these methods. Amongst 
them 55 normal sera taken at random from those 
sent for the Wassermann test may be considered 
first. 

It soon became obvious that the antileucocidin 
in human serum varies much more than the anti- 
hemolysin. But the quantity of serum available 
was usually too small to allow a separate series of 
dilutions for each factor. As a routine therefore 
four tubes of comparatively widely spaced dilutions 
were used for each form of test, the first tube contain- 
ing undiluted serum and each of the others three- 
eighths of the quantity in the preceding tube. ‘Thus 


8 
THE LANCET] 


serum, which completely neutralised the test dose of 
hemolysin in the first tube only, contained 0°4 unit, 
in the second 1 unit, in the third 3 units, and in the 
fourth 8 units. The figures for the leucocidin tubes 
in terms of K-serum were 0°01 K, 0°:027K, 007K, 
and 0°19 K. 

Of 55 sera, 41 were found to contain 0'4 unit of 
antihemolysin per c:cm., 13 contained 1 unit, and 
one 3 units, giving an average of 0°59 unit. This 
figure is probably a little lower than would have been 
obtained by a more accurate estimation, but it agrees 
sufficiently with the figures obtained by other workers. 

In the antileucocidin estimations, 10 sera were 
equivalent to 0°01 K, 18 to 0:027 K, 19 to 0°07 K, 
and 8 to 0'19 K or more. The average figure thus 
obtained is 0°063 K, but if the 8 sera with titres of 
0-19 K or more are omitted the average of the remain- 
ing 47 is 0:041 K. This latter figure is probably the 
more useful, for, a8 will be shown later, a serum titre 
of 0°19K is usually indicative of existing or recent 
staphylococcal infection. 


CULTURAL AND SEROLOGICAL INVESTIGATIONS CARRIED 
OUT ON PATIENTS 


During the past eighteen months staphylococcal 
toxoid, as supplied by the Wellcome Laboratories, 
has been used at the London Hospital in the treat- 
ment of a series of cases of staphylococcal infection, 
the patients selected being for the most part examples 
of uncomplicated chronic furunculosis. A sample of 
serum was first obtained and then a series of injections 
was given at weekly intervals beginning usually with 
0°25 c.cm. toxoid diluted 1 in 10 and working up to 
0:5 c.cm. undiluted. After a total of at least 1 c.cm. 
of undiluted toxoid had been injected a second 
sample of serum was obtained. 

In addition cultures were made when Joshe from 
lesions and latterly also from the anterior nares in 
order to confirm Dolman’s observation ë that in 
chronic furunculosis virulent cocci are often present 
in the nose for long periods and may be carried from 
there to other parts of the body by the fingers. 
Eighteen cultures were made from the nares of 
patients not suffering from nasal lesions, and in all 
but 4 of these Staphylococcus aureus colonies grew 
out. From 7 of these strains filtered toxins were 
prepared and compared with toxins produced by 
cocci isolated from a lesion in the same patient. 
In all but 1 case the two toxins were sufliciently 
similar to suggest that the lesion- Pioducmg strain 
was being carried in the nose. 


SERUM-ANTITOXINS IN CHRONIC STAPHYLOCOCCAL 
INFECTION 


In a separate paper Dr. Burrows proposes to discuss 
the clinical effects observed in patients treated with 
toxoid injections. Only laboratory results therefore 
will be considered here. 

Table II. shows the findings in 22 cases in which 
the full course of injections was given and in which 
the antihæmolysin and antileucocidin content of the 
serum was estimated both before and after treatment. 

In this series the average figures for antihæmolysin 
before and after treatment are 1'8 units and 8'3 units 
respectively; but in only 4 cases was the average 
figure of 1°8 reached or surpassed before treatment, 


and of these 2 were cases of long-standing acne - 


complicated by staphylococcal infection. If these 
two cases, Nos. 2 and 5, are omitted, the average 
titre before treatment is 1:14 units, a figure less than 
twice the normal 0°59. 

The average antileucocidin titres before and after 
treatment are 0'22 K and 0'24 K. The insignificant 


DR. F. C. O. VALENTINE: STAPHYLOCOCCAL TOXIN 


[marcy 7, 1936 529 


difference between these two figures is probably 
due to the fact that the toxoid used was prepared 
from filtrates of the type obtained from strain Wood 46, 
which gives very little leucocidin. But the average 
titre before treatment, 0°22 K, is important if the 
normal figure is accepted as 0°043K. This five- 
fold rise was presumably due to the presence of 


TABLE II 
Anti- | Anti: 
hæmo- | oidin in 
g | Sex lysin | terms of 
a bgt units. | K-serum = 
B. | A. | B.| A. 
1| M41 2 3 |0-1 |0-1 | Boils 35 years. 
2| M28) 5 11 | 0-32;0-32) Acne + +. Boils 6 years. 
-3 | M22 | 1-5 3 | 0-16} 0-16) Boils 1 year with interval. 
4| F20| 15 8 10-08 0-16) Diabetic. Boils 3 months. 
5| M28| 3 11 | 0:08 0-16) Acne + +. Boils many years. 
6 | M34] 3 11 0-08 0-04) Boils 4 months. 
T| F45| 0-4] 51004 0-08 pee ny: Blepharitis 4 years. 
8| F14| 1:5| 17 |0-16|0-16) Severe boils on face 2 years. 
Mentally feeble. 
9|M34/ 1 26 |0-16 0:08) Boils 18 months. 
10 | M36 | 0-7 5 | 0-08) 0-32} 8 months severe boils. 
11 | M22! 0:7 5 10-16| 0:32) 1 year boils with interval follow- 
ing toxoid treatment. 
12 | M39) 0:7) 5 | 0-32; 0-32) Boils 3 months. 
13| F31/ 1-5) 8 |064| 0-32 eect suppuration of glands of 
neck. 
14| F29| 1-5] 3 | 0-32! 0-32) Boils 18 months with interval 
following toxoid. 
15| M28/ 1 8 | 0-32) 0-32! Boils 5 years. 
16| F 20; 0:4| 2 |0-08/ 0-08) Boils 9 months. 
17 | M59 O-4| 5 | 0-32) 0°32} 3 weeks carbuncle. 
18 | M51! 0-7| 26 | 0-32) 0-64! 2 weeks large carbuncle. 
19 | M23; 1 5 | 0-16) 0-16) Boils at intervals for 7 years. 
20| F12| 0-7 3 | 0°16) 0-16| 6 months boils in axilla. 
21) F45) 1:5| 5 |0°64)0-64) 9 months many boils. 
22| M40) 1 8 |0-08 0°16) 2 weeks boils. 
B.=before; A. =after. 


infection and its amount is significant. It suggests 
that in cases of chronic superficial staphylococcal 
infection the spontaneous serum-antitoxin response 
to leucocidin is better than that to hemolysin. 

This conclusion is supported by a consideration 
of the individual cases in the present series. In 
Cases 4, 5, 10, 11, 18, and 22, the antileucocidin 
titre rose between the two tests and this can be 
correlated with a persistence of the infection during 
the period of treatment, which was noted in all these 
cases. In Nos. 9 and 13 the antileucocidin titre fell 
slightly and no lesions occurred while the injections 
were being given. On the other hand, one case, 
No. 6, was still getting occasional boils at the end 
of the course but his antileucocidin titre, originally 
low, had fallen. 

Nine other cases of primary superficial staphylo- 
coccal infection were treated with toxoid but through 
various accidents of non-attendance the second 
sample of serum at the end of treatment was not 
obtained. It is legitimate to add the figures obtained 
from the original sera of these patients in order 
to increase the number of cases on which the average 
titre in serum before treatment is based. The average 
figure for antihemolysin in 29 cases thus becomes 
1:2 units and for antileucocidin 0°25 K, Cases 2 and 
5 in the original series being again omitted. 


SERUM-ANTITOXINS IN CASES OF SEVERE INFECTION 


The serum was also examined in 8 cases of more 
acute and serious staphylococcal infection. (Table III.) 
This series is admittedly too small to be of much 
statistical value yet the cases fall into two groups, the 
first four being bled one week or less after the infection 
began and the second group after from two weeks to 
a month. The difference in the serum-antibodies 
K2 


530 THE LANCET] 


between the two groups is very striking. In the 
first group, the second and fourth cases were rapidly 
fatal, but the other two, both examples of face infection 
with much. oedema, were clinically “‘ settling °” when 
the serum was taken. It seems, therefore, that 
with sound non-specific treatment clinical improve- 
ment may take place before the antibody titre is 


TABLE III 
e Anti- 
Sex mar leuco- 
Case.| and lysin an in Remarks. 
age P erms 
units tK. 
1 F53 0:4 0:02 Lip infection with oedema. 
Bled after 1 week. 
2 M11 0-4 0:04 Ileum infection fatal. Bled 
within 1 weck. 
3 M 7 0:4 0:08 Nose infection with much 
cedemu. Bled within 1 week. 
4 F23 0:4 0-01 Lip infection. Fatal. 
5 M53 8 2°58 Subscapular infection. Bled 
after 4 weeks. 
6 M32 0-4 1:28 Infected hand. 
7 M15 5 1:28 Osteomyelitis of femur. Bled 
after 2 weeks. 
8 M35 5 2°56 Multiple deep abscesses Bled 


after 1 month. 


appreciably raised. Three cases in the second group 
show the typical rise of antihemolysin titre which 
occurs after deep-seated staphylococcal infection, 
but in addition there is an even greater proportionate 
rise in antileucocidin. The figure of 2°5K, twice 
obtained, appears both remarkable and significant. 
The other case, No. 6, one of severe hand infection, 
showed a great rise in antileucocidin titre but none 
in antihemolysin. There is no reason to doubt the 
accuracy of this titration, but it was unfortunately 
impossible to confirm it on a second sample of serum, 
since the patient when on the point of recovery 
died of an intercurrent infection. 
TOXINS 

In a previous paper ! evidence was brought forward 
indicating that it is usual to find that strains of 
staphylococci isolated from serious lesions are capable 
of producing leucocidin in considerable amount, 
' whereas it is generally agreed that no such correlation 
can be made between virulence against human beings 
and the ability to produce o-hxmolysin. In the 
course of the present work toxins were prepared 
from 25 strains isolated from furunculosis cases, from 
6 strains derived from cases of serious infection, and 
from 5 strains associated with sycosis barbæ. It 
was found that hamolysin production ‘bore no 
relationship to the severity of the lesion from which 
a strain. was isolated; but that all the strains from 
the cases of serious infection and all but 4 of the 
25 strains from boils produced leucocidin in consider- 
able amount, while no strain derived from sycosis 
produced any demonstrable leucocidin at all. There 
can be no doubt that these results have been modified 
to some extent by the recent observation that filtra- 
tion of a toxin removes or greatly diminishes a toxie 
factor which is only present in small amount and 
thereby exaggerates differences of toxigenicity of 
different strains. None the less it seems probable 
that strains capable of invasion of tissue, such as 
occurs in the true boil and in more serious lesions, 
will usually be found capable of producing leucocidin 
in considerable amount, whereas in sycosi8 invasion 
of tissue is slight and the cocci present appear to 
be feeble leucocidin producers. 


Discussion 


It is now generally admitted that staphylococcal 
toxin has several different properties. The majority 


DR. F. C. O. VALENTINE: STAPHYLOCOCCAL TOXIN 


[MARON 7, 1936 


of workers hold that its «-hemolytic, necrosing, 
and lethal activities are probably due to the same 
substance. The (§-hamolysin and the coagulase have 
been shown to be separate bodies. 

As regards the leucocidin, some workers hold it 
to be a distinct entity, whereas others believe that 
the «-hzmolysin destroys leucocytes as well as red 
cells, and that the staphylococcus does not produce 
a true specific leucocidin. The present work suggests 
that this divergence of opinion has arisen from the 
double action of g-hemolysin on rabbit leucocytes 
and red cells, whereas many strains of staphylococcus 
produce also a true leucocidin capable of destroying 
all phagocytic leucocytes both in human and rabbit 
blood, but without effect on red cells and lympho- 
cytes. This leucocidin is capable of acting as an 
antigen and gives rise to a specific antibody either on 
injection or following its liberation into the tissues 
by the cocci in the course of infection. 


ROLE OF THE DIFFERENT TOXINS IN STAPHYLOCOCCAL 
INFECTION ` 

It would be very unwise to attribute all the 
manifestations of staphylococcal infection to toxins 
produced by the cocci. For example, the remarkable 
ability of these organisms to survive on the skin and 
in the nares is probably a most important factor 
in the maintenance of chronic furunculosis. Cellular 
constituents such as the carbohydrate substance 
recently described by Julianelle* may be of the 
utmost importance, for example in the production 
of hypersensitivity. These two factors together 
may conceivably lie at the root of the difficult problem 
of sycosis. 

But the importance of the toxins, particularly 
when the infection has penetrated beneath the 
surface of the skin, is surely unquestionable. It 
is difficult not to correlate the massive local necrosis 
produced by the injection of g@-hemolysin into a 
rabbit’s skin with the local necrosis which characterises 
the ordinary furuncle, the commonest of staphylo- 
coccal lesions. The comparatively poor development 
of circulating antihemolysin in many patients 
suffering from chronic furunculosis may be due to the 
fact that the toxin is fixed locally in the tissues 
and does not therefore stimulate a general immunity. 
In a deeply. seated abscess the absorption of toxin 
appears to be easier since the circulating anti- 
hemolysin commonly rises considerably. 

There is no need to labour the importance of a 
leucocidin capable of destroying the phagocytic 
cells of the blood. Its presence might be expected 
to facilitate the invasion of the tissue by the cocci 
and indirect evidence is here supplied in support 
of this view by the fact that strains of cocci, 
isolated from lesions in which real invasion of 
tissue has occurred in an otherwise healthy patient, 
nearly always produce leucocidin in considerable 
amount. 

This finding has an important bearing on the 
methods used for the production of antitoxic serum 
which is used in cases of serious acute infection to 
prevent further invasion of tissue before the body 
has had time to produce its own antibodies. It is 
possible that in these cases the value of antitoxic 
serum depends more on the content of antileucocidin 
than of antihemolysin. It is not uncommon te 
isolate from a rapidly fatal case of staphylococcal 
septicemia an organism which produces only a 
feeble hemolysin but a strong leucocidin. Even 
if it is true that toxemia and death result directly 
from the accumulation of hemolysin and not of 
leucocidin, treatment should be directed towards 


THE LANCET] 


the prevention of further invasion as well as to the 
neutralisation of toxin already formed. 

Through the kindness of Dr. Parish of the Wellcome 
Laboratories it has been possible to estimate the 
antileucocidin titre of 24 ‘‘normal’’ horses. Of 
these, 6 had a titre of 0'2 K but none of 0:4 K, and of 
the remainder the majority showed a titre of 0°05 K 
or less. Two horses have been immunised against 
a toxin rich in leucocidin, one by Dr. Parish and the 
other by Dr. McClean at the Lister Institute, and in 
each case a titre of 4K was obtained, the titration, 
however, being only approximate, since 100 per 
cent. differences were used both for the estimation 
of the toxin employed and in the ultimate test of 
the serum. More recently a sample of concentrated 
serum kindly supplied by Drs. Dolman and Kitching 
from the Connaught Laboratories, Toronto, has 
yielded a titre of approximately 12K. It would 
seem probable that a figure of at least 3 K should be 
readily obtained in the crude serum by the use of a 
suitable toxin. In comparison with these figures it 
would seem to be rare for a horse immunised with 
hemolytic filtrates such as are yielded by strain 
Wood 46 to attain a titre of more than 1K in the 
crude serum. In the near future it is intended at the 
Wellcome Laboratories to immunise a horse against 
a leucocidal toxin in which the hemolysin has been 
neutralised, in the hope of establishing, if possible, 
a maximum antileucocidal figure for future reference. 

The importance of leucocidin in chronic infection is 
probably much less than in the acute case, particularly 
with regard to treatment by toxoid. Whereas in 
chronic infection the patients often develop little circu- 
lating antihemolysin, their antileucocidin response is 
usually considerable. It may be for this reason that 
serious staphylococcal infection seldom occurs in 
patients already suffering from chronic furunculosis. 
Even so, it would seem on general grounds to be 
desirable that the antigenic efficiency of toxoid should 
be maintained with reference to leucocidin as well 
as to «-hemolysin. 


Summary 


1. A method is described for obtaining a staphylo- 
coccal toxin which, with a suitable strain, is reason- 
ably rich both in «-hemolysin and leucocidin. It is 
observed that filtration may remove all leucocidin 
from a toxin originally feeble in this respect. 

2. Methods are given for the estimation of leucocidin 
in toxin and of antileucocidin in serum. A convenient 
unit of antileucocidin is suggested in terms of the 
standard K serum, B 8760, issued by the Wellcome 
Laboratories. 

3. A description is given of the susceptibility of the 
rabbit leucocyte to a-hemolysin, towards which the 
human cell is relatively if not absolutely immune. 

4. Confirmation is supplied of Dolman’s finding 
that in chronic furunculosis virulent staphylococci 
are commonly carried in the anterior nares. 

5. Evidence is produced indicating that in chronic 
superficial staphylococcal infection the antileucocidin 
of the serum commonly shows a significant increase, 
whereas the antihemolysin often does not; also 
that in deep-seated infection the rise in the anti- 
hemolytic titre of the serum is accompanied by a 
relatively greater increase in antileucocidin. 

6. A comparison of the toxigenic capacity of a 
number of different strains of “cocci suggests that 
strains which have succeeded in invading human 
tissue will commonly be found capable of producing 
leucocidin in considerable amount. 

The importance of the concentration of anti- 
leucocidin in antitoxic serum is discussed. 


PROF. A. K. HENRY: OPERATION FOR FEMORAL HERNIA 


[maron 7, 1936 531 


My thanks are due to Dr. P. N. Panton for his unfailing 
advice and criticism ; to Dr. H. J. Parish and Dr. Joyce 
Wright of the Wellcome Laboratories for their criticism 
and for the supply of standard serum and hæmolytic 
toxin ; also for their collaboration and that of Dr. McClean, 
of the Lister Institute in the immunisation of horses ; 
and finally to Dr. Burrows and other members of the 
medical staff of the London Hospital for access to the 
human material on which the work is based. 


REFERENCES 
1. Fantoni P. N., and Valentine, F. C. O. : THE LANCET, 1932, 
2. Glenny, Å. T. nand Stevens, M. F.: Jour. Path. and Bact., 
3: Bigger, J. W., Boland, C. R., and O’Meara, R. A. Q.: Ibid., 
1927, Xxx., 271 

4. Bigger, J. y: ‘ Ibid., 1933, xxxvi. , 87. 

5. Dolman, C. E EN Tar "LANCET, 1935, i., 306. 

6. Julianelle, L. and Wieghard, C. W.: Jour. Exp. Med., 


1935, lxii., 


OPERATION FOR FEMORAL HERNIA 
BY A MIDLINE EXTRAPERITONEAL 
APPROACH i 


WITH A PRELIMINARY NOTE ON THE ‘USE OF THIS 
ROUTE FOR REDUCIBLE INGUINAL HERNIA 


By Arnotp K. HEnry, M.B. Dub., F.R.C.S. Irel. 


DIRECTOR OF THE SURGICAL UNIT, KASR-EL-AINI HOSPITAL ; 
PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY 
OF CAIRO 


TuE admission of a case of femoral hernia to my 
surgical unit is so rare as to be something of an event. 
During the past year (July, 1934-June, 1935) we have 
operated on 2 such cases as against 205 of inguinal 
hernia, a high incidence considering the fact that in 
the nine previous years only 3 other patients with 
femoral hernia were admitted to my beds. I venture 
therefore to describe an operation that I have per- 
formed once only, in the hope that others with better 
opportunity will test the method and assess its 
value. 

At Kasr-el-Aini Hospital the frequency of bilateral 
lesions of the urinary tract has made us familiar 
with the midline extraperitoneal approach to the 
pelvic ureter, and using this route recently I was 
struck by the admirable exposure it gave of the 
whole region of the femoral ring. In a thin patient, 
as soon as my hand had displaced the peritoneal 
sac from beside the bladder, the view obtained of 
the four relevant structures—Gimbernat’s ligament, 
the hinder edge of Poupart’s, the fascia covering the 
pectineus, the external iliac vein—was like that in 
a specimen prepared for demonstration. This clear 
view showed me that the femoral ring could easily 
be closed by turning forward a flap “of the dense 
fascia covering the pectineus muscle, and sewing it 
to the hinder edge of Poupart’s ligament. 

We soon had the opportunity of putting these 
ideas into practice. A girl aged 14 (1935, No. 13647), 
who had developed phthisis five years previously, 
was admitted with bilateral femoral hernia of one 
year’s duration. Both hernia were reducible, and 
both projected through the saphenous opening 
without turning towards the anterior superior spine 
(Fig. 1). 

THE OPERATION 


Under gas-oxygen anzsthesia on July 10th, 1935, 
through a midline incision, I separated the recti at 
and below the navel, and stripped the unopened 
peritoneum from the sides of the bladder and from 
the pelvic wall, This at once gave a notable view 


532 THE LANCET] 


PROF. A. K., HENRY: OPERATION FOR FEMORAL HERNIA 


[MARCE 7, 1936 


of both hernial sacs, which stood out from the peri- 
toneum like horns from a snail, and passed into the 
femoral rings (Fig. 2). After a very little blunt dis- 
section the two sacs were delivered from the canals 
and brought within the abdominal wall; they were 


FIG. 1.—The two femoral herniæ. (The incision extended from 
the pubic symphysis to the left side of the navel.) 


then excised and their origins were closed. The right 
femoral ring admitted two fingers; the left was 
slightly smaller. Both were shut off in the following 
way, the entire operation ‘‘from skin to skin” 
lasting 32 minutes. 

The fascial flap.—After retracting the external 
iliac vein outwards, I made two incisions through 
the fascia covering the steep slope of the pectineus 
muscle; the first, just in front of and parallel to 
Cooper’s ligament, extending out for 14 inches from 
the free edge of-Gimbernat’s; the second running 
down and forwards at right angles to the outer end 
of the first. I then had a triangular flap of strong 
fascia—pedicled in front—which I turned forward 
and united by sutures to the hinder edge of Poupart’s 
ligament. This closed the femoral 
ring (Figs. 3 and 44). The raw 
upper surface of the pectineus 
muscle remained bare, and to 
cover it I sutured the hinder 
edge of Poupart’s ligament to 
Cooper’s ligament. The second 
line of suture, however, was not 
essential and would seldom be 
so easily accomplished as in this 
case where Poupart’s ligament 
was extremely lax. 

I found that my assistant’s 
hand formed the best retractor ; 
his palm held the abdominal 
wall, while the tips of his fingers 
drew the external iliac vein 
aside as they slid outwards 
over the fascia covering the 
the pectineus. 

The wound healed by first 
intention. 


1 The fascial flap can be raised in the 


opposite direction with its pedicle behind Ot RE Z H 
at Cooper’s ligament (Fig. 4 B). This E ARIA 
avoids leaving any raw surface of the Vif Vy 
pectineus exposed, though I doubt Lh I 
whether that has any real importance i 


since the muscle covers the pubic ramus 
thinly at this proximal level and the 
danger of a recurrent heruia burrowing 
into its fibres is unlikely. 


d 
FIG. 2.—The right femoral sac scen from the left side, after separating 
when the hand has displaced the peritoneum, 


COMMENT 


This method appears to have several advantages, 
apart from its obvious use in bilateral cases. 


(1) When the recti have been separated, the sac is 
found by a gentle movement of the hand, without dis- 
section. Its proximal part is at once delivered naked to 
the surgeon, and serves as a guide to the rest. 

(2) The variably developed, unreliable, conjoined tendon 
plays no part in this operation. At best its arch is resilient 
and must be fastened under stress to Cooper’s ligament. 
Should occasion, however, arise for its use, better access 
to the “ tendon ” is got by this route than by opening the 
inguinal canal. 

(3) In contrast to the conjoined tendon the thick fascia 
covering the pectineus muscle can be relied on to furnish 
a strong flap that will join Poupart’s ligament without 
tension and close the femoral ring. 

(4) The immediate access to a wide surface of parietal 
peritoneum that is given by this approach makes it 
possible to close and invaginate the sac at its actual 
origin, abolishing the small diverticulum which may 
remain to favour recurrence when the neck of the sac 
is drawn down into a wound for ligature. 


TIIE MIDLINE METHOD IN INGUINAL HERNIA 


After the foregoing account was written I made 
(through the courtesy of Prof. A. F. Bernard 
Shaw) a preliminary trial of this extraperitoneal 
route in a cadaver with an inguinal hernia of moderate 
size. I found that the midline incision gave the same 
admirable exposure of the origin of the sac as in 
femoral hernia. The sac could be easily delivered, 
extraperitoneally, within the abdominal wall, and 
dealt with there by ligature and invagination. 
Access to the internal ring was good, and it was easy 
to repair it from within. Further experience has 
shown that this repair is always easy if the anes- 
thetist keeps the abdominal wall lax. Seen by this 
approach, the orifice presents an unusual and striking 
appearance. Its posteromedial lip is beautifully 


defined by a thickening of the transversalis fascia. 
The anterolateral boundary of the ring is formed by 
unthickened fascia covering the deep surface of the 
internal oblique muscle. 


By suturing these two 


N 


A | W 


Á, 


,  „Ext.Iliac Vein 
S ed Hernial Sac. 


WV. STRE HALO try, 


Yin | 
f/f GE il 


the recti, 


THE LANCET] 


boundaries of the ring together from above down- 
wards the internal ring can be narrowed until it just 
transmits the cord. | 

I used the method first for inguinal hernia in the 
operating theatre in a case that was direct, bilateral, 


Fascial Flap 


Ext. Iliac Vein 
y (retracted ) 


Gimbernat 


FIG. 3.—The flap cut from the pectineus 
fascia turned forward for suture to 
Poupart’s ligament. 


and reducible. After separation of the recti I was 
able at once to pick up each sac, and both were com- 
pletely isolated and delivered within the abdominal 
wall in less than five minutes from the first incision. 
Narrowing of the ring too was rapidly accomplished 
by suture from within. 

Indirect hernial sacs naturally are more closely 
attached by their outer surface to the spermatic 
vessels, but at this level, where the vas is already 
turning sharply away from the sac to enter the pelvis, 
their separation is simplified. It must however be 
remembered that when the peritoneum is raised 
from the abdominal wall, the vas deferens—though 
placed in extraperitoneal fat—will be 
raised too. The vas is lifted up on the 
tough fibrous cord of the obliterated 
hypogastric artery which underlies it 
and adheres to the peritoneum. Trac- 
tion on the hernial sac also withdraws 
the was, with the spermatic vessels, 
from the scrotum, so that sac, vessels, 
and vas lie loose and intricate within 
the belly wall. i 

It is notoriously hard to find planes 
of cleavage between slack structures, 
but here the diffculty is easily met 
by a second assistant, who grasps the 
scrotum bensath the towels and 
gently draws the spermatic cord 
towards the patient’s feet. This simple ^` 
precaution restores anatomical rela- 
tions and greatly expedites the isola- 
tion of large  hernial 
sacs. 

The origin of the sac, 
which is closed by liga- 
ture or suture, can often 
be invaginated. To avoid 
injuring gut the “ purse- 

string” should be 
passed while the sac is 


PROF. A. K. HENRY: OPERATION FOR FEMORAL HERNIA 


Poupart 


[maron 7, 1936 533 


a pedicled flap cut from the deep surface of the 
rectus muscle. a | 

True and false necks.—Recently-the extensive view 
of the parietal peritoneum obtained by the midline 
approach has revealed a condition that may have an 


> 
w 


Pectineus 
ascia | 


Pubis 


FIG. Aa The same flap as in Fig. 3, seen in longitudinal 
section. 
The pedicle is at Cooper’s ligament. 


(B) Alternative method of cutting the fascial flap. 


important bearing on recurrence after ‘‘ radical cure.” 

The tubular hernial sac often grows much wider just 

inside the internal ring and forms there a peritoneal 

pouch proximal to the so-called neck. The junction 
of this pouch with unevaginated parietal peritoneum 
is the true neck, origin, or inlet of the sac, and unless 
that inlet is shut recurrence is likely. It would 
however be difficult through the ordinary approach 
to avoid mistaking the wide proximal pouch for 
unevaginated peritoneum; the false, apparent neck 
would then be closed instead of the pertinent real one 

(see Fig. 5). 

The more I use the midline route for operating on 
patients suffering from inguinal 
hernia only, the more I am 
struck by the fact that femoral 
rings often gape widely and 
admit a finger easily ; yet there 
is no corresponding evagination ; 

= the peritoneum lies smoothly 

ANN over them. I believe that the 

nf testimony of the wide field 

A exposed by the extraperitoneal 

` N approach will confirm the theory 

that, apart from wounds or 
operation, a- preformed con- 
genital sac is an essential cause 
of most inguinal herniæ. 


(Y | Cure of the condition will 
ie x only be radical, in the 
hi literal sense of that word, 
y CN when, after excising the 
may: sac,.we close its actual 


origin, and my impression 
is that in many cases 
repair of the canal must 
be superfluous, especially 
when thecanal is valvular 
and the hernia indirect. 


: My thanks’ are due to 
= l Dr. Mohamed Hasan el 


still open. 

If reinforcement were 
required for the closure 
of the internal abdominal 
ring, it would be easy to 
cover the weak spot with 


N. Sony. 


LA 


FIG. 5.—A wide pouch or diverticulum proximal to the false 
fat-encircled “‘neck’’ of the hernial sac (x)—a common 
finding (see text). The true inlet of the sac is where this 
pouch joins parietal peritoneum (Y). The junction is some- 
times marked internally by a rim-like thickening. 


Zeneini, resident surgeon 
in the surgical unit, 
for much useful coöp- 
eration, and to Mr. N. 
Strekalovsky for his ex- 
cellent drawings. 

K 3 


534 THE LANCET] MR. O'SHAUGHNESSY & DR. CRAWFORD : ARTIFICIAL PARALYSIS OF DIAPHRAGM [MARCH 7, 1936 


- TEMPORARY PARALYSIS OF THE 
DIAPHRAGM 


IN THE TREATMENT OF PULMONARY; 
TUBERCULOSIS 


By LAURENCE O’SHAUGHNESSY, M.D. Durh., 
F.R.C.S. Eng. 


SURGEON TO THE BRITISH LEGION SANATORIUM, PRESTON HALL, 
AND TO THE GROSVENOR SANATORIUM, ASHFORD ; THORACIO 
BURGEON TO THE LONDON COUNTY COUNCIL; AND 


J. H. CRAWFORD, M.B. Leeds 


ASSISTANT DIRECTOR, BRITISH LEGION SANATORIUM, 
PRESTON HALL 


Ir is almost five and twenty years since Stuertz . 


and Sauerbruch first induced artificial paralysis of 
the diaphragm as an accessory mode of treatment 
for pulmonary tuberculosis. Sauerbruch had prac- 
tised phrenicotomy—or section of the stem of the 
phrenic nerve within the chest—at a much earlier 
period when carrying out the radical treatment of 
diaphragmatic hernia. 

As phrenicotomy became more generally performed, 
it was apparent that paralysis of the diaphragm 
often failed to appear after the operation, and in 
1922 Felix, after his masterly study of the anatomy 
of the nerve and its accessory branches, proposed 
and carried out the operation of phrenic evulsion, in 
which the nerve was exposed in the neck and its 
peripheral end was seized with forceps and evulsed 
from the chest. In this operation often a length of 
10 cm. of the nerve was removed and a permanent 
paralysis of the hemidiaphragm naturally resulted. 

In 1931 one of us (L. O’S.) published the results 
of a series of operations of the Felix type carried 
out in the Sudan; and-up to that date phrenic 
evulsion appeared to satisfy his requirements except 
in the rarest cases. In that year, however, he had 
the opportunity of examining a patient subjected to 
a phrenic evulsion on the left side which had been 
followed by very distressing symptoms probably 
caused by a displacement of the stomach following 
an ascent of the diaphragm to the level of the third 
rib. Despite the rarity of this syndrome—Davison 
has recently reported 568 cases of phrenic evulsion 
without complication—this case was enough to bring 
the question of temporary paralysis into considera- 
tion, especially as other examples of gastric and cardiac 
distress following phrenic evulsion on the left side 
have been recorded by Rickers and by several others. 

During the last three years it has been our usual 
policy in the treatment of pulmonary tuberculosis 
to induce a temporary rather than a permanent 
paralysis of the diaphragm. The only notable excep- 
tion to this rule is in an operation undertaken for 
the obliteration of a persistent empyema cavity in 
the chest, when permanent paralysis is induced. 


TECHNIQUE 


The technique of operation is much the same as 
that described in a previous paper (L. O’S.). 


The patient is given an injection of omnopon gr. 1/3 
and scopolamine gr. 1/150 an hour before the operation. 
During the operation he lies on his back with a narrow sand- 
bag beneath the neck, fitting exactly between the occiput 
and the first dorsal vertebra, with his chin pointed up 
and away from the operation area. The line of incision, 
two fingers-breadth above the clavicle, is some 2 cm. 
in length, passing horizontally over the posterior border 
of the sternomastoid muscle in such a way that two- 
thirds of the incision is lateral to the muscle. An intra- 


- desired. result. 


dermal weal is raised with a solution of 4 per cent. Novocain 
in the line of the incision, and with due precautions 3 c.cm. 
of the solution is injected into the deeper underlying tissue. 

After incision .of the skin and platysma the posterior 
border of the sternomastoid muscle is exposed, defined 
by blunt dissection and retracted inwards. The posterior 
belly of the omohyoid is then exposed and retracted 
downwards and then thefascia covering thescalenus anticus 
comes into view. A subfascial injection of the anzsthetic 
solution is then carried out and, after a minute incision 
of the fascia, the surface of the muscle is defined by blont 
dissection. The phrenic nerve is exposed running an 
oblique course towards the inner border of the muscle, 
and in the lower part of the wound it is seen disappearing 
beneath the transverse cervical vessels. The nerve is 
gently isolated, raised on a blunt hook, injected with 
novocain, and crushed with a strong pair of artery forégeps. 
The wound is then closed by suture. 


It will be observed that no attempt is made to 
identify and crush the accessory phrenic nerve, 
although this would seem in theory desirable. While 
recognising the importance of Felix’s original work 
on the ‘‘neben-phrenicus,’”’ we can only state that 
the operation as described has produced paralysis in 
43 out of the 44 cases, and in tle single failure a 
more extensive dissection still failed to produce the 
In view of this we are disinclined to 
modify the simple technique outlined. 

It must also be recognised that in phrenicothlasty,* 
as in phrenicotomy, there are certain local operative 
risks, and the operation should only be carried out 
by a surgeon sufficiently experienced to deal with 
the serious haemorrhage which may result from the 
accidental: wounding of an aberrant branch of the 
subclavian artery. It is. well to remember that 
fatalities.have been recorded from this complication. 
A second local complication, which may also have 
fatal results, is air embolism following a wound of 
the external or internal jugular vein. If part of a 
patient’s lung is already rendered useless by disease, 
his reaction to the temporary blockage of part of the 
pulmonary circuit, which follows the admission of a 
small quantity of air into a systemic vein, is con- 
siderably more alarming than the trivial disturbance 
which is the only usual sequel to such an accident 
in a patient with healthy lungs. 


RESULTS 

In 43 out of the 44 cases which are the subject 
of this communication, phrenicothlasty produced a 
paralysis persisting for an average period of six 
months—in one case movement returned after five 
months and in another paralysis persisted for nine 
months—and it appears to give rather more con- 
sistent results than the alternative measures. In a 
recent account of the injection of alcohol into the 
nerve Morin records periods of paralysis ranging 
from five to fifteen months. In 4 of our cases a second 
operation was carried out when a further period of 
paralysis of the diaphragm seemed indicated, and in 
1 of these paralysis failed to appear. 

It is not our intention here to discuss the value 
of hemiparesis of the diaphragm in the treatment of 
phthisis. A recent review of the question by Morriston 
Davies renders this superfluous. There is also an 
analysis of 330 operations by Schwarzmann and 
Waltach and an account of 654 operations by 
Nehil and Alexander. The views expressed by 
one of us in an earlier paper as to the value of the 
operation have undergone little. change. One of 
its most valuable uses is to supplement the régime of 
absolute rest imposed on the patient suffering from 


* This term, derived from the Greek @\dw (I crush, or bruise), 
is perhaps preferable to ‘‘ phrenic crush.” 


THE LANCET] MR. O'SHAUGHNESSY & DR. CRAWFORD : ARTIFICIAL PARALYSIS OF DIAPHRAGM [MARCH 7, 1936 535 


1 


11.i.3t 


14.iii.34 


8.v.35 


: FIG. 1.—Cavity system in right middle zone. Sputum contains tubercle bacilli. 
FIG. 2.—Right leaf of diaphragm raised and paralysed. No T.B. in sputum. 
FIG. 3.—Right leaf of diaphragm raised but moving. No T.B. in sputum. Patient at work. 


an exudative lesion. The old controversy as to the 
value of paresis of the diaphragm in the case of lesion 
of the upper lobe seems to have been settled by the 
work of Weber on the réntgenkymography of the 
lung. As Kremer and von der Weth have also shown, 
diaphragmatic movement has a very definite effect 
on the upper lobe provided adhesions have formed 
in the interlobar sulcus, and the expert radiologist 
is now in a position to decide this point with certainty 
before operation is contemplated. Phrenicothlasty 
is never considered as an alternative to artificial 
pneumothorax. It is sometimes used to supplement 
an incomplete artificial pneumothorax, and it is 
often employed, we believe usefully, as a test opera- 
tion before proceeding to more radical surgery ; only 
rarely is it carried out as an independent measure. 
We have probably made too little use of the opera- 
tion as a palliative measure for the irritative cough, 
dragging pain, and dyspepsia of the late case of 
phthisis. i 
CASE-HISTORY 

Male, aged 27; two years’ history of pulmonary 
tuberculosis commencing with a large hæmoptysis. On 
admission the right lung showed cavitation in both upper 
and middle lobes, with increased root shadows on the left 
side (Fig. 1). Artificial pneumothorax was tried without 
success, and a phrenicothlasty performed on the right side 
in January, 1934; the sputum was then markedly positive. 
Paralysis of the right leaf of the diaphragm was produced, 
paradoxical movement being observed on screening. 
Fig. 2 shows the radiographic appearance 2} months after 
operation—the gradual disappearance of the cavities on 
the right side and the clearing of the contralateral side 
will be noted. The sputum was now negative and there 
was complete subsidence of all constitutional symptoms, 
the patient (a former bank clerk) now being up all day and 
doing 44 hours’ daily occupational therapy in the village 
settlement. 

The initial duration of paralysis of the hemidiaphragm 
was 7 months, and at the end of this period a second 
phrenicothlasty was performed to maintain the paralysis. 
After this second operation, normal movement was 
observed to have returned at the end of 5 months. Fig. 3 
shows the radiographic appearance at the end of this 
period; the diaphragm on the right side is still somewhat 
raised, while the cavitation is now completely resolved. 

The sputum has remained consistently negative and the 


patient has gained 22 Ib. in weight. He has now returned 


to his normal employment. 


CONCLUSION 


Some have been led to advocate a crushing of the 
phrenic nerve rather than its evulsion because of 
the danger of producing some lesion within the chest 
during the latter procedure. We do not consider 
phrenic evulsion, discreetly and carefully performed, 
a dangerous operation but have adopted phrenico- 
thlasty on quite other grounds. We have observed 
an increasing number of patients with bilateral 


‘phthisis for whom some form of bilateral collapse 


operation would offer a prospect, and the only 
prospect, of cure, but a paralysed diaphragm has 
ruled out such a possibility. In the young patient 
a paralysed hemidiaphragm does not produce signs 
of respiratory distress—indeed in a previous paper 


one of us has described patients who tolerated com- 


plete paralysis of the diaphragm with equanimity. 
But it has recently been suggested that in middle age 
paresis of the diaphragm may constitute a more 
serious handicap: Kochs found that phrenicotomy 
produced a greater reduction of vital capacity in 
middle-aged patients than in young patients. The 
possible detrimental effects of the paralysis on cardio- 
vascular function in later life must also be borne in 
mind, and the recent experiments of Nissen and 
Wustmann on the effect of diaphragmatic movement 
on the caval blood flow are of interest in this con- 
nexion. We therefore believe that it will be of 
probable advantage for the patient described in the 
above case-history to have a healed tuberculous 
lesion and a moving diaphragm; for should his 
lesion again become active he is a suitable subject 
for any form of treatment which may be necessary, 
and if, on the other hand, his disease remains per- 
manently arrested there is no chance of his having 
to pay for this benefit by an impairment of respiratory 
or cardiovascular function in his later life. 


We wish to thank Dr. J. B. McDougall, medical director 
of Preston Hall, for permission to publish these cases, and 


Dr. A. Ross for his coöperation in their radiological 


investigation. 
(Rejerences at foot of next page) 


536 THE LANCET] MR. THOMAS AND OTHERS: MALARIA 


ACCIDENTAL TRANSMISSION OF 
MALARIA BY BLOOD TRANSFUSION 


By W. L. Tuomas, F.R.C.S. Edin. 


HON. SURGEON TO THE EAR, NOSE AND THROAT DEPARTMENT, 
THE ROYAL HOSPITAL, WOLVERHAMPTON ; AND 


S. Keys, M.R.C.S. Eng. 


LATE ASSISTANT PATHOLOGIST AND BLOOD TRANSFUSION 
OFFICER AT THE HOSPITAL 


With a note by 
S. C. DYKE, D.M. Oxon., F.R.C.P. Lond. 


PATHOLOGIST TO THE HOSPITAL AND DIRECTOR OF THE 
BLOOD TRANSFUSION SERVIOR 


THE following is believed to be the first instance 
of the accidental transmission of malaria in the course 
of blood transfusion to be reported in this country. 


The patient was a man aged 26. Heo was first seen 
- by one of us (W. L. T.) in May, 1935, with a malignant 
growth of the nasopharynx ; for this he received radium 
treatment at the Royal Hospital. He was readmitted in 
August, 1935, with a diagnosis of septicemia secondary 
to an infection of the middle ear; he was then seriously 
ill and emaciated, and had been running a remittent 
temperature of up to 103° F. for five days. Under treat- 
ment the temperature subsided in a fortnight, leaving the 
patient in a very weak condition. A week later, although 
there had been no further evidence of activity of the infec- 
tion, he appeared to be losing ground. A blood count 
showed: hæmoglobin, 38 per cent.; red cells, 2,040,000 
per c.mm., and white cells, 7900. 

In view of the anzmia it was decided to have recourse 
to blood transfusion, and a first transfusion was given on 
August 24th, 1935. As donor, a brother-in-law was used ; 
blood of both donor and recipient belong to Group O 
(IV. Moss). Eighteen ounces of blood were withdrawn 
and administered. The transfusion was followed by 
considerable clinical improvement; on August 29th the 
blood showed Hb. 58 per cent., and red cells 4,220,000. 
A second transfusion was given on Sept. 9th. The same 
donor was again used and 10 oz. of blood was withdrawn 
and administered. Both transfusions were performed by 
S. K. On both occasions the blood was citrated ; infusion 
was carried out by the three-way syringe; the 
infusion needle was introduced by vein puncture without 
incision, 

On Sept. 12th, three days after the last transfusion, the 
patient developed a high intermittent fever with rigors. 
Examination of the blood on Sept. 17th showed: Hb., 
38 per cent.; red cells, 2,440,000; white cells, 4400; 
no morphological abnormalities of red or white cells. 
Blood culture was negative. 

The temperature and the rigors persisted and the 
clinical condition so impressed one of us (W. L. T.), who 
had had considerable experience of malaria in the Far 
East, with its general resemblance to tertian malarial 
infection, that a further examination of the blood was 
asked for. On Sept. 19th further films of blood were 
-taken both about one hour before and actually during the 


(Continued from previous page) 
MR. O’SHAUGIINESSY & DR. CRAWFORD: REFERENCES 


Davis, H. M.: THE LANCET, 1935, ii., 418. 

Davison, R.: Bull. City of Chicago, Municipal Tuberculosis, 
Sanatorium, 1933-34, xiii.—xiv., 140. 

Ee W. and von der Woth: Zeits. f. Tuberk., 1934, 
xxi. 

Morin, J. ’s Rev. de la tuberc., 1933, i., 808. 

Nehil, Z. W.,and Alexander, J.: Jour. Thor. Surg., 1933, ii., 549, 

Nissen, R., ‘and Wustmann, Ò.: Deut. Zeits. f. Chir. -» 1927, 


cciii., 204. 
O’Shaughbnessy, L.: THE LANCET, 1932, ii., 767. 
Rickers, L.: Beitr. Z. Klin. d. Tuberk., 1933, Ia iU 175. 
Sauerbruch, F.: Münch. med. Woch., 1913, lx., 
Schwarzmann, E., and Waltach, E.: Beitr. EN 1934, 


lxxxiv., 160. 
Stuertz, D.: Deut. med. Woch. . 1911, xxxvii., 2224. 
Kochs, K.: Beitr. z. Klin. d. Tuberk., 1930, lxxiii., 74. 


TRANSMITTED BY BLOOD TRANSFUSION [MARCH 7, 1936 


occurrence of a rigor, and in these the parasite of benign 
tertian malaria (Plasmodium vivax) was demonstrated 
without difficulty. On treatment with quinine binhydro- 
chloride grs. 20 daily the rigors ceased and the temperature 
rapidly subsided. Quinine was continued in decreasing 
doses for two months. The patient was last seen on 
Jan. 14th, 1936; he had then had no relapse, his general 
health had much improved, and incidentally no sign of 
the nasopharyngeal growth could be found. 

The patient had never been out of England and the 
possibility of his having contracted malaria in this country 
appeared remote in the extreme. Suspicion fell on the 
infused blood. Inquiry elicited the fact that the brother- 
in-law who had acted as donor was a regular soldier who 
had served in India from 1927 to November, 1933. The 
only illness from which he had suffered while in India was 
sandfly fever ; while abroad he had never had any rigors. 
In June, 1934, after his return to this country, he had a 
short series of shivering attacks each lasting two or three 
days; his own doctor gave him some medicine, after 
which these attacks ceased and he had been perfectly 
well since. While in India he had not received quinine 
prophylactically. 

Examination of the donor’s blood showed no malarial 
parasites. 


NOTE BY DR. DYKE 


The transmission of malarial infection by the 
infusion, either intramuscularly or intravenously, of 
infected citrated blood is of course a commonplace 
of antisyphilitic treatment. The main interests in 
the above case attaches to the transmission of the 
infection by the blood of a person who had never 
knowingly suffered from malaria. The infection was 
evidently contracted in India; but there seems to 
be no doubt that the donor experienced no symptoms 
of the disease while there. He was questioned as to 
his attack of sandfly fever; this appears to have 
been mild but true to type and the fever was unaccom- 
panied by rigors. Symptoms of malaria did not 
appear until he had been six months in this country, 
and were then mild and unrecognised as such. 

In all about a score of cases of transmission of 
malaria. in the course of blood transfusion from 
donors not known to be suffering from the disease 
are now on record. The first was reported by Woolsey? 
in 1919. The transfusion of blood from an apparently 
healthy donor to a patient suffering from pernicious 
anemia was followed on the same night by symptoms 
of malaria. Immediate examination of the blood 
both of donor and recipient showed malarial para- 
sites, and in spite of the absence of symptoms the 
donor was evidently suffering from heavy malarial 
infestation. This is the only recorded case in which 
examination of the blood of the donor showed malarial 
parasites; their presence in sufficient numbers in 
the blood to be demonstrable in ordinary films 
apparently accounts for the extremely short incuba- 
tion period of the disease in the infused subject. 

The whole subject of the transmission of malarial 
infection in the course of blood transfusion has 
lately been minutely examined by Ackermann and 
Filatov ? at the Leningrad Institute for Blood Trans- 
fusion. They have collected in all a total of 18 cases 
recorded up to the time they wrote. They are 
impressed with the danger of introducing malarial 
infection by the use of blood of donors who have 
ever dwelt in a district in which malarial infection 
is endemic. They experimented upon the effect of 
keeping blood with and without the addition of 
quinine. 

For conservation of the blood they used a solution 
consisting of sodium citrate 5-0 g., sodium chloride 7:5 g., 
potassium chloride 0-2 g., and magnesium sulphate 0-04 g. 
to one litre of distilled water. To this was sometimes 
added quinine hydrochloride to the extent of from 0-2 to 


THE LANCET] 


1:0 g. to the litre. The blood was stored at 4° to 6° R. 
(5° to 8° C.). They found that, whether quinine had been 
added or not, after 12 hours’ keeping the blood was 
always infective; after 24-72 hours it was sometimes 
infective, after 96 hours never. The addition of quinine 
seemed merely to decrease the severity of infection and 
possibly in some instances to render the blood non-infective. 


Since the appearance of the work of Ackermann 
and Filatov, a further case has been reported by 
Harvier, le Brun, and Lafitte 3 to the Société Médicale 
des Hôpitaux de Paris. The donor had been in 
Algiers for two years, ten years previous to giving 
the blood, and in Gaboon up to three years before ; 
he had never knowingly suffered from malaria. He 
had regularly taken 0-25 g. quinine daily while abroad. 
In the discussion following the presentation of this 
case M. P. Emile-Weil said: “ I have never had the 
annoyance of seeing malaria develop after a trans- 
fusion because I regard everyone who has been in 
the colonies or who has lived in a malarial country, 
even if they have not had fever, as being unrecog- 
nised malarial subjects (paludéen ignoré), and I 
refuse without having recourse to any biological 
tests to accept them as donors.” M. Le Bourdellés, 
on the other hand, while admitting the existence of 
chronic cases only brought into evidence by the 
development of malaria after the infusion of their 
blood, expressed the opinion that these are ‘‘ very 
rare occurrences and that a large number of malarial 
subjects after repatriation are completely cured 
from the clinical, hematological, and serological 
standpoints.” 

Various speakers in the course of this discussion 
made reference to ‘“‘Henry’s reaction” for the 
identification of malarial infection. 


This reaction was described by Henry ‘ in 1928. Pro- 
ceeding from the fact that malarial infestation leads to the 


‘ liberation in the blood stream of iron and of melanin, he 


. sidered that he had been able to do this. 


tried to demonstrate the presence of antibodies against 
these substances in the blood of malarial subjects. Using 
as antigens an albuminate of iron in the form of ‘‘ Methafer 
Bouty,’’ and melanin derived from ox retine, he con- 
Adida ë in 1929 
repeated Henry’s work and reported very favourably on 
it as a means of diagnosis of malarial infection. The test 


< has since received a certain amount of attention; Greig, 


van Rooyen, and Hendry #! and Wiseman +? have been 
unable to agree with Henry’s postulates as to the nature 
of the test, but appear to think it may have some use in 
the diagnosis of malarial infection. 


Apart from the case of Grubb ° in which infection 


‘ was conveyed from a recipient who was actually 


suffering from malaria to the donor, all recorded 
cases of the ‘transmission of malaria by means of 
transfusion have been from subjects not known to 
be suffering from the disease. In those recorded by 


~ Qehlecker,’ Schnitzler,°® Mayanz,® Harvier and others,’ 


< and Nobécourt,!° and in the case reported above the 


donors were unaware that they had ever had the 
infection. In those of Oehlecker, Nobécourt, and 
Harvier the donors, while resident in malarial dis- 


> tricts, had regularly taken quinine. 


‘The evidence as to the existence of malarial infes- 


< tation in the blood of those who never knew they 


-1 


:: had suffered from the disease is irrefutable. 
- probable that a latent infestation in course of time 
-dies out, but it is at present difficult to set a term 
z- to its persistence. 


It is 


In Nobécourt’s case a donor who 


. did not know he had had malaria, and had left the 


region of endemic malaria in 1924, infected a recipient 
in 1931. 
The facts make it clear that anyone who has 


~ resided in regions in which malaria is endemic i8 a 


*, potential carrier of the parasites, and that the use 


CLINICAL AND LABORATORY NOTES 


[manon 7, 1936 537 


of such persons as donors is fraught with risk to the 
recipient. The reaction of Henry is still in the 
experimental stage, and until some reliable means 
of identifying latent infection is available it seems 
advisable not to use donors who have lived in districts 
where malaria is endemic. 


¢ 


REFERENCES 

1. Woolsey, G.: Trans. New York Surg. Soc., Oct. 26th, 1910. 

2. Ackermann, Vv. ,and Filatov, A.: Jour. Trop. Med. and Hyg., 
1934, xxxvii., 49. 

3. Harvier, P., de Brun, R., and Lafitte, A.: Bull. et mém. 
soc. méd. hôp de Paris, 1934, 1., 423. 

4. Henry, A. F. X.: Paris méd., 1928, 583. 

5. Adida, P.: Gaz. "des H6p., 1929, oii., 1137. 

6. Grubb, A. S.: Brit. Med. Jour., "1919, ii., 74. 

Te Oehlecker, F.: Deut. Med. Woch. 2 1920, Xlvi., 1025. 

8. Schnitzler, H.: Zentralbl. f. anirug., 1929, lvi., 1438. 

9. Mayanz, L. A.: Chir. Arch., 

10. Nobécourt, $ Liége, R., a ee Bull. de Soc. de 

ii Pédiat. "de Paris, 1932, xxx., 453. 


. Greig, E. D. W. 
THE LANCET, 1934,i 3 
- Wiseman, R. Howitt: THE LANCET, 1934, ii., 


TECHNIQUE OF VARICOSE VEIN 
INJECTIONS 


. Van Rooyen, C. E., and Hendry, E. B.: 
543. 


By M. J. BENNETT-JONES, M.Ch. Liverp., 
F.R.C.S. Eng. 


RESIDENT SURGICAL OFFICER. LIVERPOOL ROYAL INFIRMARY? 


HONORARY SURGEON TO THE BOOTLE GENERAL HOSPITAL 


AFTER surveying large numbers of patients who 
have had varicose vein injections, I am convinced 
that unsatisfactory results are chiefly due to bad 
technique. I have come to the conclusion that the 
majority of varicose vein injections are still given 
with the patient standing, because it is easier to 
introduce the needle in this position. Colt, Ramsay, 
and Morrison,! however, say that when one hears 
of patients with enormous varices being injected in 
the standing or sitting position it is evident that 
there is a lack of appreciation of the principles, 
concerned. I would like to go further than this by 
condemning all varicose vein injections given in thé 
standing position, and I will describe a satisfactory 
“empty vein” technique that can be used in 
all cases. 


DISADVANTAGES OF INJECTIONS INTO DISTENDED 
VEINS 


The first disadvantage of the standing position is 
the dilution of the sclerosing solution with the large 
amount of blood in the vein. This point has often 
been raised, but many still think that this can be 
overcome by using larger amounts of stronger 
sclerosing solutions; this is apt to be followed by 
a very severe localised reaction. The other dis- 
advantages of injections into distended veins result 
from the high venous pressure; I do not think this 
point has been sufficiently emphasised. The high 
venous pressure causes extravasation of the sclerosing 
solution into the perivenous tissues, and often causes 
a perivenous cellulitis at the site of the injection ; 
it has even caused an injection ulcer,? although the 
injection was given intravenously. A varicose vein 
already has impaired elasticity, and also probably 
excessive permeability of its endothelium; it is 
rational to assume that the venules of the vasa 
vasorum are also dilated and more permeable. In 
the injection treatment it is therefore advisable to 
assist the contraction of the vein as much as possible, 
in order to obtain the “‘stiction’’ effect, and yet to 


538 THE LANCET] 


avoid excessive reactions and liability to necrosis of 
the vein. These desirable effects have been found 
to be best produced by using an empty vein technique. 


EMPTYING THE VEIN 


Without an Esmarch’s bandage it is impossible to 
produce an absolutely empty vein, but the more 
the limb is elevated the more empty do the veins 
become, and the degree of emptiness Brena by 
this method is sufficient. 

. Attempts have been made to empty veins by com- 
plicated apparatus. Schmitt ? used a double-barrelled 
syringe, after placing a proximal and distal tourniquet 
on the segment of the vein to be injected. He 

‘“ emptied ° the vein with one syringe, and injected 
the sclerosing solution with the other. Nobl‘ also 
used two constricting bands on the limb. The 
difficulty, however, lies in the presence of com- 
municating veins, which allow a superficial vein to 
fill although it is occluded at both ends. Colt ® has 
mentioned that during varicose vein operations, 
bleeding occurs from the communicating veins: these 
operations were performed with the leg horizontal or 
slightly elevated, so more elevation is required to 
stop the flow. 

Steubner è realised how important it was not to 
inject a varicose vein with the patient standing, 
although he used the erect posture for the needle 
insertion ; he devised accordingly a special table to 
enable the change in posture to be made. His 
method has serious drawbacks. First, it involves 
cumbersome apparatus and is therefore unlikely to 
be widely accepted ; secondly, the needle may slip 
out during the change in position; and thirdly, the 

limb can only be elevated to the horizontal position. 


TECHNIQUE 


Having decided that a well-elevated limb is best 
for injection, it is necessary to have a simple, certain 
method of producing at first a distended vein for the 
introduction of the needle, and then a collapsed 
vein for the injection, with the limb elevated the 
whole time so that there is no change in position. 
The basis of the technique is that a pneumatic 
tourniquet, inflated to a pressure of 180 mm. Hg, is 
sufficient to occlude all the veins of the lower limb, 
including the deep ones, so that the superficial veins 
remain distended when the leg is well elevated. 


An ordinary sphygmomanometer is placed on the 
lower third of the thigh with the patient standing, chiefly 
on the other foot so that the thigh muscles are relaxed, 
and the tourniquet is inflated to 180mm. Hg pressure. 
He then lies down on a couch, witb his chest slightly 
supported, and the affected leg is raised on a box. The 
first injection is given at the periphery. When. the 
distended vein has boen entered, the pressure in the 
tourniquet is easily released with the loft hand. Before 
injecting the solution it is advisable to wait until tho 
veins visibly collapse. When the needle is withdrawn it 
is usual to apply temporary pressure, but it will be observed 
that the puncture does not bleed as it invariably does when 
veins are injected in the standing or even horizontal 
position. The limb should remain raised until an Elasto- 
plast bandage has been applied. 


I have found, like many others,' that 30 per cent. 
sodium salicylate solution is the most reliable of 
the common sclerosing agents, while the very few 
refractory cases invariably respond to 10 per cent. 
sodium. morrhuate. 


RESULTS OF TREATMENT 


By this technique the number of injections required 
to cure a patient has been much diminished, although 
the dose of 30 per cent. sodium salicylate has been 


CLINICAL AND LABORATORY NOTES 


[MARCH 7, 1936 


4-5 c.cm. for an average case. Excessive reactions 
have, however, been more infrequent and trouble 
at the site of the injection has become unknown. 

By comparing similar cases, I think that injections 
starting at the periphery with this technique yield 
better results than internal saphenous vein ligation 
followed by injections. A cramp-like pain in the leg 
after salicylate injections is the only real disadvantage, 
but this is not severe enough to discontinue its use 
until the discovery of another solution that is painless 
and as reliable. Fainting occurred in two patients 
immediately after injection, but an excessive dose was 
given in one and probably also in the other; both 
patients were quite fit within five minutes, and they 
both obtained excellent results. If the injector is 
afraid of the solution entering the general circulation, 
and he wishes to use larger doses of solution, the 
tourniquet can be again quickly inflated to 180 mm. Hg 
pressure as soon as the veins have collapsed, so that 
the sclerosing solution is loculated in the veins; 
this addition to the technique is only required for the 
largest veins. Slow-injection is apparently a sufficient 
safeguard in the majority of patients, if moderate 
doses are given. 

SUMMARY 


(1) The advantages of an “ empty vein ’’ technique 
are stressed. (2) A simple effective technique is 
described, which I hope will be useful to a wider 
circle of vein injectors. 


I wish to thank the staff of the Liverpool Royal 
Infirmary for permission to treat their cases, and the 
successive house surgeons, who have also carried out the 
technique in a large number of cases. 


` REFERENCES 


. Colt, G. H., Ramsay, I. S. W., and Morrison, M. M.M.: 
Brit. Med. "Jour., 1935, ii., 49. 

. Patey, D. : THE LANCET, 1931, il., 284. 

. Schmitt, F. A.: Dermat. Woc -> 1932, Xev., 1718. 
Nobl, G.: Med. Klin., 1931, En y s5 1855. 

. Colt, G. H. : Brit. Med. Jour., 1929, ii., 848. 

: Steubuer, R. W.: Surg., Gyn., and Obst., 1930, li., 169. 


Cau ft 


RUPTURE OF UTERUS WITHOUT 
SYMPTOMS 


By I. H. K. Stevens, M.D., M.R.C.P. Lond. 


HON. ASSISTANT PHYSICIAN TO THE KENT AND CANTERBURY 
HOSPITAL; CONSULTING OBSTETRICIAN TO THE COUNTY 
ROROUGH, CANTERBURY 


In the following case a woman carried on her normal 
occupation of housewife for six weeks after > a 
of the uterus. 


Mrs. B., aged 39 years. It was her seventh pregency; 
five children had been born alive and there had been one 
miscarriage. The fifth child was delivered by Cæsarean 
section, which was performed for central placenta praevia 
on Nov. 23rd, 1929. The last menstrual period in the 
soventh pregnancy began on March 10th, 1935. The 
estimated date of birth was, therefore, Dec. 18th—20th, 
1935, but no child was then born; some pains were felt, 
actually between these dates, but they were not very 
marked and they passed off again. There was no dilata- 
tion of the cervix and it was thought by her doctor 
that there had been a mistake about the dates, as the 
uterus did not appear to have reached the size of a full 
term prognancy. The woman remained at her work as & 
housewife and was first seen by meon Jan. 30th, 1936, as it 
was now considered that there was a possibility of ‘post: 
maturity, even if there had been a mistake of a month 
in the dates. 

On examination the patient did not seem to be in any 
way unwell. Temperature, 98° F. ; pulse, 84; blood 
pressure, 134/76 mm. Hg. Abdominal examination 
revealed a pregnancy, by size about 34-36 weeks, and 


THE LANCET | 


CLINICAL AND LABORATORY NOTES 


[MARCE 7,1936 539 


there was some tenderness on palpation. The fœtus was 
in the right sacro-anterior breech position. No fetal 
movements were observed and no fotal heart sounds 
could be heard. On vaginal examination there was a 
slight reddish-brown sanious discharge, said to have been 
present since Dec. 20th. The cervix was small and firm ; 
there was no dilatation. No presenting part of the foetus 
could be felt, and no definite opinion as to the condition of 
the body of the uterus could be formed owing to tender- 
ness and rigidity. 

The patient was removed to hospital with a view to 
further investigation and termination of the pregnancy. 
No satisfactory evidence could be obtained of the previous 
Cesarean section, but questions to the patient elicited 
the fact that the puerperium had been complicated and 
followed by severe illness. Examination of the urine 
showed specific gravity 1030. No albumin or other 
abnormality. ` 

X ray examination confirmed the presence of a fœtus: 
the report was as follows: presence of fœtus, skull 
collapsed. 3 

In view of the history it was decided to operate to 
remove the foetus and if necessary the uterus. 

At operation.—The abdomen was opened by Mr. A. B. 
Beresford-Jonos by a subumbilical midline incision. On 
opening the peritoneal cavity the fœtus was found 
to be lying free and was removed: the lie was 
transverse with the head towards the left. The intestines 
were matted with vernix caseosa, The uterus was about the 
normal size in & multipara; there was along rent in the an- 
terior wall of the uterus which was removed by total hyster. 
ectomy. There was no blood or organised blood-clot in 
the peritoneal cavity. The peritoneum was sutured over the 


SPONTANEOUS SUBLUXATION OF THE 
ATLANTO-AXIAL JOINT ` 
By Jupson T. CHESTERMAN, M.R.C.P. Lond., 
F.R.C.S. Eng. 


SURGICAL REGISTRAR, SHEFFIELD ROYAL HOSPITAL 


THIs condition still seems to be of sufficient rarity 
to report, for I believe only about 25 cases have been 
placed on record. 

;Case-history.—The patient was a girl, aged 10, admitted 
to the Sheffield Royal Hospital on August 4th, 1934, 
complaining of “stiffness of the neck.” She had been 
perfectly healthy until February, 1934, when during 
confinement to bed for an attack of acute tonsillitis she 


1 


8.viii.34. 
FIG. 1.—Displacement of first cervical vertebra over the second. 


FIG. 2.—Reduction of deformity 


vaginal stump and a drainage-tube stitched into the 
vagina. The abdomen was closed without drainage. 

Progress.—After a brief rise of temperature to 100-4° F., 
on the day following the operation, the patient made an 
uninterrupted recovery and was discharged in good 
health. 

Examination of fetus and placeniu.—The foetus was 
macerated and covered with vernix caseosa. The finger- 
nails were fully developed and it therefore appeared to be 
a full term pregnancy ; the weight was 4 lb. The placenta 
was found lightly adherent to the uterus, near the ruptured 
scar. It was shrunken and thin, 4} in. in diameter; the 
total weight with umbilical cord was 7 oz. There was no 
sign of an extra-uterine attachment. 

The uterus had undergone complete involution. There 
was a rent in the anterior wall, presumably through the 
scar of the previous Cesarean section, about three-quarters 
of the whole length. 


In my opinion labour occurred between Dec. 18th 
and 20th, 1935. During this the uterus ruptured 
through the old Cesarean scar and expelled the 
foetus and placenta into the peritoneal cavity. This 
is verified by the condition of the uterus, placenta, 
and foetus as well as by the progress of the case as 
described above. Six weeks later the woman was 
apparently in normal health, with normal temperature 
and pulse-rate. She had complained only of slight. 
abdominal discomfort and an intermittent blood- 
stained discharge. There was no evidence that she 
had suffered from hemorrhage or shock and she made 
a complete recovery from the operation. 


developed stiffness of the neck—a condition which had 
been slowly becoming worse ever since. 

Examination.—Positive findings were: head held 
forward and to the left, also slightly downward, but can 
be turned to the right with an effort; no tenderness, 
muscle wasting, or spasm, no glands or tumour felt; 
limitation of movement of the head upon the shoulders in 
all directions. Radiography on August 8th showed displace- 
ment of the first cervical vertebra on the second (Fig. 1). 

Treatment.—¥or two months the child was kept lying 
flat with extension applied; afterwards she was sent 
home with a Jones’s collar which was worn for five months. 
When she was seen on Sept. 27th, 1935, there was no 
deformity or limitation of movement and she was in 
perfect health. Radiograms showed satisfactory reduction 
and calcification (Fig. 2). 


Watson Jones! points out that the condition is 
2 l due to hyperæmic decalci- 
fication of the atlas, with 
loosening of the ligaments 
attaching the odontoid 
process to the atlas, con- 
sequent upon nasopharyn- 
geal or other infection at 
the base of the skul. 
Clinically three groups are 
met with: (1) dislocation 
with pressure on the 
medulla causing immediate 
death; (2) subluxation 
with pressure on the cord 
giving rise to quadriplegia ; — 
and (3) the common group 
of which the above is a 
typical example. 


I wish to thank Mr. J. B. 
Ferguson Wilson for allowing 
me to report the case and 
Dr. J. L. Grout for the radio- 


27.ix.35 grams, 


1 Brit. 


Jour. Surg., 
Xvi., 30. 


1934, 


540 THE LANCET] 


ROYAL SOCIETY OF MEDICINE 


SECTION OF MEDICINE 


AT a meeting of this section held on Feb. 25th the 
chair was taken by Dr. H. MORLEY FLETCHER, 
vice-president. Dr. G. W. PICKERING opened a 
discussion on 


Obliterative Arterial Disease 


as it affects the limbs. The chief clinical types, he 
said, were thrombo-angiitis, degenerative, senile, and 
diabetic forms, and embolism—which all affected 
arteries of any size and caused loss of pulse. Ray- 
naud’s disease with necrosis affected small artories. 
All these forms except embolism were progressive, 
but a sudden single attack might occur in small 
arteries at the extremities in the bilateral gangrene 
of the young, of the aged, or of paroxysmal hxmo- 
globinuria. The term “ Raynaud’s disease °” should 
be restricted to the spasmodic type due to over- 
reaction to cold in small limb vessels. In severe 
cases the vessels became progressively obliterated. 
The outstanding problem was the nature of the 
factors determining the obliterative process. Only 
in the vascular complications of cervical rib could 
the process -certainly be arrested. There was no 
evidence that any form of treatment materially 
influenced the course of the disease in other types. 
The condition could be recognised by intermittent 
claudication : a constant, aching pain felt in a muscle, 
induced by exercise and nothing else, and relieved 
by rest. This pain was due to the accumulation of 


chemical substances which normally were removed | 


by the circulating blood, and might appear in severe 
anemia, but otherwise was pathognomonic of struc- 
tural disease of the vessels. Other diagnostic indica- 
tions were gangrene (which, in the absence of physical 
chemical or mechanical destructive agents, was also 
an absolute indication), absence of arterial pulsation 
in a warm limb, skin temperature, and the reactive 
hyperemia test. The skin temperature was first 
measured under ordinary environmental conditions, 
and in obliterative vascular disease the affected limb 
was cooler than the other. This, however, might be 
found in other conditions, including hysteria. Any 
disused limb was likely to be cold. The temperature 
was measured again after removal of vasomotor 
tone by spinal or sympathetic nerve block or by 
warming the body. A difference of several degrees 
might then be found between the two limbs, and a 
typical curve was pathognomonic if there were no 
indication of interference with the sympathetic 
nervous system. With a little practice a very fair 
estimate of skin temperature could be made with 
the hand. The reactive hyperemia test was in 
many ways the best, being delicate and simple. 
The limb was first warmed in a bath, raised to let 
the blood flow out, and the circulation abruptly 
stopped with a sphygmomanometer cuff. Then 
the limb was kept warm in the bath for about five 
minutes and the cuff abruptly released. In the 
normal limb or one with spasm the blood fiowed 
rapidly back to the skin. In obliterative vascular 
disease the skin just below the cuff flushed 
in three or four seconds; about ten seconds later 
blood might creep into the calf, and finally, but slowly, 
to the digits. The. test gave an indication of the 
lowest level for amputation. The blood-flow could be 
increased by sympathectomy, which was the only 


MEDICAL SOCIETIES 


[MAROH 7, 1936 


permanent method ; by vasodilator drugs and heat— 
which were disappointing; by warming the body; 
and by suction and pressure therapy. Heating a 
limb increased metabolism and so might increase 
blood-need more than blood-flow. Suction and 
pressure applied alternately seemed to be a promising 
measure. It gave less satisfactory results in the 
presence of extreme occlusion, massive gangrene or 
slough, severe infection or dermatophytosis, and 
osteomyelitis. The only contra-indications were 
encapsulated pus and severe infection. The main 
place of temporary measures lay in tiding over the -/ 
time between obliteration and the opening up of 
collateral vessels. | 


THE SURGEON’S CONTRIBUTION 


Prof. J. PATERSON Ross described experience with 
this condition at St. Bartholomew’s Hospital. The 
symptoms were different according to whether the 
obliteration was in the terminal vessels or higher 
up. In the former case the chief symptoms were 
pain and gangrene. If the pulse were absent in the 
dorsalis pedis and posterior tibial arteries the case 
was usually one of diffuse arterial disease with 
accompanying obliteration higher up—notably in 
senile and some diabetic patients. The only treat- 
ment was amputation above the knee. When the 
pulses were present it was a little difficult to under- 
stand the lesion. Some of the patients were diabetics. 
Sometimes there was disease of the popliteal artery 
insufficient to obliterate it. Surgery should be 
avoided as long as possible in these cases where only 
a single toe was affected, and should be as conserva- 
tive as possible. The pain was sometimes present . 
before gangrene and was an expression of poor 
nutrition in the skin and subcutaneous tissues. It 
was relieved by anything which improved nutrition. 
Sympathetic ganglionectomy was usually successful. 
Obliteration of the main vessels was associated with 
intermittent claudication and severe pain in the leg. 
Lumbar ganglionectomy for claudication gave dis- 
appointing results. The pain in the calf might be 
dramatically sudden in onset and might appear 
after an apparently successful ganglionectomy. The 
removal of a thrombosed portion of the artery 
had been known to relieve it. Arteriography had 
given accurate information about the vessels, notably 
in showing the frequency of atheroma in the popliteal 
artery. 


Mr. A. M. Boyp showed a series of arteriograms 
illustrating the help given by this method. Localised 
disease of the popliteal artery, he said, could be 
discovered by no other means. 


THE PATHOGENESIS 


Prof. H. M. TURNBULL reported on 112 amputa- 
tions for gangrene, 95 having been done for atheroma 
and 17 for thrombo-angiitis obliterans. The majority 
of the atheroma cases had been associated with 
medial calcification and a few with medial fibrosis. 
There had been nearly 40 per cent. females, and all 
the patients had been aged. In the intima there 
was a great increase of the hyperplastic layer, and 
some degeneration—sometimes calcification but often 
fatty atheroma. This increase of the intima could 
reduce the lumen to a small canal and form a sort 
of new vessel round it. That alone was often enough 
to produce gangrene. Total occlusion might be pro- 
duced by fatty atheroma: imbibition of the intima 
with lipoid. A commoner way was organisation of 


THE LANCET} 


a thrombus. The condition was so widespread that 
a collateral circulation seemed almost impossible ; 
no healthy arteries were available. In thrombo- 
angiitis obliterans males were in the great majority ; 
the average. age was much younger (31-56), and often 
the patients were diabetic. There had been no 
necropsy in this series, and the study of amputated 
limbs was unsatisfactory. It appeared, however, 
that the obliteration by organised thrombus began 

- in small arteries and proceeded towards the heart. 
There was always evidence of inflammation, but this 
did not imply that inflammation preceded throm- 
bosis. There had been little or no evidence of adven- 
titia inflammation or of intimal cushions as a basis 
for thrombosis in smaller arteries. In larger vessels 
the intima showed thickening, vascularity, and a 
delicate collagenous stroma—an extension of the 
inflammatory reaction organising the clot. It also 
showed in most cases large areas of hypertrophy in 
the popliteal artery and its branches, forming great 
cushions, but this process did not, probably, give rise 
to thrombosis by itself. The cushions were degen- 
erate areas of hypertrophied intima, probably 
formed secondarily to obstruction in the smaller 
arteries. In two cases there had been endarteritis 
fibrosa, but no associated thrombosis. The veins 
showed a focal or general intimal hypertrophy, but 
that might be an adaptation to a reduced flow and 
was also seen in the smallest arteries. 


DISCUSSION 


Dr. PARKES WEBER said that the causes of thrombo- 
angiitis obliterans were not known. A constant 
problem was whether or not to stop all use of tobacco ; 
it seemed that smoking played a part and absolute 
abstention at an early stage might just make the 
difference. 

Dr. Otto LEYTON found it hard to believe that 
gangrene was never due to spasm, and quoted a 
case where spasmodic gangrene had occurred in a 
diabetic. He recalled successful Symes’ amputations 
for gangrene of the toes, although at the operations 
no ligatures had been necessary. He doubted whether 
a pulse were always lost before intermittent claudi- 
cation. 

Dr. J. D. ROLLESTON referred to the rare cases of 
obliterative disease after infectious fevers. Gangrene 
of the leg had followed diphtheria in two cases, and 
fatal double gangrene of the legs had followed measles 
once in his experience. 


SECTION OF UROLOGY 


AT a meeting of this section on Feb. 27th, with 
Mr. R. OGIER WARD, the president, in the chair, a 
paper on 

Horseshoe Kidney 


was read by Mr. R. H. O. B. Ropinson. He said 
that the incidence of horseshoe kidney in cases of 
renal disease was 1 in 125. Male patients pre- 
ponderated over females in the proportion of 8 to 3. 
The U-shaped mass lay lower than the usual kidney 
level, and the pelves lay anteriorly because normal 
rotation could not occur. The mass was heavier 
than two normal kidneys. Lower pole fusion was 
commoner than upper pole fusion. In upper pole 
fusion the suprarenals might also be fused, and this 
should be borne in mind if extirpation of a part of the 
kidney was contemplated. There was usually one 
artery to each half, and one artery to the isthmus. 
Radiographically the lower renal poles were invisible, 
the pelves low, and the inferior calices on one or 


ROYAL SOCIETY OF MEDICINE: UROLOGY 


[manoH 7, 1936 541 


both sides lay internal to the ureter: The minimal 
basal angle ranged from 60°-90° in the normal 
radiogram, with an average of 90°. In horseshoe 
kidney it was reduced, and in his series averaged 57°. 
The ureters showed a “ flower vase” arrangement, 
each having a slight S-shaped bend so that together 
they outlined the contours of a vase. Mr. Robinson 
showed a series of radiograms of the condition, in 
which the pelves were seen to be low, often elongated, 
and bizarre in shape, and the reduction of the 
minimum basal angle was demonstrated. The com- 
plications, he said, were obstruction to outflow of 
urine, with the development of hydronephrosis and 
pyonephrosis or calculi; or the horseshoe, like the 
normal kidney, might:be involved by tuberculosis 
or tumour formation. The condition required: no 
treatment per se. In Thompson’s 19 cases only 3 
showed renal disease. Pain was a fairly common 
symptom. Abdominal tumour: was not a prominent 
physical sign ; statistics showed its presence in 30 per 
cent. of cases. In performing heminephrectomy the 
first step was to tap a hydronephrosis or remove 
calculi if present. Later. the kidney could be 
approached extraperitoneally from the lateral position 
and the isthmus divided between clamps. Horse- 
shoe kidney was probably comparatively .common 
and could be diagnosed by routine pyelography. 

In the discussion which followed, Mr. A. RALPH 
THOMPSON said that in some cases unilateral kidney 
was really a variety of horseshoe kidney. In the 
latter condition the fused kidney was prevented from 
rising to the normal kidney level by the inferior 
mesenteric artery ; if it did succeed in rising it was 
forced to go to the left side, and then had the form 
of a solitary kidney with two ureters. He thought 
the term “fused kidney,” which covered this con- 
dition, should be preferred to “horseshoe kidney ”’ 
which did not. | 

Mr. F. McG. LOUGHNANE described a. case in 
which he had divided the isthmus of a horseshoe 
kidney through a right loin incision, and fixed the 
right kidney but not the left by nephropexy. Subse- 
quently there was leakage of urine from the right 
kidney through the wound; this was eventually 
stopped by diathermising the sinus. He now con- 
sidered that a second incision should always be made 
in these cases in order to fix the left kidney as well as 
the right lest leakage of urine from the left kidney 
into the tissues should occur and cause disaster. 

Mr. H. A. M. WuHitsy described a case in which 
it had been necessary to remove the left half of a 
horseshoe kidney in a youth of 17; the patient had 
died of peritonitis on the eighth day. 

Sir W. DE CouRCcCY WHEELER had performed 
heminephrectomy of a tuberculous horseshoe kidney, 
the anatomical condition being recognised during 
the operation. 

Mr. JOHN EVERIDGE had seen two cases of ruptured 
horseshoe kidney in one month, and in both he had 
sutured the ruptures and avoided heminephrectomy. 
Rupture was probably not an uncommon accident to 
a horsehoe kidney ; a jar on the abdomen might be. 
sufficient to cause it, because the kidneys were fixed 
by the isthmus. He thought it would be wise 
nowadays to divide the bridge by endothermy to 
avoid hæmorrhage. 


Mr. T. J. MILLIN contributed a paper on the 
Surgical Treatment of Impotence 


He said that inability to produce erection might be 
due to : (1) congenital or acquired abnormalities of the 
external genitalia; (2) systemic disease ; (3) neuro- 


542 THE LANCET] 
pathies ; (4) endocrine disorders; (5) neurasthenia ; 
(6) functional causes; or (7) it might be transitory 
as a result of prolonged abstinence. Three other 
conditions might be responsible for the disability— 
namely, trauma of the perineum, inflammation of the 
perineum, and premature senility (occurring between 
40 and 50 years of age). Physiologically erection 
depended on either psycho-sensorial or cutaneo- 


motor reflexes, and involved cerebral, lumbar, and ~ 


sacral nerve centres. Lowsley in New York had 
experimented by ablation and by plication of the 
bulbo- and ischio-cavernosus muscles in dogs, and had 
found that the power of erection was considerably 
influenced by the action of these muscles. He had 
then tried the effect plicating these muscles in man. 
The operation was performed with the patient in 
the lithotomy position and a bougie was passed into 
the urethra. The bulbo-cavernosi muscles were 
plicated and the ischio-cavernosi approximated 
towards the midline by means of ligatures of chromi- 
cised ribbon catgut. In Lowsley’s series complete 
success had followed the operation in 9 cases of 14. 
In his own series of 8 cases there were 4 complete 
and 2 partial successes. The cases should be selected 
and those with a neuropathic history excluded. 

Mr. A. E. RocHE described a case of impotence 
following rupture of the urethra in which the disability 
had possibly been of psychological origin. 

Mr. Wuitsy recalled a patient who had been 
impotent for 15 years following rupture of the 
membranous urethra by a shell wound during the 
war. He had treated this man by diathermy to the 
spine and rectum, orchitic injections, and suprarenal 
extract. After two years erection had been 
re-established. , 

Mr. THOMPSON quoted cases illustrating that 
epispadias and hypospadias were not necessarily 
associated with impotence. 

Mr. V. W. Dix wanted to know whether the four 
successful cases in Mr. Millin’s series had been exposed, 
before operative treatment, to the vigorous influence 
of Mr. Millin’s personality. 


Mr. MILLIN replied that the two cases he had 
treated before operation had both been failures. 

The PRESIDENT said he had seen some of Lowsley’s 
work in New York, and believed that Lowsley claimed 
that the operation was only useful in cases where 
there was impotence due to injury of the perineum. 


~ A discussion on 


Steinach II. Operation for Prostatic 
Obstruction 


was opened by Mr. A. ELLIOT-SMITH, who said that 
that this operation consisted in bilateral ligature of 
the efferent ducts of the testicle as they passed to 
the globus major of the epididymis. Ligature of the 
vas deferens (Steinach I.) was liable to produce 
swelling and tenderness of the epididymis, from 
collection of testicular secretions. The Steinach II. 
operation occluded the testicular ducts before they 
reached the epididymis, and the tunica albuginea 
prevented undue swelling of the body of the testicle. 
Dr. Paul Niehans, of Clarens, was the first to use 
this operation for prostatic obstruction.! Local 
anesthesia was used and a silk ligature was passed 
round, the digital fossa of the epididymis so as to 
occupy the groove between the globus major and the 
body of the testicle. Mr. Elliot-Smith had himself 
performed the operation on 20 cases, but had lost 
sight of 2 after two and three months respectively. 


1 Sco THE LANCET, Feb. 8th, 1936, p. 307. 


ROYAL SOCIETY OF MEDICINE: UROLOGY 


[MAROH 7, 1936 


Of the remaining 18 patients, 3 had died and 15 had 
left hospital with fairly good control of micturition ; 
2, however, had had a recurrence of prostatic obstruc- 
tion 8-10 months later and had been treated by 
prostatectomy. Sixteen patients in the series had 
been admitted with acute retention, and of these 
9 had had persistent retention over periods varying 
from ten days to five weeks; 5 of these passed urine 
normally on the day of the operation and the other 


4 passed urine on the second, fourth, seventh, and ` 


thirteenth day respectively. Two patients in the 
series were admitted with suprapubic cystostomies. 
Although normal micturition might begin soon after 
the operation, it was quite usual for the residual 
urine to exceed the amount passed naturally for the 
first week. In the absence of infection, the residual 
urine of his cases had come down to 1 or 2 oz. over 
periods varying from one week to five. Difficulty in 
starting the act of micturition seemed to be abolished 
once normal micturition had begun. Some degree of 
frequency might persist. Having examined his old 
cases, he was convinced that there was a definite 
decrease in the size of the gland following operation. 
Thirteen cases in his series of 18 had been relieved 
by the operation and were still under observation, 
the periods since operation ranging from one month 
to eighteen. 

Mr. H. P. WINSBURY WHITE described a case in 
which the residual urine had amounted to 18 oz. on 
the day before operation. Following the operation 
the patient developed acute retention leading to 
uremia. A catheter had been tied in until he had 
passed the crisis, and the residual urine was now 
down to 4` oz. and the patient was progressing 
favourably. a 

Prof. G. GREY TURNER had seen Mr. Elliot-Smith’s 
cases and had been much impressed. He thought 
the method deserved thorough trial.—Mr. A. CLIFFORD 
Morson asked what was the pathological nature of 
the prostatic obstruction treated by Mr. Elliot-Smith. 

Mr. Drx asked whether there was any advan- 
tage in Steinach II. over the Steinach I. operation, 
in which the vas deferens was ligatured or a 
part of it was excised. Did ligature of the vas 
really cause any tenderness of the head of the 
epididymis ? 

Mr. EVERIDGE said that patients with incipient 
prostatic symptoms were beginning to make 
inquiries about this operation. Some investi- 
gation was necessary to find out whether operation 
on these younger patients was desirable. 

Mr. J. G. YATES BELL said that many surgeons 
ligatured the vas before performing suprapubic 
cystostomy, as a safeguard against epididymitis. If 
there was no danger of such infection occurring, 
Steinach II. might be adopted instead of Steinach I. 
as a preliminary to the operation. 

Mr. Jacobs said he thought that Steinach IJI. 
was not suitable in all cases of prostatic obstruction, 
and described a case in which there had been improve- 
ment in frequency following the operation, but in 
which the residual urine had increased in amount, 
and suprapubic cystostomy had become necessary 
owing to the onset of uremic symptoms. 

Mr. S. I. Levy mentioned two patients who had 
become more vigorous and active following Steinach II. 
operations, and also, according to the nurses, younger 
looking. On the other hand, a patient of 80, on 
whom he had operated the day before, was now seein 
elephants and robbers. = 

Mr. LOUGHNANE asked what was the effect 
of the operation on kidney function, and Mr. 


i 


THE LANCET} - 


E. W. RICHES reminded the meeting that cases of 
prostatic obstruction often showed fluctuation of 
symptoms. After an attack of acute retention a 
patient might remain well for years. The renal 
function should be thoroughly investigated before 
and after the operation. 


Mr. RocHE suggested that both Steinach I. and IT. 
might be performed as a preliminary to the supra- 
pubic operation.—Dr. HeY remarked that Dr. 
Niehans claimed that Steinach II. was evan 
in cases of carcinoma of the prostate. 


In replying, Mr. ELLIOT-SMITH said that spermato- 
genesis was believed to be diminished by Steinach IT., 
and that this gave it an advantage over Steinach I. 
He had seen no epididymitis in his cases but agreed 
that both operations might be done as a safeguard 
before a suprapubic cystostomy. He had noticed no 
mental changes in his patients. All the prostates in 
his series were large, not small and fibrous. Two, 
removed post mortem from patients who died, showed 
a decrease of epithelium and an abundance of the 
fibrous elements. 


MEDICO-LEGAL SOCIETY 


At the meeting of the society held at Manson 
House, Portland-place, on Feb. 27th, Mr. C. 
AINSWORTH MITCHELL, D.Sc., the president, being 
in the chair, Mr. H. W. LINSTEAD read a paper on 


Statutory Safeguards against Poisoning 


with special reference to the work of the Poisons 
Board. He said that according to the Registrar- 
General’s report 892 persons died in Great Britain 
from poisoning in 1934, the average annual number 
for the last ten years having been 815. He proposed 
to indicate some of the causes of those deaths, the 
statutory safeguards provided in the Pharmacy and 
Poisons Act, 1933, and the recently made rules. 
Hitherto the duty of deciding what substances should 
be subjected to statutory control had been vested in the 
Council of the Pharmaceutical Society, and a Depart- 
mental Committee, reporting in 1926, testified to 
its honourable and distinguished service. But it 
was thought undesirable that such an important 
duty should be carried out otherwise than by a 
Minister responsible to Parliament. The Home 
Secretary was advised on the rules to be made under 
the Act by the Poisons Board, who had also prepared 
the Poisons List. The List and Rules were now 
before Parliament. 


Misuse of poisons, said Mr. Linstead, was classifiable 
under the three headings: suicide, accident, criminal 
poisoning other than suicide. 


The extent to which suicide could be prevented 
depended on whether it was premeditated or 
committed because of means readily at hand to 
carry out a sudden impulse. The Departmental 
Committee had endeavoured to ascertain whether 
the easy accessibility of coal-gas caused persons to 
commit suicide who would not otherwise have done so. 
In favour of this supposition was the considerable 
increase of the rate of suicide among females of 
recent years, the increase being entirely in coal-gas 
deaths. The Committee were agreed, at any rate, 
that the publicity given to cases of suicide by poison- 
ing had been the cause of the adoption of this means 
through suggestion and imitation, and therefore 
recommended a drastic statutory limitation of the 
publicity given in newspapers to inquests on suicides. 


MEDICO-LEGAL SOCIETY 


[maron 7, 1936 543 


Apart from coal-gas, lysol and hydrochloric acid 
were most commonly used by suicides in the proportion 
respectively of 1000, 300, and 90°per year. There 
were now available less toxic substitutes for the two 
latter substances: halogenated phenols were coming 
into use as disinfectants, and non-toxic powders 
for domestic purposes. It was therefore regrettable 
that the Home Secretary, against the recommenda- 
tions of the Poisons Board, had permitted both lysol 
and hydrochloric acid to be sold by any trader who 
successfully applied to the local authority to have 
his name added to the list of poison sellers. Though 
aspirin had been used as a means of suicide the 
evidence as to its danger did not seem to warrant the 
scheduling of this drug as a poison. The Poisons 
Board had directed attention to the need for greater 
control over the derivatives of barbituric acid. Each 
of the many analogues of Veronal had been termed 
the safe hypnotic, yet each in turn found its way 
into the statistics of deaths from poisoning. Though 
fatalities from this group of drugs had increased 
during recent years the total number was not yet 
large. For the tighter control of these drugs the 
new legislation provided that they should be supplied 
to the public upon medical, dental, or veterinary 
prescription only, the prescription being valid for 
one occasion only, unless the prescriber. ordered 
repetition. The new legislation contained few pro- 
visions which were likely seriously to decrease the 
use of poison for suicide, and the greater availability 
of lysol might be reflected in an increase in the suicide 
figures from this poison in the coming years. | 


Accidents were liable to occur wherever poisons 
were used. For example, halogenated derivatives 
of carbon, such as carbon tetrachloride and di- and 
tri-chlorethylene, both widely used as industrial 
solvents, might have toxic effects. Continual inhala- 
tion of these vapours caused toxic jaundice. The 
Poisons Board had suggested that it might be desirable 
to require the labelling of the containers of these 
substances with a warning of the character of the 
contents, and ‘the precautions to be taken in using. 
The manufacture of pharmaceutical preparations 
containing poisons had nowadays to be undertaken 
by or under the supervision of a pharmacist, a member 
of the Institute of Chemistry, or a person who for a 
period of three years before the Rules came into 
operation had been continuously engaged in the 
manufacture of such preparations. Certain biological 
products were allowed to be manufactured by or 
under the supervision of a medical practitioner. 
In the past, accidents had occurred due to the sale 
of such substances as solutions of ammonia, hydro- 
chloric acid, and disinfectants in sauce bottles, 
whisky bottles, and even milk jugs by traders who 
kept no poison bottles; this led the Poisons Board — 
to recommend that listed sellers of Part II. poisons 
should be required to sell those poisons in sealed 
containers as sealed by the manufacturer. However, 
the value of this recommendation had been weakened 
by a modification permitting solutions of ammonia, 
hydrochloric acid, and salts of lemon to be packed 
by the listed seller. 


The compounding of medicine containing poison 
was restricted to hospitals, pharmacies, and medical 
practitioners’ establishments. Any person, however 
small his pharmaceutical knowledge, was allowed 
to open a shop and undertake the dispensing of 
medical prescriptions. Nor had we in this country, 
said Mr. Linstead, adopted the precaution against 
accidents which. existed in most countries on 
the continent, the reservation to the medical 


544 THE LANCET] 


MEDICO-LEGAL SOCIETY 


[MARONE 7, 1936 


practitioner of prescribing and to the pharmacist. 


of dispensing. In Scotland there was a convention 
whereby the medical practitioner did not supply his 
own medicines. Little could be done by legislation 
to prevent accidents from poisons occurring in the 
home; except by labelling and a distinctive shape 
of a bottle containing poison. The too frequent 
use of the word “ poison,” particularly when applied 
to substances not highly toxic, diminished the 
cautionary value of the word. For medicine to be 
taken internally the following words might be 
substituted: ‘“‘Caution; it is dangerous to exceed 
the stated dose.” Mr. Linstead quoted one case 
in which a poison was bought in a poison bottle, but 
was turned into a milk jug so that the bottle could be 
returned and the deposit refunded. In another 
case a fowl was destroyed by strychnine in order to 
destroy a neighbouring fox; but a farm: labourer 
found the fowl and took it home for the family dinner. 
The carrying of poisons by railway was carefully 
regulated to prevent leakage, but, so far, no parallel 
regulations had existed for carriage by road. Rules 
to fill this gap had now been made. No general 
provision was found to be practicable for the more 
ready identification of poisons. 


Two circumstances contributed to accidental 
poisoning from substances designed for medical 
purposes, perhaps on medical advice: (1) the 
idiosyncrasy of individual patients, and (2) the taking 
for long periods of poisons which had a cumulative 
effect. The Board had to consider a number of 
poisons which were known to have caused death or 
serious impairment of health when taken in medicinal 
doses. The effect of regular ingestion of acetanilide 
in producing toxic jaundice had long been recognised, 
and its use as an ingredient in proprietary medicines 
had now been checked by including it in Part I. 
of the Poisons List. Attention was also directed to 
the part played by pyramidon in producing agranulo- 
cytic angina; the Board had imposed a restriction 
limiting the supply of this drug to a medical prescrip- 
tion, so barring its use in proprietary medicines. 
The nitrophenols and nitrocresols were liable to 
produce untoward results, even in medicinal doses, 
unless the basal metabolic rate of the patient was 
regularly determined. Atleast one death had occurred 
in this country from using such a preparation for 
slimming purposes. Under the Poisons Rules these 
preparations might be supplied to the public upon 
medical prescription only, and steps had been taken 
to acquaint practitioners with the precautions 
necessary in the administration of these drugs. 


Turning to the use of poisons for criminal purposes, 
Mr. Linstead said that one of the principal objects 
of the new legislation, as of the old, was to prevent 
the use of poison for murder, or, at the worst, to 
facilitate the detection of the murderer. It sought 
to do this by making the poison difficult to obtain, 
and the transaction easier to trace by means of a 
record kept by the seller, and by the label placed on the 
container. 
now surrounded by numerous restrictions. The 
registration of all pharmacies by the Pharmaceutical 
Society and the listing of premises of sellers of 
Part II. poisons by local authorities would do much 
to facilitate the task of the police in tracing the 
supply of a poison by circumscribing the scope of 
their inquiries. The progressive increase in the 
delicacy of methods of chemical analysis rendered 
it very difficult now for a poison used for crime to 
escape detection. Among the legal aspects of the 
question was a substantial increase in penalties, 


Such poisons as arsenious oxide were 


though the maximum fines imposed were not excessive 
in comparison with those prescribed in similar modern 
statutes. The rule-making powers conferred upon the 
Secretary of State by Section 23 of the Pharmacy and 
Poisons Act, 1933, were very wide, and were such 
as to discourage any except the most enthusiastic 
litigant from taking a case to appeal, since. any 
decision could soon be invalidated by a modification 
in the rules. l 


DISCUSSION 


Sir WILLIAM WILCOX said that the report of the 
Poisons Board represented an upheaval of the pre- 
existing conditions, and it remained to be seen how 
the new enactments would answer in practice. Some 
difficulties were to be expected at first. The recom- 
mendations of the Board had not been followed 
implicitly, as some of the enactments had been 
modified by the Home Secretary. He agreed that 
the possibility of purchasing lysol and hydrochloric 
acid from a person who knew nothing of poisons was 
a danger. One of the great steps forward taken by 
the Board was in placing under control] drugs which 
on account of their toxic action ought to be dispens- 
able by only medical men and pharmacists. Barbitu- 
rates had hitherto been easily obtainable, and yet 
they were undoubtedly drugs of addiction. The 
ordinary person was not in danger of becoming an 
addict, but the neurotic and unstable was very liable 
to do so. A further important point was that the 
prescription for these drugs would in future be 
retained by the dispenser ; if the patient was allowed 
to keep the prescription the restrictive clause would 
be largely cancelled, as he could run round to various 
chemists with it and so lay in a good stock. If there 
was need to repeat the dose, the number of repetitions 
must be stated, and the pharmacist should register 
the details. Australia several years ago adopted 
regulations restricting the use of drugs of the verona] 
group, though so far they had not stipulated that 
the pharmacist must retain the prescription. Drugs 
which had received special attention included the 
atophan group, which caused toxic jaundice. He 
was glad to know that in future strychnine was to 
be prohibited for the purpose of destroying animals ; 
it would be interesting to see whether the substitutes 
for this purpose would prove efficient. 


Dr. Jupan JoNnA (Melbourne) said that in Australia 
the pharmacist was not required to retain the prescrip- 
tion containing a dangerous drug but to cancel it 
with a large-lettered rubber stamp, so that there was 
no chance of it being repeated without authority. 
Patients liked to retain it as a memento of the fee 
paid to the doctor. Though there were safeguards 
against repetition, there were none against purchasing 
large quantities at a single time. He suggested that 
the time had arrived for an “ honest advertisement ”’ 
Act, a matter in which he would like to see Great 
Britain take the lead. 


Mr. R. L. CoLLETT, F.I.C., said one of the difficulties 
in connexion with this legislation was that the 
substances concerned were important products, 
apart from being poisons; they were used in 
industry in large quantities, also in research and in 
analytical work. The problem of the Poisons Board 
had been complicated by the difficulty of ensuring 
adequate protection to the public without imposing 
excessive restrictions upon industry and the practice 
of the sciences. His own experience of the leather | 
industry ten years ago was that of seeing men shovel 
red arsenic into vats of lime and soda with a wooden 
spade; those substances were lying on the floor 


THE LANCET] 


of the tannery. He congratulated the Board on the 
reasonable spirit with which they had removed 
noxious restrictions from industry while safeguarding 
the public. It was. easier to get a rule altered if 
experience showed. it was inadvisable than to establish 
the restriction in the first place. 

Mr. H. E. CHAPMAN said a year or two must elapse 
before it would be known whether the present system 
of control would be more effective than that previously 
in force. S 

Mr. F. BuLLOocCa, D.Ph., was glad that the Poisons 
Board and the Home Secretary did not see eye to eye 
over some of the enactments. The Board recom- 
mended that poisons used for animal medicines and 
sold as proprietary medicines should be limited to a 
certain series of poisons ; but now, through the action 
of the Home Secretary, that limitation had been 
suddenly withdrawn and so the whole gamut of 
poisons was open to animal medicine manufacturers. 

Prof. J. G. WRIGHT (Royal Veterinary College) said 
that no member of the veterinary profession had a 
seat on' the Poisons Board. . He congratulated the 
Board on their decision regarding the use of poisonous 
substances in vermin beds ; he protested against the 
use of poison baits which had been indiscriminately 
laid. Dispatching animals by arsenic and phos- 
phorus meant a miserable death. Morphine was 

largely used by the veterinarian as a pain reliever, 
as also was cocaine, which drug had such a more 
sedative action on the dog’s cornea than did any other. 

The PRESIDENT thought that if the Poisons Board 

could be invested with more power than at present, 

many of the existing difficulties would disappear. 
As an instance, meta fuel, which had been investigated 
by Sir William Willcox, Dr. Cox, and himself, ought 
to be labelled as a poison. It was used in the cinema 
industry for producing an impression of snowstorms, 
and was sold in small boxes, looking like sweets, which 
could be purchased by anybody. It had been eaten 
as a sweet by accident. 


Mr. LINSTEAD, in reply, said an attempt had been 
made to get over the formula on the bottle difficulty 
by requiring disclosure of the usual scientific name 
on the bottle or packet. He had been glad to learn 
that strychnine was not necessary as a vermin killer. 


SOCIETY OF MEDICAL OFFICERS OF 
HEALTH 


THE maternity and child welfare group of this 
society held a meeting in London on Feb. 21st with 
Dr. G. C. M. M’GonIGLE (Stockton-on-Tees) in the 
chair. 


Prevention of Maternal Mortality: the 
. Rochdale Experiment 


Dr. ANDREW TOPPING (senior medical officer, 
London County Council; late M.O.H. for Rochdale) 
read a paper entitled Some Factors in Maternal 
Mortality with special reference to the part played 
by Publicity in its Prevention. He began by explain- 
ing the alarm and dissatisfaction expressed by the 
public at the continued high maternal mortality-rate 
as the psychological reaction to the death of a mother 
in childbirth, and pointed out that there were other 
conditions—e.g., diphtheria and acute appendicitis— 
in which lives were lost in an equally unnecessary 
manner without arousing any comparable: public 
feeling. In the present situation however there were 


SOCIETY OF MEDICAL OFFICERS OF HEALTH 


[mance 7, 1936 545 


certain redeeming features, and it should be noted 
in the first place that the method of reckoning the 
rate was in several ways fallacious. Clearly the basis 
of the rate should be the total pregnancies, and 
since this was not taken as the basis, and varying 
factors such as the increase in abortion and the 
decrease in fertility were not comprehended in it, 
comparisons both with the past and with other 
countries were misleading. If these considerations 
were taken into account the place of this country 
in the international standard of obstetric efficiency 
would be near the top instead of, as at present, 
about half-way up. Again, all recent reports had 
emphasised that about half the maternal deaths 
were avoidable, but this classification into ‘‘ avoid- 
ability °” was unsatisfactory because, for example, 
the fatal case of eclampsia which had received 
no antenatal care was classed as an avoidable death,, 
whereas it was well known that eclampsia occasionally 
might arise despite every precaution. It was also 
noteworthy that this basis of 50 per cent. of avoidable 
deaths was largely taken from areas in which the 
maternal mortality-rate was high. In areas in which 
the rate was low far less than 50 per cent. were 
avoidable, 


When he had first taken up antenatal work in a 
metropolitan borough Dr. Topping had been struck 
by the intense interest taken by pregnant women 
in their condition, and had found them eager to 
coéperate if the reasons for their coöperation were 
intelligently explained. When he moved to 
Lancashire he found that the health visitors employed 
by the Lancashire county council were exceedingly 
good and careful in instructing the mothers in the 
various practical details of the hygiene of pregnancy 
and confinement. At Rochdale the maternal mortality- 
rate was much higher than in the surrounding districts 
in which the Lancashire health visitors worked, 
and in fact it had been for some years the highest 
in England. His first task was to interview the 
practitioners, many of whom he had come to know 
personally, and from these he received many 
suggestions about possible causes of the high rate, 
such as rickets, malnutrition, and industrial work. 
A study of the forms of investigation into maternal 
deaths convinced him, however, that none of these 
reasons held good and that the two main factors were 
lack of antenatal care and unnecessary interference. 


The first step in the campaign was to hold a 
meeting of the medical, social, and religious bodies 
in the area. There was a large attendance, aided 
perhaps by the provision of a dinner by a generous 
supporter, and a publicity campaign was decided 
upon. Numerous meetings were then held averaging 
‘about twice weekly, addressed by Dr. Topping 
himself, his maternity and child welfare medical 
officer or other doctors. No alarming propaganda 
was indulged in and it was emphasised that pregnancy 
was a normal natural condition which was perfectly 
safe if the mother did her share, Mothers were 
urged to accept antenatal care, to report the slightest 
abnormality at once, and to accept in-patient treat- 
ment if recommended. They were told that. half the 
maternal deaths were preventable and that the rate 
in Rochdale could quite easily be lowered. Pamphlets 
were distributed in which the main causes of death 
and how to avoid them were simply explained— 
i.e., disproportion, abnormal presentation, “ kidney 
weakness,” and puerperal fever. ‘‘Don’t listen to 
grandmother but visit our antenatal clinic and give 
-yourself and your unborn baby a square deal” 
was the sort of slogan used. The local newspaper 


546 THE LANCET] 


gave valuable help by printing everything submitted 
by the health department in-exactly the form in 
which it was received and without scare headlines. 
The local medical and midwives associations 
coéperated handsomely, and without their help 
the scheme would have been unworkable. 

At the same time certain improvements and 
enlargements were made in the antenatal clinics. 
A few criticisms of the work at these clinics were 
heard, the usual one being that the medical staff 
of the clinics took no share in the actual confinement. 
This was dealt with by publicity suggesting that the 
criticisms would be more valid if their authors 
performed their antenatal work properly, and the 
criticism was also partly met by sending a full report 
of the antenatal examination to the doctor or mid- 
wife concerned whether any abnormality was found 
or not. On the reverse side of the form of report 
was a space for the details of labour and puerperium 
to be noted and returned to the public health depart- 
ment. Other steps taken were the appointment of a 
consultant, the. provision of a unit for puerperal 
sepsis, and the drawing up of plans for a new maternity 
home. In addition the ten best midwives in the 
town were guaranteed an income a very little more 
than their previous average income, and telephones 
were installed in their houses; this ensured their 
coöperation, gave them a definite status, and softened 
their regret if one of their cases was admitted to 
hospital. Nearly all these measures, said Dr. Topping, 
had been taken by most ‘boroughs, although some- 
times the letter rather than the spirit of the recom- 
mendations had been carried out. The only difference 
in Rochdale lay in the intense propaganda; for 
example, the mothers quickly came to know what a 
real antenatal examination connoted and any doctor 
or midwife who scamped it was very soon talked 
about very much to his or her disadvantage. Again, 
the pressure to interfere from the patients and their 
relatives was enormously reduced and the routine 
use of forceps fell very greatly. 

The publicity campaign was begun in 1931. The 
average maternal mortality-rate for the four years 
1928-31 was 9-0 per thousand; for the four years 
1932-35 it was 3-0 per thousand (1-75 in 1935); 
and it was, therefore, fairly safe to conclude that 
these results were due to the campaign. Propaganda 
based on the truth could do nothing but good. The 
secret was complete honesty: ‘‘tell the mothers 
why they should do what is wanted and they will 
do it.” 

FACTORS IN MORTALITY 


Responsibility for maternal deaths might lie with 
any one or more persons—e.g., the patient, the 
midwife, the doctor, the hospital, or the local authority. 
As far as the patient is concerned certain factors were 
not her fault, so to speak, and comparisons between 
different areas might therefore be fallacious. For 
example, he had lately been investigating the reasons 
for the differing rates in the East End and West End 
of London and had found that the proportion of 
primigravide and the age of the first pregnancy 
were higher in the West End. Another factor was 
the variation in the illegitimacy rates, it bemg known 
that the maternal mortality for illegitimate births 
was considerably greater than that for legitimate. 
Again, hospital accommodation clearly varied 
enormously, and the figures of various hospitals and 
organisations were not necessarily comparable, largely 
because of the selection of cases. 

As far as the patient was concerned the apportion- 
‘ment of blame was very difficult. The fact of 


SOCIETY OF MEDICAL OFFICERS OF HEALTH 


[MARON 7, 1936 


pregnancy was still often concealed, sometimes 
because of a false feeling of shame and sometimes 
because it was hoped that a successful abortion or 
miscarriage might be managed. The increase of 
abortion of recent years was very serious; according 


to a recent article by Dr. Parish of St. Giles’s 
hospital, the number had quadrupled in the last 
five years. Of 1000 patients admitted (half of 


whom were infected) 485 admitted instrumental 
interference, 111 admitted to the use of drugs, 
and 9 admitted that they had been to 2 criminal 
abortionist. He thought that it was not so much 
poverty as the desire of young couples not to restrict 
their amusements which was leading to this increase. 


Of midwives there were two opposite types which 
did harm: (1) the kind who thought she knew 
everything and deprecated bringing in medical 
assistance even when necessary ; and (2) the nervous 
kind who frightened her patient, sent for the 
doctor unnecessarily, and urged him to interfere. 
The problem of the doctor, however, presented 
the greatest difficulty. The training he received 
was lamentably inadequate at most schools, and 
the average man went into practice with no real 
practical experience. Many were extremely com- 
petent, but it was idle to deny that deaths were 
often directly due to lack of knowledge, errors of 
judgment, carelessness, hurry, or unwillingness to 
call in expert assistance. Though there was, and 


must be, an important place for general practitioners 


in any midwifery service it must be ensured that 
all who undertake the work are keen and competent. 
In spite of everything that so many authorities 
had said concerning droplet infection it was rare 
to find a doctor who would wear a mask. Every 
public health officer who had the task of investigating 
maternal deaths could quote not one but several 
cases in which a shocking ignorance or carelessness 
had apparently been displayed, and one of his 
councillors had actually proposed that a coroner’s 
inquest should be held on every maternal death. Such 
a procedure, Dr. Topping thought, would do a great 
deal of good, but would lead to more trouble than 
was justified. The consultant, also, might share the 
responsibility for failure. Some were too prone 
to interfere unnecessarily; they felt that they had 
not justified their existence unless they displayed 
some tour de force. Her eagain public knowledge 
of the facts would be useful, for.it would prevent 
women from thinking that the consultant got his 
money for nothing if he adopted a policy of masterly 
inactivity. Many consultants had been remiss in 
not emphasising the part played by bad midwifery 
in the causation of maternal deaths. 


Finally there. were ways in which the voluntary 
hospital or loca] authority might fail in their duties. 
It was freely admitted that some municipal hospitals 
were not so good as others, but rare to hear any 
voluntary hospital referred to as anything less than 
a cross between, say, Guy’s and the Edinburgh Royal. 
But any hospital must be at fault if it purported 
to deal with maternity cases and fell short of accepted 
standards. Among local authorities many fulfilled 
recommendations in the letter, but not in the spirit. 
Their hospitals, too, might be inadequate ; 


of the medical officer in charge might not command 
the respect of practitioners. 


ments ; 


their 
antenatal clinics might not offer the requisite comfort 
and privacy, and the experience and qualifications 


There should be con- 
tinuity between antenatal and in-patient depart- 
there should be a self-contained pyrexia 
unit ; the consultant should be an accepted authority, 


THE LANCET] 


and practitioners should not be openly or tacitly 
discouraged from making full use of his services. 
The medical officer of health was gravely at fault 
if he did not do his utmost to get his committee 
to do more than the minimum, and was to be pitied 
whether blameworthy or not, if his relations with 
practitioners were not cordial. 


DISCUSSION 


Dr. E. H. T. Nasu (Heston and Isleworth) inquired 

whether there had been any difference in unemploy- 
ment over the period in question in Rochdale. He 
asked because of the remarkable effects of the giving 
of milk in the Rhondda Valley which were especially 
evident during a nine months’ strike when the women 
were properly fed for the first time from voluntary 
sources. 
Dr. Dunstan BREWER (Swindon) found that 
even in an area in which the rate was low many 
deaths were still preventable though, of course, there 
was an irreducible minimum. He quoted a case 
in which the urine and blood pressure had been 
examined at 9 a.m. and found to be normal and the 
woman was having an eclamptic fit at 4 P.M. As 
far as statistics were concerned Dr. Brewer thought 
that the only possible basis was the convention 
adopted in New South Wales under which every 
death in a woman between the ages of 15 and 45 is 
considered to be a maternal death unless proved to 
the contrary. A scrutiny of all such deaths resulted 
in the true maternal mortality-rate in his area being 
always double that returned by the Registrar- 
General; for example, an inquiry into the death of 
a young woman from “ myocarditis ° revealed that 
a post-mortem had demonstrated a knitting needle 
in the peritoneum. Such an inquiry was only 
possible, unfortunately, in the smaller boroughs. 
The age at primiparity was important as was shown 
by the recent Canadian report. Dr. Brewer doubted 
whether the increase in abortions was genuine; 
might it not be due merely to lessened concealment 
and increased hospitalisation? On the other hand, 
he was certain that the art of obstetrics had 
degenerated in recent years. 

The CHAIRMAN (Dr. M’Gonigle) wondered whether 
a too liberal interpretation of the Central Midwives 
Board rules for sending for medical aid by midwives 
was leading to harm through interference in normal 
cases. In some cases there was undoubtedly 
dichotomy between midwives and doctors. 


- In reply, Dr. ToppineG said that the incidence of 
unemployment had not varied in Rochdale during 
the period under discussion: in any case it was not 
the poor mother who died. He too had been 
impressed by the results of the Rhondda milk experi- 
ment, but he understood that a propaganda campaign 
had been initiated at the same time. His main 
contention, he said, was that once the true facts were 
known public opinion would be so strong that improve- 
ments would follow in all branches of the service 
whatever the cost. Undoubtedly, in his opinion, 
the time had come to speak the truth and shame the 
devil. Let the blame go where it belonged : to a 
careless public, an inefficient midwife, an inept 
doctor, or a badly run health department. 


KENT CoUNTY OPHTHALMIC AND AURAL HOSPITAL. 
On Feb. 14th Lady Davis opened the new buildings at 
this hospital at Maidstone. The president, Sir Edmund 
Davis, and Mr. E. W. Meyerstein have promised to give 
£2000 towards the extensions, but there still remains a 
debt of £3000. 


LIVERPOOL MEDICAL INSTITUTION 


[marcH 7, 1936 547 


LIVERPOOL MEDICAL INSTITUTION 


AT a pathological meeting of this institution 
on Feb. 20th, with Dr. E. GILBERT Bark, vice- 
president, in the chair, a paper on 


Bacteriological Aspects of Puerperal Sepsis 


was read by Prof. HEDLEY Wricut. The term 
puerperal fever, he said, was not synonymous with 
puerperal sepsis in the narrower sense, for in a series 
of 125 cases of fever in the puerperium it was found 
that only 48 were due to infection of the genital 
tract. Of these only 14 were due to hemolytic 
streptococci and 10 were attributed to anaerobic 
streptococci. The occurrence of fever in the puer- 
perium called for full clinical and bacteriological 
examination of the patient. But severe sepsis was 
most commonly due to hemolytic streptococci, 
although as Colebrook had shown a not inconsiderable 
proportion of cases was due to anaerobic strepto- 
cocci. In hemolytic streptococcal infections blood 
cultures were negative in some 74 per cent. of cases 


: and where positive the numbers present were usually 


small (less than one organism per c.cm. to 1000 per 
c.cm.) according to Hare, and comparable with the | 
numbers found in infective endocarditis and other 
bacterizmias. The blood infection was, therefore, 
to be regarded as a minor feature in the disease. 
There was sufficient evidence to indicate that the 
hemolytic streptococci which caused this condition 
were not derived from among the normal inhabitants 
of the genital tract. Where such organisms had 
been found in the vagina before delivery the puer- 
perium had followed an uneventful course. This 
was because the normal inhabitants were serologically 
and biologically distinct from the strains which were 
pathogenic for man; these fell into one large group 
which could be subdivided into a large number of 
types. This particular group had been found almost 
exclusively in the respiratory tract of normal human 
beings, the feces of patients suffering from an 
infection of the upper respiratory tract, and on the 
hands of some normal persons. That the respiratory 
tract was the main source of infection in the puer- 
perium was therefore to be expected, and in 103 cases 
reported by various authors 99 had actually been 
traced to’ such a source, 79 to some person in 
attendance and 20 to the patient’s own throat or 
nose. Specific treatment with the sera available 
appeared to be completely useless, and it was possible 
that this was in part due to the difficulty of obtaining 
a serum adapted to the particular infecting strain, 
though more probably to the fact that recovery. 
from infections of this kind was largely influenced 
by incompletely recognised factors within the local 
focus of infection in the genital tract.. 


In the discussion which followed, Dr. H. H. 
MAcWILLIAM said that in the acute and severe cases 
of puerperal septicemia there was very little localisa- 
tion of the infection. He regarded thrombosis in the 
veins aS an important factor in limiting spread. 
In these acute cases the vessels in the placental 
site did not show the clotting found in this situation 
in patients. who had died from some other cause. . 
When thrombosis occurred in the iliac veins the 
prognosis was relatively favourable and it was likely 
that thrombosis was very much more common in the 
Ovarian veins than is suspected. Antimicrobic serum 
was useless, but Dr. MacWilliam thought that under 
certain conditions antitoxic serum, probably by 
supplying complement, was one of the most effective 


548 THE LANOET] 


MIDLAND MEDICAL SOCIETY 


[maRcH 7, 1936 


agents we possess. Until recently the experience 
at Walton Hospital, Liverpool, was that if a good 
growth of hemolytic streptococci was obtained from 
the blood in a broth medium by simple technique 
the patient nearly always died. About two years 
ago treatment with human serum was adopted, and 
since then the recovery-rate had been quite high. 


MIDLAND MEDICAL SOCIETY 


AT a meeting of this society held at Birmingham 
on Feb. 5th, with Prof. W. H. WYNN, the president, 
in the chair, a paper on 


Diverticulitis of the Colon 


was read by Prof. SEYMOUR BARLING. He thought 
the condition was due to weakness at certain points 
in the bowel between the longitudinal bands, asso- 
ciated with abnormal stresses in the large bowel. 
This weakness he attributed to previous inflammation. 
The term ‘“‘ prediverticular state’’ he considered a 
misnomer, for he had seen a patient in the so-called 
prediverticular phase, with four years’ symptoms, 
in whom at laparotomy temporary diverticula 
could be seen whenever the bowel was in spasm. In 
such a case diverticula had already formed. Another 
patient had died of ulcerative colitis, the musculature 
being involved in inflammation from the mucous 
membrane ; and though the X ray picture was that 
of the ‘‘ prediverticular state °’ no diverticula were 
present post mortem. There was a type with fibrosis 
and narrowing of the bowel wall, apparently due to 
inflammation and fibrosis strengthening instead of 
weakening the muscle-fibres, the diverticula being 
apparently incidental in some cases. Diverticulosis— 
where fully developed diverticula were present— 
was slowly progressive, but the symptoms were of 
a minor character and seldom necessitated operation. 
Cases with secondary infection were the ones usually 
seen by the surgeon and represented the true diver- 
ticulitis ; the patients were mostly over 60 and it 
was the result of slowly progressive changes which 
might be overlooked in the early stages. Initial pain 
might be slight or severe; a tender colon might be 
palpable in the left iliac fossa and occasionally 
severe hemorrhage was a sign—it had occurred in 
3 cases out of the speaker’s series of 28. Obstruction 
was not uncommon and might occasionally be due 
to carcinoma superimposed on the diverticular 
disease. Prof. Barling had had 5 cases with carci- 
noma out of 28. Early cases required medical treat- 
ment and surgery was needed chiefly for obstruction, 
spreading sepsis, or fistula. The disease was not the 
surgical curiosity it was considered to be and had 
to be kept in mind when an abdominal condition 
presented itself. 


Dr. T. L. Harpy asked if any useful purpose was 
served by the term ‘“‘diverticulosis.”” It suggested 
an active morbid process associated with symptoms, 
but many authorities did not regard it as such. 
Diverticula were present in about 5 per cent. of 
patients over the age of forty, a figure obtained by 
Rankin and Brown at the Mayo Clinic from 24,620 
_ radiological examinations of the colon and 1925 
post-mortem examinations. Whether uncomplicated 
diverticula ever of themselves gave rise to symptoms 
was debatable, his own view being that the symptoms 
complained of at that stage were due to an associated 
disturbance of bowel function, accidental rather than 
incidental to the diverticula. Dr. Hardy’s personal 
experience of diverticulitis was, he said, small, and 


he had records of only 22 cases (16 men and 6 women) 
in the past six years. He agreed with Prof. Barling 
that diverticula were largely manifestations of wear 
and tear; they showed themselves usually in the 
degenerative or decrescent period of life, the average 
age in his series being 58. Of his 22 patients 14 were 
noted as being obese and flabby. He did not think 
it need be assumed that spasm played an important 
part in the formation of diverticula, or that sympa- 
thetic or parasympathetic and endocrine influences 
were necessarily responsible ; for neither true colon 
spasm, a much more common disorder, nor the 
various forms of colitis led to the formation of 
diverticula. The dangerous potentialities of diverti- 
cula needed no emphasis. According to Rankin, m 
about 15 per cent. of cases they became inflamed and 
gave rise to symptoms, the remainder being dis- 
covered accidentally. By their shape and feeble 
musculature, retention of fecal material was en- 
couraged, and the way to subsequent infection and 
diverticulitis laid open. The physician saw these 
cases for one or more groups of symptoms—disturb- 
ance in the normal routine of bowel movement, 
abdominal pain, local or regional colitis, or vague 
ill-health associated with fever, shivering, and 
leucocytosis. Treatment took the form of what was 
somewhat euphemistically called “colon hygiene,” 
and was as necessary, as a protective measure, where 
diverticula have been discovered accidentally as 
it was in established diverticulitis. At first, and 
whenever acute symptoms were evident, a bland 
diet of cereals, milk, eggs, and fish was desirable, 
with a period of rest in bed. Later, a full, wel- 
balanced diet might be planned, though some loss 
of weight should usually be aimed at. Roughage 
must be always avoided and soft vegetables should 
be passed through a sieve. The bowels needed 
scrupulously careful regulation to avoid extremes ; 
soft, semi-formed stools should be aimed at, but any 
form of irritating aperient was absolutely contra- 
indicated. Rectal irrigation, if carefully given through 
tube and funnel at a pressure of certainly not more 
than 18 in. and limited to one pint, was occasionally 
valuable, especially where there was acute pelvic 
inflammation. An occasional enema of warm olive 
oil up to 6 oz., given over-night and retained till 
the morning, might also be used as a routine once 
a week or at longer intervals. Belladonna and 
hyoscyamus were certainly valuable in relieving 
the spasm and pain associated with diverticulitis. 
The mode of life should be one of all-round modera- 


tion ; exercise in the form of walking, golf, shooting, 
and riding was good. A system of general massage 
and graduated abdominal exercises such as were 
embodied in the term ‘‘abdominal culture’ were 
useful. Abdominal massage, however, was an 


appalling blunder, and Dr. Hardy had seen it pre- 
cipitate an attack of subacute obstruction. A well- 
fitting belt to maintain intra-abdominal pressure was 
desirable when there was much protrusion. 


Dr. Harotp Brack said that of 432 patients 
examined by barium enema in 1934, 68 showed diver- 
ticula (36 men and 32 women). He thought that few 
of those with diverticula developed diverticulitis, 
and mentioned that 15 per cent. of cases with carci- 
noma of the colon showed diverticula. It must be 
remembered that radiological abnormalities were not 
necessarily the cause of the patient’s symptoms ; 
one patient had numerous diverticula but the symp- 
toms were later shown to be due to a ureteral calculus. 
Dr. Black thought the inflammatory bowel wall 
changes might be a result of the diverticula rather 


THE LANCET] 


than their cause, and that a degenerative change 
in the musculature. of the bowel was a precursor. 

Dr. J. F. BRAILSFORD did not think that diverti- 
culitis was a contributory factor in carcinoma coli. 
Any association of the two diseases was probably 
accidental. 

The PRESIDENT asked whether the condition 
might not be a disease of. civilisation. Was the 
colon undergoing atrophy ? What were the possible 
causative dietetic factors? He did not believe that 
inflammation was the cause of diverticula, but held 
that irregular bowel contractions were. possibly 
concerned. He had seen two cases of plumbism 
with diverticula present. : 


PATHOLOGICAL SOCIETY OF 
MANCHESTER 


AT a meeting of this society on Feb. 12th Prof. 
S. L. BAKER and Dr. J. CRIGHTON BRAMWELL read 
papers on the 

| Pathology of Heart Disease 


Prof. BAKER pointed out that inflammatory lesions 
in the myocardium itself appear to play little part 
in the production of myocardial failure. Vascular 
lesions due to coronary obstruction, atheromatous or 
syphilitic, were the chief cause of gross myocardial 
lesions. The development of a collateral circulation 
by anastomoses between coronary branches and 
pericardial branches from extracardiac thoracic 
vessels could modify the effects of coronary occlusion, 
particularly if this occlusion was gradual. Cases of 
complete obliteration of both coronary orifices by 
syphilitic disease had been reported ; here the heart 
was supplied for a time entirely by such collaterals. 
Most workers at the present time believed that 
angina pectoris was produced by anoxemia of the 
myocardium ; it was usually, though not always, 
associated with coronary narrowing. 

Cases of cardiac failure with myocardial hyper- 
trophy formed an important group; such failure 
often occurred apart from valvular lesions in persons 


REVIEWS AND NOTICES OF BOOKS 


[anon 7, 1936 549 


with hypertension. A proportion of such cases 
showed coronary athero-sclerosis, but there were 
many without coronary obstruction in which, apart 
from hypertrophy, the myocardium showed -no 
appreciable pathological change. The cause of myo- 
cardial failure in such hearts was a matter for, 
speculation. There seemed a probability that the 
vascular supply failed to keep pace with the greatly 
increased bulk of’ hard-worked muscular tissue. 
Karsner and his co-workers had shown that in 
cardiac hypertrophy there was no appreciable increase 
in the number of muscle-fibres but a great increase 
in the mean diameter of each fibre. Unless the 
number of capillaries per muscle-fibre was greatly 
increased such hypertrophied fibres would be inade- 
quately supplied with blood. No one had as yet 
investigated the problem from this point of view. 

_ Summing up the pathology of myocardial failure, 
it could be said that, excluding acute toxic effects, 
factors interfering with the blood-supply, and certain 
rare cases of lesions of the conducting system, there 
remained a large group of cases of myocardial failure 
without adequate pathological findings. Here one 
had to assume that there was functional damage 
from overwork and possibly a failure of the blood- 
supply to keep pace with the demands of the hyper- 
trophied and heavily worked muscle-fibres. 

Dr. CRIGHTON BRAMWELL, after reviewing the 
changes which had taken place in the outlook on 
cardiology during the past fifty years, suggested that 
patients complaining of cardiac symptoms might be 
classified in three groups: (1) those with heart 
disease, (2) those with neuro-circulatory asthenia, 
and (3) those in whom symptoms were attributable 
to an anxiety neurosis. The first group consisted of 
inflammatory, degenerative, and other lesions of the 
heart itself, while in the second group the cardiac 
manifestations were secondary to such conditions as 
focal sepsis or disease in other parts of the body. 
Heart disease, neuro-circulatory asthenia, and anxiety 
neurosis might all be present in the same patient ; 
in fact it was rare to meet with a case of heart disease 
in which there was not some element of neurosis. 


REVIEWS AND NOTICES OF BOOKS 


Localized Rarefying Conditions of Bone 
By E. S. J. Kine, M.D., D.Sc., M.S. Melb., F.R.C.S. 
Eng., F.R.A.C.S., Honorary Surgeon to Out- 
patients, Melbourne Hospital; Stewart Lecturer 
in Pathology, University of Melbourne. London: 
Edward Arnold and Co. 1935. Pp. 400. 35s. 


ONE of the most fascinating features of medicine 
is the appearance, waxing, and waning of certain 
morbid conditions as centres of interest and attention. 


The interest aroused by particular diseases or injuries | 


varies enormously from one decade to another quite 
independently of their prevalence. At the moment 
anything labelled “‘ osteochondritis ’ evokes a prompt 
response from orthopedic surgeons, and the issue of 
a complete guide book to this maze of conditions is 
therefore timely. The initial and greatest difficulty 
is one of nomenclature: the G.O.M. of the osteo- 
chondritides (though not the first to be described) 
has been christened no fewer than fiteen times, and it 
is to be hoped that the name selected by Mr. King, 
‘“ osteochondritis of the upper epiphysis of the 
femur,” will now be accepted as the official title, if 
only for the sake of simplicity. 

In this work the author has brought together all 
that is known about the various forms of osteo- 


chondritis and certain types of bone atrophy. His 
command of the vast literature on the subject is so 
complete ‘that the reader must be on guard lest he 
should overlook the author’s own useful contributions. 
There is hardly an epiphysis in the body that has not 
been the site of an osteochondritis, and Mr. King 
has been vigilant in collecting references to all the 
forms of it, however rare. Legg-Perthes’ disease and 
Osgood-Schlatter’s disease are not typically ‘‘ rarefying 
conditions of bone’’ and have little relation, as the 
author shows (p. 291), with Kitimmell’s disease and 
its allies which are. All the same, a most useful 
service has been rendered in bringing together both 
groups of these puzzling conditions, and this book 
will almost certainly be a standard work of reference 
for many years to come. The first section deals with 
bone as a tissue, radiographic appearances, and 
certain anatomical features; the second describes 
every known form of osteochondritis. It is exasperat- 
ing that, despite the efforts of Mr. King to lay before 
us all that is known, we are still very much in 
the dark about the etiology and pathology of this 
type of bone disease. Good functional recovery so 
frequently follows conservative treatment that 
conscientious surgeons have had little opportunity 
of obtaining pathological material, and experimental 


550 


work has, for the most part, given little help. 
Various forms of bone atrophy, in which trauma 
plays a definite part, are described in Section III., 

and here again the exact causation is a matter for 
speculation. An excellent account of osteochondritis 
dissecans completes this work for which (apart from 
an X ray reproduced upside down on p. 287) we 
having nothing but praise. 

The title of the book is nőt of the author’s 
choosing ; it was the subject set for the Jacksonian 
Prize of the R.C.S. for 1933, which distinction Mr. 
King won. 


THE LANCET] 


Bacteriology of Typhoid, 


Salmonella, and Dysentery Infections and Carrier 
States. By Leon C. Havens, M.D., Director of 
Laboratories, Alabama Department of Public 
Health. New York: The Commonwealth Fund ; 
London: Humphrey Milford, Oxford University 
Press. 1935. Pp. 158. 7s. 6d. 


Now that the enteric fevers have become an inter- 
mittent rather than a continuous problem in this 
country a book by an enthusiastic worker with 
long experience of an endemic zone is particularly 
valuable. The late Dr. L. C. Havens was director 
of laboratories to the Alabama Department of Health, 
and in this little book he has given us the fruits of 
his experience in a clear and attractive form. The 
manual is essentially practical, but certain theoretical 
matters such as the different antigens of the typhoid- 
salmonella group are simply and adequately dis- 
cussed. Stress is laid on the fallacious nature of a 
purely serological diagnosis of the enteric infections. 
The author points out that it should be possible to 
isolate the causative organism in a large percentage 
of cases, and he devotes a good deal of attention to 
the methods by which this can be done. The descrip- 
tion of salmonella infections is apposite, and the 
subject has been shorn of the complexities with 
which it is usually presented in English bacterio- 
logical literature.. A list of references giving in full 
the titles of papers is supplied at the end of each 
chapter and adds to the usefulness of an excellent 
little monograpa 


An Index of Treatment 


Eleventh edition. By Various Authors. Edited 
by Rosert Hurcuison, M.D., LL.D., F.R.C.P., 
Consulting Physician, London Hospital. Bristol: 
John Wright and Sons, Ltd.; London: Simpkin 
Marshall Ltd. 1936. Pp. 1020. 42s. 


THE eleventh edition of this classic work, which 
begins with the editor’s admirably succinct remarks 
on the principles of therapeutics, includes many 
subjects not dealt with in previous editions. For 
example, articles are supplied by the editor on agranu- 
locytosis and its treatment by pentnucleotide, by 
Prof. A. W. M. Ellis on alkalosis, and by Dr. G. W. 
Bray on the complex problem of allergic disease. 
Dr. Donald Hunter writes on idiopathic steatorrhaa 
and tetany in the adult and the various techniques 
of cisternal puncture and its therapeutic possibilities 
are described by Dr. W. M. Feldman. Two other 
important new articles are by Dr. C. Newman on the 
functional disorders of' the gall-bladder and by 
Dr. R. Lightwood on the anæmias of childhood. 
Many other sections have been revised or rewritten 
in the light of recent knowledge, but it is gratifying 
to see that those of Mr. James Sherren, a former 
editor, have been substantially retained. The surgical, 


REVIEWS AND NOTICES OF BOOKS 


[Manon 7, 1936 


X ray, and glandular therapy of acromegaly are 
discussed by Dr. H. Gardiner-Hill. Prof. L. J. Witts 
deals with the treatment of the anæmias and Dr. 
S. Levy Simpson with that of Addison’s disease by 
cortin injections. The section on the ear has been 
rewritten by Mr. L. Graham Brown, and Mr. Eardley 
Holland writes on calcium gluconate in the modem 
treatment of eclampsia. The treatment of acute 
nephritis by orange juice, of hypertensive encephalo- 
pathy by venesection and lumbar puncture, and of’ 
the various types of renal cedema are clearly expo ee 
in Prof. Ellis’s contribution on nephritis. There 
nine articles by Mr. Victor Dix on various ealo. 
urinary conditions and Dr. Levy Simpson describes 
the treatment of Raynaud’s disease by calcium, 
parathyroid, thyroid, cestrin, and, if necessary, 
ganglionectomy. The potentialities of superficial 
and deep X ray therapy are summarised by Dr. J. F. 
Carter-Braine and the indications for treatment by 
Sanocrysin, artificial pneumothorax, phrenic paralysis, 
and thoracoplasty are described in Dr. L. S. T. Burrell’s 
masterly article on pulmonary tuberculosis. 

It is no exaggeration to say that this book is a 
necessity to all who are seriously concerned with 
therapeutics, and the practitioner, temporarily 
depressed by lack of therapeutic success, will find 
herein much to cheer and inspire him to further 
effort. 


Thorpe’s Dictionary of Applied Chemistry 


Supplement to Vol. III. By JocELYN FIELD 
TuorPE, C.B.E., D.Sc., F.R.S., F.I.C., Professor 
of Organic Chemistry and Director of Organic 
Laboratories, Imperial College of Science and 
Technology ; and M. A. WHITELEY, O.B.E., D.Sc., 
F.I.C., formerly Assistant Professor of Organic 
Chemistry at the College. London: Longmans 
Green and Co., Ltd. 1936. Pp. 166. 21s. 


In the course of their preparation of the first two 
volumes of the supplement to Sir Edward Thorpe’s 
classic work, the editors realised that within the 
past decade so many new technical terms have been 
coined that even the expert may find it difficult to 
understand expressions used outside his own branch 
of chemistry. To meet this difficulty they have now 
issued, together with the index to the supplement, 
a glossary of the terms used in it and of some other 
words and phrases which are in vogue in laboratory 
and factory. In completing the supplement they 
have thus provided us also with a compact indepen- 
dent work of reference whose value is enhanced by 
its pleasing and legible type. 


Chronic Streptococcal Toxzmia and Rheu- 
matism 
By J. D. HINDLEY-SMITH, M.A. Camb., M.R.C.S., 
L.R.C.P. London: H. K. Lewis and Co., Ltd. 
1935. Pp. 275. 7s. 6d. 


TuE streptococcus is cast for the part of villain in 
this book and is held responsible by the author for an 
unpleasant condition which is called chronic strepto- 
coccaltoxæmia. This condition which, he believes, may 
begin in childhood, is gradual in its progress and 
in its method of establishing itself, but may ulti- 
mately condemn those who suffer from it to a life 
of semi-invalidism. Chapter I. opens well. Most 
readers will be in sympathy with the author’s claim 
that the clearly defined and labelled diseases which 
progress according to a definite programme, and are 
described in text-books, account for à minority of 


THE LANOET] © 


the ills of mankind ; .whereas most of the diseases 
met with in general practice are neither well defined 
nor really understood, and much good could be done 
by collecting and sorting out clinical observations, 
particularly those made by experienced practitioners. 
When, however, Dr. Hindley-Smith proceeds to 
such statements as “‘ the vast majority of cases suffer- 
ing from chronic toxemia are suffering from acid 
toxemia, and the causes giving rise to acid toxemia 
are legion,” most of us will part company with him. 
This conception of acidity and acid toxemia in rela- 
tion to the rheumatic diseases has surely been dis- 
carded. In their book on chronic arthritis reviewed 
in THE LANCET (1935, i., 618) Pemberton and Osgood 
say wisely: ‘‘ One frequently hears from patients the 
statement that his doctor has told him he was ‘too 
acid,’ to counteract which condition he was given 
alkali in some form. The time is past when medical 
men can afford to tolerate such vagaries which have 
neither clinical nor scientific justification.” Dr. 
Hindley-Smith’s suggestion that the victim of pro- 
longed anesthesia will experience the feeling of 
general poisoning throughout the system long after 
consciousness has returned is also misleading. The 
alarming picture drawn of the sufferer from chronic 
streptococcal toxemia is surely exaggerated. So 
the book goes on, a mixture of shrewd observa- 
tion and comment interlarded with loose statements 
for which there is no scientific support. All we can 
say of it in praise is that the section on treatment 
should help the doctor whose patients are clamouring 
for “‘ something to be done.” 


The Anti-Drug Campaign 


An Experiment in International Control. By S. H. 
BAILEY, Senior Lecturer in International Relations, 
London School of Economics and Political Science. 
London: P. S. King and Son, Ltd. 1936. 
Pp. 264. 12s. 


Mr. Bailey has put together a useful and timely 
account of the tangled story of the efforts to secure 


international control of the traffic in dangerous 


drugs, from the Shanghai Commission of 1909 to 
the Convention on Limitation of Manufacture of 
1931. In an appendix extending over a hundred 
pages there are set out the provisions of the Hague 
Convention of 1912, the Geneva Agreement and 
Convention of 1925, the Bangkok Agreement and 
the Limitation Convention of 1931. The evolution 
of international control of the traffic in opium, 
morphine, heroin, and cocaine is described, but it is 
recognised that side by side with the licit demand, 
clandestine opium smokers and drug addicts create 
an illicit demand of unknown volume. There is 
thus encouraged the harvesting of quantities of the 
raw materials which bear no relation even to the 
most liberal estimates of legitimate requirements. 
The author regards the Hague Opium Convention of 
1912 as an event of the highest significance, being 
the initiation of a multilateral international instru- 
ment for combating a world-wide evil. In view of 
the persistence of legalised opium-smoking in the 
Far East, he naively remarks that it is difficult to 
resist the conclusion that European Powers have 
taken a lighter view of their responsibilities to the 
peoples subject to their administration in Eastern 
Asia than to their nationals in their home countries. 
The improvements effected under the Geneva Con- 
vention of 1925 in the control of international traffic 
in drugs and the creation of the Permanent Central 


REVIEWS AND NOTICES OF BOOKS 


-being the aim.’ 


[maron 7, 1936 551. 


Opium Board are set off against the failure to limit 
the production of raw opium and coca leaves to 
legitimate requirements, a step contemplated by the 
League of Nations and demanded by the United 
States delegation. That more ‘remained to be 
done was shown by the Secretariat of the League 
when it reported that between 1925-29 more than 
100 tons of habit-forming drugs derived from morphine 
passed into illicit traffic. The disclosures in the 
“ Naarden case,” where a licensed Dutch factory 
was found to have exported over 2000 kg. of heroin 
and 860 kg. of morphine to the Far East in a little 
more than one year shocked a good many complacent 
people, as did also the revelation by Russell Pasha 
of the havoc wrought in Egypt by uncontrolled 
drug factories in Istambul. There followed in 
1931 the conference and convention on the limitation 


of manufacture and distribution of narcotic drugs 


which did not, however, extend to the production 
of raw opium, coca leaves, prepared opium, or Indian 
hemp. The attempt to establish a quota system 
for allocating to each nation a proportion of the 
world requirements of the drugs in question having 
been abandoned, the supervisory body, set up by 
the 1931 Convention, has achieved considerable 
success in securing both national and international 
control of the traffic in narcotic drugs. Much 
remains to be done, notably in the restriction of 
production of raw opium and coca leaves, but the 
author is justified in ending his. lucid account of the 
anti-drug campaign with the conclusion that from 
the tangle of mixed motives which divide the erratic 
course of governmental policy a constructive purpose 
has emerged and seems destined to prevail. 


A Short Ante- and Post-Natal Handbook 


By R. Ketson Forp, M.D., M.M.S.A., St. Olave’s 
Hospital, Rotherhithe. London: Humphrey Mil- 
ford, Oxford University Press. 1935. Pp.141. 6s. 


_ OUR medical schools and hospitals have something 
to learn, especially on antenatal supervision, from the 
clinics and hospitals under local health authorities. 
The public antenatal clinics are primarily a system 
of constructive hygiene, whereas those of the teaching ` 
and voluntary hospitals or departments remain too 
exclusively a means of picking out doubtful or 
abnormal cases for special observation and manage- 
ment. Hence we look for greater prominence of 
the hygienic, social, and educational aspects in a 
manual by one in the service of a local authority 
than in similar books from the teaching schools. 
Dr. Kelson Ford’s introductory chapter is excellent 
in that these aspects are placed in the foreground of 
the picture. The reason for antenatal. supervision 
is much more than the detection of pelvic deformity 
and albuminuria. Stress is laid on the necessity for 
the careful study of the individual patient, her - 
instruction in hygiene for herself and the infant after 
birth ; the advice to the doctor to make an effort 
to assess the attitude of mind in which pregnancy 


-is regarded is much needed. Although Dr. Ford has 


laid down the principles clearly and concisely, 
he has not been successful in weaving them into the 


-texture of practice with the same clarity and emphasis. 
The ‘‘ Author’s Note,” 


which occupies the place and 
office of a preface, does not say more of the object 
he had in mind than that “no attempt has been 
made at. being exhaustive, a helpful suggestiveness 
This aim has undoubtedly been 
fulfilled, for he has produced a useful and stimulating 


552 THE LANCET] 


guide to ante- and post-natal care that will appeal 
to a large class of family practitioners, from whom 
much is now expected in the way of such service. 

Our chief regret is that Dr. Ford has thought fit 
“ to collect information not always readily accessible ” 
into a small handbook, which is not the place for 
out of the way information. The outstanding instance 
is an encyclopedic classification of monstrosities and 
malformations, happily relegated to the appendix, 
where it takes up more space than any of the other 
and more suitable matters considered therein. 
Although he apologises for including much that is 
elementary, these portions modified in the light 
of personal experience form the most valuable charac- 
teristic of his book, and would best bear expansion. 
Further detail in such matters as physical exercises 
for pregnant and lying-in women or in the technique 
of assessing the patient’s mental reaction to preg- 
nancy would have been a welcome addition and most 
helpful. We trust, also, that other authors in the 
service of public authorities will not feel constrained 
to include such a disclaimer as “ the London County 
Council is in no way responsible for any opinion or 
matter presented.” It is a terrifying suggestion that 
city fathers and county councillors might assume 
some form of censorship over medical thought and 
practice, even if only among those in their own 
service. 


Urology in Women 


Second edition. By E. CATHERINE LEWIS, 
M.S. Lond., F.R.C.S. Eng., Surgeon to the Royal 
Free Hospital; Surgeon and Urologist to the 
South London Hospital for Women. London: 
Bailliére, Tindall and Cox. 1936. Pp. 100. 6s. 


MINOR urinary troubles in women are particularly 
liable to be missed or to receive inadequate treat- 
ment. This is specially true of lesions of the urethra 
and bladder, organs that lie on the boundary of 
gynecological practice and in which the gynzco- 
logist as a rule is not keenly interested. Minor 
lesions of the urethra are often missed, and the 
examination of this structure even by the urologist 
himself is often perfunctory. It was therefore the 
sections in the previous edition of this book which 
dealt with such conditions as urethral prolapse, 
urethritis, stricture, displacements of the bladder, and 
vesical neck obstruction that proved especially 
valuable. In this edition sections on nephroptosis 
and on changes in the ureters during menstruation 
and pregnancy have been added. 

The book should be studied not only by practi- 
tioners, but also by gynecologists and urologists. 


Glandular Physiology and Therapy 


A Symposium prepared under the auspices of the 
Council on Pharmacy and Chemistry of the 
American Medical Association. Chicago : American 
Medical Association. 1935. Pp. 528. $2.50. 


Durine 1935 a series of excellent articles on 
glandular physiology and therapy appeared in the 
Journal of the American Medical Association, prepared 
under the auspices of the council on pharmacy and 
chemistry of that Association. These articles have 
now been collected together to form a symposium 
of a comprehensive nature. The last publication 
of the kind appeared originally in 1925 and in revised 
form appeared two years later. Since then, however, 
remarkable advances have taken place in endocrino- 
logy. Each chapter is an authoritative discussion 


THE RED CROSS AS SANCTUARY 


[MARCH 7, 1936 


by a well-recognised worker.. Thus, Evans writes 
upon the clinical manifestations of dysfunctions of the 
anterior pituitary and the growth hormone; Collip 
deals with the inter-relationship among urinary, 
pituitary, and placental gonadotropic factors; Allen 
discusses menstruation and the physiology of cestro- 
genic principles ; and Marine writes on goitre ; other 
chapters are supplied by Best, Joslin, Aub, Aschheim, 
Fishbein, Novak, and Zondek. 

. Clinicians and physiologists alike will appreciate 
this symposium. : 


ee + ee ee 


THE RED CROSS AS SANCTUARY 


A MEMORANDUM on observance of the Red Cross 
in warfare has been prepared for presentation to the 
Italian Ambassador by members of the medical 
profession. Its terms are as follows :— 


We, who sign this memorandum as members of the 
medical profession, wish in this way to express our profound 
uneasiness at the news of certain incidents that have 
occurred in the course of the present war between Italy 
and Abyssinia. It is reported that on six occasions units 
clearly displaying the Red Cross have been bombed 
from the air by the Italian forces; and it seems to be 
established that on some of these occasions, at least, 
the action was premeditated. 

The members of our profession have never assumed 
or claimed that they, any more than other citizens, should 
be held immune from the risks of war. The character 
of their work calls for men and women of normal courage ; 
and the casualties among doctors attached to fighting 
units during the European War are themselves proof that 
this protest is no mere personal one. Our sense of 
indignation lies far deeper. In wartime, the wounded 
and those who attend them have for long past been 
considered as in a sanctuary when beneath the Red Cross. 
Amongst civilised peoples the Red Cross has been looked 
upon as an assurance that, above the shifting tides of 
national strife, commercial rivalry and war, there still 
lives the true bond of common humanity. If this per- 
manent bond, symbolised by the respect customarily paid 
to the Red Cross, is also to be destroyed, then mankind 
takes a further step backwards towards the chaos of 
barbarism, 

The fact that our profession usually does its work 
unostentatiously makes it all the more becoming that 
we should from time to time express ourselves most 
emphatically on a matter that so gravely touches our 
professional conscience. It is necessary that all who 
follow the. vocation of medicine should insist that the 
symbol of the Red Cross in war be held absolutely 
sacrosanct. 


In order that the protest may be as effective as 
possible, all those who wish to associate themselves 
with it are requested to communicate as soon as 
possible with Dr. T. O. Garland, 23, South Hill 
Park-gardens, London, N.W.3, so that their names 
may be added to the list of supporters. 

The preliminary list of supporters, we are informed, 
includes :— 


Rt. Hon. Christopher Dr. H. Joules. 


Addison, P.C. Dr. Peter Kerley. 
Dr. G. F. Barhan. Dr. John D. Kershaw. 
Dr. F. G. Bushnell. Dr. W. Howlett Kelleher. 
Dr. D. Elizabeth Bunbury. Dr. R. D. Lawrence, 
Dr. William Barr. Dr. R. A. Lyster. 
Dr. E. Vipont Brown, Mr. C. Lambrinudi. 


Dr. H. Crichton Miller. Mr. Philip H. Mitchiner. 
Prof. Millais Culpin. Prof. J. R. Marrack, 


Dr. W. R. Dunstan. Dr. S. V. Pearson. 
Mr. P. G. Doyne. Dr. Alfred Salter. 
Prof. W. M. Frazer. Dr. D. R. Saggar. 


Dr. David Forsyth. 
Prof. Major Greenwood. 
Dr. Helen Gillespie. 

Mr. Somerville Hastings. 
Dr. P. D’Arcy Hart. 

Mr. Cecil Joll. 


Dr. M. W. Walmsley. 
Prof. E. J. Wayne. 
Dr. Robert F. Collis. 
Dr, Stella Churchill, 
Dr. Doris Odlum, 


THE LANCET] 


MESCALINE IN PSYCHIATRIC RESEARCH 


[marcu 7, 1936 553 


_. ‘THE LANCET 


LONDON : SATURDAY, MARCH 7, 1936 


MESCALINE IN PSYCHIATRIC RESEARCH 


THE field for controlled experimental research 
in psychiatry is still so small that it demands 
intensive cultivation. One of the few methods 
available is a pharmacological one—i.e., the use 
of intoxicating drugs. The psychosis thus pro- 
duced can be studied with a much closer regard to 
experimental requirements than is possible with 
the mental disorders in general, dependent as 
they are on a variety of causes which the investi- 
gator can seldom influence in any predictable 
direction. Foremost, though not unique, among 
the intoxicants that may be used for research 
along such lines is mescaline. Now available as 
a synthetic drug, its ritual use on the American 
continent stretches back to the time before the 
Spanish Conquest. Fascinating as are the ethno- 
logical associations of the mescal plant, it is as a 
source of beatific visions that it has become gener- 
ally and somewhat romantically known.in Western 
Europe. The visions consist of fantastic forms 
and colours constantly changing but always 
bright. Dr. MACDONALD CrITcHLEY, who made 
some subjective experiments in 1930, described 1— 
“a meadow with buttercups and daisies; now it is 
changing into a stereotyped park, with a bandstand 
and with chairs, each one of which is whizzing rapidly 
round on its own axis. Butterflies are coming in 
from all sides; the bandstand has disappeared. The 
butterflies all collect into the centre and arrange 
themselves into a circular, brightly coloured flower- 
bed, rotating rapidly in a clockwise direction, in a 
most wonderful manner . . . now a huge field of 
primroses . . . a complicated pattern like Hampton 
Court maze, brightly coloured with objects moving 
quickly in a snake-like, sinuous fashion along the 
apparently endless pathways of the maze.” 


All who have enjoyed the contemplation of just 
such sights and sequences in a Sily Symphony 
will appreciate what a state of rapture they may 
induce. The range of the abnormal phenomena to 
which mescaline gives rise is, however, wider and 
more important from the investigator’s point of 
view than the visual disturbances alone. The inde- 
pendent phenomena in other sensory territories, the 
synæsthesiæ, the alteration in bodily feeling, the 
disorder experienced in space and time-judgments, 
the effects on mood and thought, the deper- 
sonalisation and the power of detached observation 
of oneself are among varied manifestations which 
have been closely studied by psychiatrists. WEIR 
MITCHELL and HAvELtock ELLIS drew attention 
to them in the last century ; since the war some 
workers at Heidelberg, Rovnrer in France and 
others have examined the matter thoroughly. 


1 See THE LANCET, 1930, ii., 863. 


At the meeting of the’ Royal Medico-Psycho- 
logical Association on Feb. 26th Dr. Erica Gurt- 
MANN described investigations to which .he had 
contributed before he came to England, and gave 
an account of the further mescaline research 
which he and others are carrying out at the Maud- 
sley Hospital. By means of the Rohrschach test, 
administered to the same persons before and after 
intoxication, he had observed the changes in 
those responses which are regarded as indicative . 
of the psychological type and personality of the 
subject. By this means the contribution of 
the individual to the psychosis—a question of 
the first importance for psychopathology—can be 
studied, as well as the effect of specific noxael on 
psychic structure; the rôle of perception in the 
total personality also enters into the field of 
experiment. On the same subjects (normal volun- 
teers) Dr. W. H. Husert and Dr. AUBREY LEwis 
studied by a special optical technique the changes 
in Gestalt-formation produced by the drug ; striking 
variations were found, again bearing on the 
importance of the perceptual side of personality. 
Comparative investigations, using the same tech- 
nique, but without mescaline, on schizophrenic 
patients and others with depersonalisation were 
made, and provide an instance of the valuable 
approach which mescaline affords to the study of 
mental illness, especially where, as in schizophrenia, 
the investigator cannot otherwise than by mescaline 
himself gain any subjective experience of the 
incommunicable phenomena. Dr. GUTTMANN has, 
moreover, iù conjunction with Dr. W. S. Mactay, 
attempted to make therapeutic use of the drug. 
The known effects on sensory function led them 
to expect that the symptom of depersonalisation 
with feeling of unreality might be so modified or 
abolished temporarily by small doses of mescaline 
that the patient would be more accessible, after 
this relief, to psychotherapy. The results, so far 
as feelings of external reality were concerned, 
conformed to expectation (though not in all cases) 
and the change extended beyond the period of 
intoxication. Incidentally Dr. GuTTMANN and 
Dr. Macuay hold that to give mescaline continu- 
ously to any patient would not be justifiable while 
we know so little about the dangers of chronic 
mescaline intoxication. 


The information available about the oxidative 
and enzymic activities of the brain during mescaline 
intoxication has so far indicated only a common 
mode of action of narcotics and throws no light 
on the specific effects of the drug. Dr. P. K. 
McCowan stressed the importance of further 
research into these activities. Dr. GUTTMANN 
referred to the physical changes which appear during 
intoxication and to their metabolic significance. 
It is noteworthy that in 1932 an observer reported 
that in hashish intoxication the output of salt 
and water is increased, without any concomitant 
hydremia; it is not known whether any corre- 
sponding change is associated with mescaline. It 
is an attractive speculation that there may be 
links between mescaline and some of the end- 
products of protein metabolism—e.g., tyrosine— 


554 THE LANCET] 


to which it is chemically allied; an attempt to 
discover whether some perversions of normal 
metabolism result in the production of a toxic 
substance closely akin to mescaline pharmaco- 
logically as well as chemically might be fruitful. 
Admittedly no substance closely related chemically 
to mescaline has as yet been found capable of 
giving rise to its remarkable effects; whether 
further research be metabolic or psychological, 
the value of a pharmacological approach to the 
_ problems of psychiatry can hardly be doubted. 


HEAT REGULATION AND FEVER 


In his Arris and Gale lectures just delivered 
before the Royal College of Surgeons of England 
Dr. JOHN BEATTIE reviewed various aspects of 
the heat-regulating mechanism of the body, and 
expressed his belief that this mechanism is much 
more complicated than has hitherto been realised. 
The notion that heat regulation is dominated 
completely by a single centre is in his opinion 
misleading, and he was able to show that sections 
at different levels of the central nervous system 
produce widely different effects. The argument in 
favour of a single centre has been founded largely 
on experimental demonstration that section of 
the cervical cord completely abolishes the heat- 
regulating mechanism so that the animals become 
poikilothermic. To support this conception there 
is also the older evidence from heat piqûre, and 
the more recent observations that local heating 
of the hypothalamus is followed by lowering 
of the body temperature, and local cooling by a 
rise in the body temperature. To the contrary, 
however, we have abundant clinical evidence, 
beginning with a case recorded by BRroDIE in 
1837, that in man complete destruction of the 
cervical cord is not always followed by a loss 
of heat regulation and that even fever has 
been observed in such patients. A few isolated 
observations on animals are also on record such 
as those of GoLTZ and Ewatp in 1896, and the 
more recent ones of Pororr,! where heat regulation 
was maintained after removal of the spinal cord 
from the cervical region downward with subse- 
quent cutting of the vagus and sympathetic in the 
neck. In order to determine the reason for this 
contradiction, THAUER,? working in BETHE’s labora- 
tory, has lately carried out an extensive experi- 
mental reinvestigation of the effects of section of 
the cervical cord on a large number of rabbits, 
guinea-pigs, and rats. Suspecting that the dis- 
crepancies might be due to immediate shock effects 
masking the true results of the operation, he 
endeavoured to improve the operative technique 
and post-operative treatment. By keeping the 
animals immediately after the operation in a 
thermostat at 28°-30° C. and by careful attention 
to their feeding, he succeeded in keeping a number 
of animals alive for several weeks, and three rabbits 
for two months after the operation. In all these 
animals the heat-regulating mechanism was almost 
completely restored, although during the first few 


1 Popoff, N. F.: Arch. f. d. ges. Physiol., 1934, cexxxiv., 137. 
* Thauer, R.: Ibid., 1935, cexxxvi., 102 


HEAT REGULATION AND FEVER 


[mance 7, 1936 


days after the operation it was severely impaired. 
When once the heat regulation had been restored 
subsequent cutting of the cervical sympathetic and 
of the vagi, and even subsequent partial removal 
of the thoracic spinal cord, failed to impair it. 
THAUER’S results agree, therefore, with those of 
Pororr in showing that in warm-blooded animals 
after complete exclusion of the central nervous 
system the heat regulation of the body can be 
efficiently maintained by a peripheral mechanism. 
The nature of this peripheral mechanism has been 
indicated by the work of CRAMER, who showed in 
his well-known monograph ® that in addition to 
the nervous mechanism for heat regulation there 
is a humoral mechanism with which the thyroid 
and adrenal glands are particularly concerned. 
Since most of the factors concerned in heat regula- 
tion are controlled by the sympathetic nervous 
system, they can be brought into play either by 
nervous or by humoral stimulation. Thus fever 
can be produced experimentally by functional 
hyperactivity of the thyroid or adrenal glands, 
and THAUER has shown that his animals deprived. 
of their central nervous control still respond to 
infections or to the injection of pyrogenic substances 
by fever. 


The experiments of Poporr and of THAUER 
must, of course, not be interpreted as denying the 
existence of a nervous mechanism for heat regula- 
tion or of a central codrdination of such a 
mechanism. Such a conclusion would be as crude 
and as misleading as the reverse one that the 
thyroid or adrenal glands have no part in the 
processes of heat regulation because these processes 
can still be efficiently maintained after removal of 
one or other of these organs. We are being led 
to a belief that there are two mechanisms for heat 
regulation, one central and the other peripheral, 
a conception in keeping with modern physiological 
trends in other bodily functions. In the control of 
water metabolism, the control of equilibrium, and 
in sensory discrimination there are parallels for 
the overlaying of a crude peripheral type of regu- 
lation by a more delicate centralised one. On 
our present knowledge of heat regulation it 
must be supposed that the intracranial appa- 
ratus is not essential to an adequate working, 
but rather by allowing an interplay between the 
different peripheral factors serves to increase 
their efficiency, especially under pathological 
conditions. 

The conception of a single centre dominating heat 
regulation has tended to sterilise progress, and a 
study of Laxr1n’s Lettsomian lectures * reveals how 
scarce investigations on the phenomenon of fever 
—one of the most frequent and important clinical 
symptoms—are in the recent physiological, patho- 
logical, and clinical literature. It is easy to under- 
stand why this should be so. On the unitary 
conception fever is explained as being due to some 
action on the heat-regulating centre in the brain 


= which is likened to a thermostat, and in fever is 


3 Cramer, W.: Fover, Heat Poeuiniion; Climate, and the 
Thyroid- -Adrenal Apparatus, London, 1928. 

‘Lakin, ©. E.: Disb bances of the Body Temperature, 
THE LANCET, 1934, ii., 467. 


EEE EEE'S'SZS~=~ “== a. 


THE LANCET] 


supposed to be “set” at a higher temperature. 
But from what has been said above, and from 
what Dr. BEATTIE said in his lectures, it is clear 
that if there is a heat-sensitive zone in the brain 
there must also be other thermo-regulators outside 
it—represented perhaps by the sympathetic ganglia. 
Formerly it was assumed that the fever of infectious 
diseases is due to the action of bacterial toxins on 
cerebral centres; but it has now been shown 
that many bacterial toxins circulating in the 
blood cannot pass the blood-brain barrier,5 which 
is additional evidence that their effects must be 
on the periphery. Moreover, it is now known that 
some pathological conditions of the thyroid or 
adrenal glands are associated with a pyrexia 
indistinguishable from that of an acute infection, 
for which in the past they have been frequently 
mistaken. This recent work on the decentralisation 
of sympathetic functions may well open up new 
fields for clinical applications in the pathogenesis 
and treatment of infectious diseases and of other 
pyrexial conditions whose origin is at present only 
surmised. 


ACUTE NICOTINE POISONING 


Last week Dr. L. P. LockHart drew attention 
in our columns to a case in which a father, in 
order to make his 14-year-old boy give up smoking, 
adopted the heroic measure of forcing him to eat 
a cigarette. Curiously enough, “the father’s 
_action appears to have received the approval of 
the court,” and Dr. Locxwart rightly raised a 
protest. It is salutary to remember that poisoning 
by small doses of concentrated nicotine is usually 
rapidly fatal, and that present-day remedies are 
often of no avail. Admittedly recorded fatal cases 
are few, but as Esser and Kuan ° point out their 
incidence has increased recently. In many of 
them nicotine is taken with suicidal intent, but 
paisoning has also occurred in factories where 
concentrated nicotine is. handled and in tobacco 
factories. Non-fatal poisoning is seen among 
‘cigar and cigarette makers who inhale tobacco 
dust and among workers who bandle concentrated 
nicotine and may have their skin splashed with it. 
The main symptoms are ocular troubles, such as 
partial blindness with limitation of the fields of 
colour vision, functional heart disease, and nervous 
disorders. ALICE HAMILTON’? says that new 
workers in factories often suffer from the same 
disorders as the inexperienced smoker—headache, 
palpitation of the heart, rapid irregular pulse, 
nausea, and vomiting. She regards the evidence 
for the existence of chronic nicotine poisoning as 
scanty because sooner or later an immunity to 
the drug is established. However this may be, 
it is certain that more cases of acute nicotine poison- 
ing are occurring at the present time, and it is 
therefore important that an adequate ‘method of 
treating it should be found. 


ae V., and Elkeles, A.: THE LANCET, 1934, 


i., 

* Esser, A., and Kuhn, A.: Deut. Zeits. f. d. ges. gerichtl. 
Med., 1933, xxi., 305. 

1 Hamilt ton, ies. New York, 
1934, p. 246. 


Industrial Toxicology, 


ACUTE NICOTINE POISONING - 


[marcy 7, 1936 555 


FRANKE and THomas,® who have just reviewed 
the subject, say that apart from the usual pro- 
cedures for removing any unabsorbed poison and 
the administration of stimulants, they have been 
unable to find any description of a rational treat- 
ment for nicotine poisoning. The condition is 
usually considered to be hopeless: “this pessi- 
mistic attitude is apparently due to the belief 
that the drug causes generalized paralysis of the 
central nervous system, based on the fact that 
complete muscular paralysis, loss of reflexes and 
paralysis of respiration (and finally of circulation) 
follow its absorption in sufficiently large doses.” 
Their own experiments on dogs, however, lead them 
to think that death from nicotine poisoning is caused 
by peripheral, rather than central, paralysis of the 
respiratory muscles. Further, they show that 
nicotine does no evident irreparable damage to 
any of the structures on which it acts, and that 
the administration of very large doses is not incom- 
patible with reasonably prompt and apparently 
complete recovery when appropriate treatment is 
started in time. FRANKE and THOMAS come,to 
the important conclusion that nicotine poisoning 
should be regarded as a temporary respiratory 
emergency comparable with drowning or electric 
shock, and should be treated in the same way 
as these two conditions, especially by artificial 
respiration. ‘They tried various means of treat- 
ment and resuscitation on 52 dogs poisoned with 
nicotine and found that if artificial respiration 
was applied before the circulation had failed, 
and maintained until the muscular paralysis had 
disappeared, each animal made a complete re- 
covery. When treatment was started after failure 
of the circulation, artificial respiration by itself 
was usually not sufficient ; but that if the animals 
were given in addition intracardiac injections of 
epinephrine (adrenaline) and indirect cardiac mas- 
sage about half of them recovered. The important 
thing about these experiments is that they demon- 
strate that the circulatory failure which follows 
fatal doses of nicotine in dogs is not necessarily 
permanent, but that if the heart can be restarted 
and artificial respiration mene? prompt 
recovery is usual. 


If FRANKE and THomas’s onelan are valid 
and can be applied to man they should lead to 
an increase in the proportion of recoveries from 
acute nicotine poisoning ; for these authors have 
been able to find only 3 recorded in which artificial 
respiration has been used in its treatment. MOORE 
and Rowse ° in 1897 pointed out that the observed 
effects of nicotine could all be as readily ascribed 
to a curare-like action of the drug as to a central 
paralysis; and GoLD and Brown ’® have recently 
presented strong evidence that in animals it causes 
a peripheral rather than a central paralysis of 
respiration. It appears therefore that artificial 
respiration is the basis of a rational treatment for 
acute nicotine poisoning. 


* Franke, F. E., and Thomas, J. E.: Jour. Amer. Med. 
Assoc., Feb. 15th, "1936, p. 507. 
„° Moore and Rowe: I of Physiol., 1897, xxii., 273. 
° Gold, H., and Brown, F.: Jour. Pharmacol. and Exper. 
Thero a 1935, liv., 143. 


556 THE LANCET] 


PENAL CASES IN CAMERA BEFORE THE 
G.M.C. 


THE prolonged hearings in camera recently of 
penal cases coming under the consideration of 
the General Medical Council may have been taken 
as evidence of a tendency on the part of the Council 
- to conduct more of such proceedings without a 
public audience. But as a matter of fact the 
situation is not so, and the circumstances at the 
last session of the Council were quite fortuitous. 
It is inadvisable, however, that an impression 
should remain that the G.M.C. is embarking upon 
a new policy of secrecy. 

The penal jurisdiction of the Council rests sub- 
stantially on these three words in the Medical 
Acts—“ after due inquiry.” The Acts provide 
that, in cases other than those based on convic- 
tions of felony or misdemeanour, the Council, if 
it finds “after due inquiry ” that the practitioner 
has been guilty of infamous conduct in a profes- 
sional respect, may direct the Registrar to erase 
the practitioner’s name from the Register. We 
need not now refer to the unfortunate phraseology 
which has led to frequent protest. The word 
infamous has a technical legal meaning explained 
by the judges as disgraceful or dishonourable in 
a qualified professional man acting as such; but 
the scope of the words “after due inquiry ” has 
never been exactly defined. When an action of 
the Council has been the subject of legal inquiry 
the Law Courts have taken the view that the Council 
can be trusted to manage its own business properly 
and competently, and they will not interfere 
unless the complainant can show a substantial 
impropriety of procedure. The Council’s procedure 
is governed by its standing orders, which 
probably lack the statutory force comparable with 
the by-laws of some other semi-public bodies. But 
the orders give the Council wide powers of discre- 
tion in deciding which, if any, parts of the case shall 
be heard in camera. The Council is obliged only 
to open the case, that is to have the charge read, 
and to give the judgment in public, and variation 
from procedure in courts of law is conspicuous. 
All courts are open to the public unless in the 
opinion of the judge it would be clearly impossible 
to do justice at a public hearing, and the judge’s 
discretion here is limited. The class of cases in 
which courts have restricted publicity are those 
in which the subject matter of the action has 
been some secret process ; those where a witness 
must give evidence of such a distressing kind that 
he would not bring his complaint at all if he knew 
that the hearing would be public; and thirdly, 
where disorder is held reasonably certain to break 
out in court during the hearing. The General 
Medical Council is only concerned with cases of 
the second class, and has interpreted its discretion 
widely. The criterion applied by the Council it 
would seem is not whether justice can be done at 

all in public but whether it can be better done in 
private, while taking note of the fact that in the 
interests of decency some cases had better be heard 
in camera. Anyone who has followed the penal 
procedure of the Council at all closely will know 


PENAL CASES IN CAMERA BEFORE THE G.M.C. 


[maRcH 7, 1936 


how few are the cases that fall under the latter 
heading ; and it must be remembered that medical 
men summoned to appear before the Council 
may be willing, and naturally would be when 
innocent, to have the procedure a perfectly public 
one, the decision to hold the inquiry in camera 
being that of the Council. 

When public attention is arrested by penal 
cases before the G.M.C., there is a natural surprise 
that the verdict of the Council, though it may 
deprive a professional man of his livelihood, is 
subject to no appeal. The victim’s friends, think- 
ing him innocent, attack the doctor’s profession 
for an act of injustice which is final. This absence 
of appeal is due not to the caprice of the profes- 
sion but to the will of Parliament as declared in 
the Medical Acts. From disciplinary decisions in 
other professions—dentists and solicitors, veteri- 
nary surgeons and architects—there is in each 
case an appeal to the High Court under the corre- 
sponding statute. The Medical Acts alone make 
no such provision. Consequently, as Lord Justice 
BoweEn observed, when “due inquiry ” has been 
made by the G.M.C., “the jurisdiction of the 
domestic tribunal, which has been clothed by the 
Legislature with the duty of discipline in respect 
of a great profession, must be left untouched by 
courts of law.” But the courts of law will inter- 
vene fast enough if the tribunal displays bias or 
transgresses the rules of what is rather vaguely 
called “natural justice ”? in its inquiry. In that 
event, it is safe to predict, amendment of the 
Medical Acts will follow. 


ON Tuesday, March 24th, at 5 P.M., Sir Thomas 
Barlow will take the chair at the hundredth annual 
general meeting of the Royal-Medical Benevolent 
Fund, which is being held at 11, Chandos-street, 
London, W.1. 


THE appointment of Mr. Wilfred Trotter, F.R.S., 
to a chair of surgery in the University of London, 
tenable at University College Hospital medical school, 
is recorded in another page. No academic honour 
could enhance the reputation of one who has long 
been recognised not only as a master of his craft 
but as a scholar whose ripe philosophy pervades all 
his N But by consenting to sacrifice the 
leisure gained through retirement from private 
practice he confers additional distinction on the 
institution which he has already served for many years. 


Mr. GEORGE VERITY, who died at his home at 
Chesham Bois on Feb. 28th, was a truly practical 
friend to the cause of medicine. He was for close 
upon thirty years chairman of the governors of 
Charing Cross Hospital, and everyone concerned with 
the welfare and organisation of the great London 
hospitals knew of the work which he did at Charing 
Cross and admired the foresight and energy displayed. 
Ile accepted the responsibilities of chairmanship at a 
critical period in the history of the hospital which 
was suffering perhaps more acutely than any other 
of the metropolitan institutions from financial 
depression. The fine position in public and scientific 
esteem in which the hospital is now held was greatly 
due to Verity, for whom, in his labours, no ideal 
was too large to aim at and no detail was too small 
for attention. He has left a great name in the 
hospital world. 


THE LANCET] 


[marcu 7,1936 557. 


ANNOTATIONS 


WEIGHT-LOSS AND POST-OPERATIVE 
MORTALITY IN GASTRIC SURGERY 


POST-OPERATIVE pulmonary complications are 
notoriously more common after upper abdominal 
operations than after most other major surgical 
procedures, and the factors that determine them are 
still imperfectly understood. Among those factors 
is undoubtedly the patient’s ‘‘ resistance,” both to 
infection in general and to operative shock—an 
imponderable factor, one would have said, a measure 
of which would be of great value were it feasible. 
H. O. Studley,! of Cleveland, has just suggested that 
it may be in some degree ponderable after all, and 
that literally. He took a series of 46 consecutive 
patients operated on for gastric and duodenal ulcer, 
excluding urgent laparotomies for perforation and 
acute hemorrhage. There were 7 post-operative 
deaths (15 per cent.) These seemed to bear no 
relation to age, pre-existing cardiac or pulmonary 
disease, the position of the ulcer, the presence of 
pyloric stenosis, or the nature and technique of the 
operation. When he calculated, however, the amount 
of weight that the patients had lost before they came 
to operation, he found that 6 of the 7 deaths occurred 
among those who were 20 per cent. or more below 
their normal or highest known weight. This group 
contained 18 patients, with weight-losses ranging from 
21 per cent. to 43 per cent. Five out of the 6 who 
died developed pulmonary infections, which may be 
supposed to have been the chief cause of death, 
although in 2 of them the wound ruptured as well. 
The sixth apparently died from wound rupture alone. 
In the other group of patients, numbering 28, who 
had lost only 3-19 per cent. of their maximal weight, 
5 examples of pulmonary infection occurred but 
were not fatal, while the only death that did occur 
was due to ileus of mechanical origin. 

On such scanty evidence the author’s thesis cannot 
be accepted as a sound conclusion, but as a tentative 
suggestion it is worth considering. Thyroid surgeons 
have come to think that a rising weight in a patient 
with thyrotoxicosis augurs well for a smooth passage 
in thyroidectomy, and it may well be that slow 
changes in body-weight, not produced by disturbances 
in water balance, are a useful indication of the body’s 
general metabolic well-being and of its “ resistance.” 
More observations are easily made, and are worth 
making. But if the thesis should come to be sustained, 
it is not necessarily to be used as an argument against 
what Studley calls “the policy of delay in advising 
surgical treatment of chronic peptic ulcer, . . . now 
generally followed.” It rather points to the need 
for such pre-operative preparation of the patient as 
will restore some of his lost weight and strengthen 
his resistance ; except in cases of obstruction, rest 
in bed and suitable feeding—in some cases perhaps 
duodenal or jejunal tube-feeding—will often achieve 
this end, and in the obstructed cases the same thing 
can be done by means of a preliminary jejunostomy 
made under local anesthesia. 


MEDICAL OPUSCULES 


: THE reading supplied in this interesting volume of 
‘“* Opuscula Selecta >° (issued by the Nederlandsch 
Tijdschrift voor Geneeskunde, Amsterdam) is of a 
varied sort. It is made up of letters interchanged 
between distinguished doctors of different nationalities 


3 Jour. Amer. Med. Assoc., Feb. 8th, 1936, p. 458. 


and sometimes between them and their patients, 
dealing with surgical and. medical incidents that may 
be considered to have formed sign-posts in science. 
The dates range over the sixteenth, seventeenth, and 
eighteenth centuries. Dr. M. A. Van Andel points 
out in an interesting editorial preface that only by 
such letters could diffusion of medical information 
take place at a time when very few scientific books 
were printed and those only at great expense, while 
during ‘the infancy of printing the suggestion of 
journalistic production could not have occurred to 
any mind. Undoubtedly the savants of this grand 
period in scientific activity exchanged many valuable 
contributions to knowledge in this manner, and the 
doctors as well as other leaders of thought were 
great letter-writers, their patients often: being 
described in the most particular terms. It may be 
noted, here, that Guido Patin avers that there is 
a8 much difference. between a doctor’s dependence 
upon information from a distance about the condition 
of a patient as between Alexander the Great con- 
ducting a campaign personally and a king making 
war through his generals—the difference between 
conjecture and discovery. The letters throughout 
abound in theoretic commentaries which to some 
extent take the place of the clinical conferences of 
to-day. The authors include, among others, Vesalius, 
Van Beverwijck, Descartes, Boerhaave, Petrus 
Camper, and three communications from certain later 
surgeons are added, among them notes from Diderik 
Ort and Johan Ramaer to Prof. Tilanus describing 
cases of gastrotomy. The book is illustrated with 
pictures of many of these old masters, which are 
accompanied by biographical notes carefully dated. 
There is, alas, no index, thus adding to the difficulty 
of the reader, who will find the languages employed 
by the writers not necessarily familiar though 
the letters are furnished sometimes with Latin 
translations. 


NARCOSIS IN ANIMALS AND MAN 


THE danger of applying to human beings con- 
clusions drawn solely from experiences with animals 
was one of the morals drawn by Prof. J. G. Wright 
when he spoke on the use of non-volatile narcotics 
at the Royal Society of Medicine last week. His 
paper, read before the section of comparative 
medicine on Feb. 26th, showed what great advances 
the practice of anesthetics has made of recent years 
in veterinary surgery. Even for minor operations 
anesthesia is now usual, and is generally obtained by 
the combination of narcosis and local anesthetics. 
Slow intravenous injection of Nembutal is a highly 
satisfactory means of getting narcosis in both dogs 
and cats. For the horse the enormous amounts 
required, grs. 200 for example, render this drug 
impracticable economically. All animals have a 
natural fear of restraint, which at once puts them 
into a different category from the average normal 
human subject. Fear and struggling greatly increase 
the risks associated with inhalation anzsthesia, and 
it is in abolishing these that the intravenous use of 
narcotics has so well proved its value in animal 
surgery. The excitement sometimes witnessed in 
narcosis was, Prof. Wright said, hard to explain. 
It shed some light, another speaker suggested, on the 
psychological causes attributed to the excitement 
often witnessed in human patients of certain type 
after consciousness had been abolished and when it 


“was supposed that the ‘subconscious’? mind had 


558 THE LANCET] 


assumed uncontrolled sway. Avertin, Prof. Wright 
believes, is not nearly so satisfactory in veterinary 
as it is in human surgery. Dr. D. H. Belfrage, who 
gave a capital summary of the use of the non-volatile 
narcotics by anesthetists practising among mankind, 
expressed a preference, on the whole, for avertin, 
but approved highly of nembutal for young children. 
Mr. Basil Hughes thought that by a combination of 
avertin and local anesthetics he achieved results: in 
abdominal surgery even better, so far as the post- 
operative state was concerned, than those claimed by 
Finsterer for splanchnic analgesia. Mr. Hughes 
related cases showing the possible danger of Evipan, 
and claimed good results for the use per rectum of a 
mixture of magnesium sulphate, paraldehyde, ether, 
and gum acacia. Sir Frederick Hobday, while 
admitting the excellent work made possible by newer 
methods, thought that chloroform properly given 
still held a big place in veterinary surgery. 


FUNCTIONS OF THE PINEAL 


A CURIOUSLY indecisive controversy has raged for 
centuries over the functions of the pineal gland. 
Indeed, it might well be claimed that there is 
as much experimental evidence for the view of 
Descartes, who considered the pineal the seat of the 
soul, as for that of more modern writers who connect 
the pineal directly with virility. It has been shown 
that the organ is not essential to life; the curious 
syndrome of precocious puberty and somatic over- 
growth which has been described in young boys 
suffering from tumour of the pineal has been variously 
attributed to hyper- and hypo-function of the gland, 
while Harvey Cushing has attributed these phenomena 
to secondary effects upon the pituitary. Experi- 
mental extirpation of the pineal gland in animals 
has led to consistently negative results according to 
certain workers, and to the appearance of macro- 
genitosomia and obesity in the experience of others. 
The results of feeding the organ to young animals 
have been equally confusing. The evidence is in fact 
conflicting even as to whether the gland has any 
endocrine function at all. Rowntree and his col- 
laborators! have now recorded the results of injection 
of a pineal extract prepared after the technique of 
Hanson, using successive generations of rats. These 
authors had previously found that continuous 
administration of thymic extract to successive genera- 
tions of parent rats had resulted in precocity in the 
offspring, a method which suggested the present 
experiment. The pineal extract was injected intra- 
peritoneally, and the offspring of the injected rats 
were mated in pairs; the offspring of these were 
also injected. The authors found little effect on the 
first generation under treatment, but succeeding 
generations have shown progressively more marked 
retardation of growth and precocity of development 
from the third generation onward. The resulting 
animals were therefore ‘‘ precocious dwarfs”; in 
addition to having in early life large genitalia sug- 
gestive of those seen in macrogenitosomia præcox, 
the young animals were of bizarre and characteristic 
appearance, with ‘‘short snout, broad face, round 
head, heavy jowl, and bulging eye.” The authors 
comment on the high incidence of eye disease in 
these animals, blindness being common, though 
usually unilateral. Bilateral cataracts, bilateral 
anophthalmia, and congenital hypertrophy were also 
observed. These results, which were obtained on 
several hundred rats, are of peculiar interest if they 


1 Rowntree, L. G., Clark, J. H., Steinberg, A., and Hanson, 
A. M.: Jour. Amer. Med. Assoc., Feb. Ist, 1936, p. 370. 


FUNCTIONS OF THE PINEAL 


[manon 7, 1936 


can be proved definitely to be due to a substance 
present in the pineal; they appear paradoxical when 
compared with the condition associated with tumours 
of the pineal—the stimulation of bodily growth and 
of genital development. Some caution must be 
exercised in accepting the results obtained as due 
to the action of the pineal itself, however, since the 
extract used represented an acid aqueous derivative 
(probably a picrate) and contained 0:21 per cent. 
free trinitrophenol, whilst it is perhaps significant 
that more refined extracts were less active. 


RESEARCH IN TROPICAL MEDICINE 


THE work of the Medical Research Council has 
never been restricted by territorial limitations, but 
hitherto the Council have not been able to assist 
investigations in the tropics except on isolated 
occasions, although they have regularly made grants 
for work at home in relation to tropical problems. 
An intention to take a more active part in field work 
is indicated by the establishment announced this 
week of a tropical medical research committee. The 
decision to appoint this new committee has been 
taken by the Medical Research Council in consultation 
with the Colonial Office. It will give advice and 
direction in the prosecution of such investigations 
as the Council may be able to promote, at home or 
abroad, into problems of health and disease in 
tropical climates, and make suggestions for research 
in this field. It will include representatives of the 
Colonial Office and of the Liverpool and London 
schools of tropical medicine, with other members 
appointed as individual experts in tropical medicine 
or in different branches of medical science. The 
original members are: Prof. J. C. G. Ledingham, 
F.R.S. (chairman), Prof. A. J. Clark, F.R.S., Dr. 
N. Hamilton Fairley, Prof. W. W. Jameson, Dr. 
Edward Mellanby, F.R.S., Miss Muriel Robertson, 
D.Sc., Sir Leonard Rogers, F.R.S., Dr. H. Harold 
Scott, Sir Thomas Stanton, Dr. C. M. Wenyon, 
F.R.S., Prof. Warrington Yorke, F.R.S., and Mr. 
A. Landsborough Thomson, D.Sc. (secretary). 


NON-SPECIFIC IMMUNITY OF THE 
PERITONEUM 


Many substances have been proposed and used 
for inducing a pre-operative increase of resistance 
to bacterial infection in the peritoneal cavity. Some 
years ago H. L. Johnson??? reported that amniotic 
fluid introduced into the peritoneal cavity reduced 
the incidence of adhesions after Cesarean section, 
and that the fluid increased the resistance of the 
cavity to infection. The same author and his 
associates 3 now present an extensive survey of this 
latter phenomenon in dogs. They have used a 
chemically prepared fraction of bovine amniotic 
fluid and compare its action with that of papain, 
sodium merthiolate, sodium ricinoleate, and Bact. coli 
vaccine. The merthiolate and saline alone produced 
very little response. Papain, which has been used to 
prevent adhesions, dissolved fibrin and the meso- 
thelial layer of the peritoneum, but induced no 
beneficial inflammatory reaction. The ricinoleate 
was apparently toxic. Bact. coli vaccine induced a 
large leucocyte response in the peritoneal exudate 
and in the blood which reached a maximum in 
24 hours and was maintained up to 72 hours. The 
exudate was heavily blood-stained, extensive hæmor- 
rhage had occurred in the subserous tissues, and the 


? Surg., Gyn., and Obst., 1927, xlv., 612. 
* New Eng. Jour. Med. and Surg., 1928, cxcix., 661. 
. 3 Surg., Gym., and Obst., February, 1936, p. 171. 


THE LANCET] 


cellular response was mainly histiocytic. The 
amniotic concentrate induced a pink exudate; the 
maximum white cell response occurred in 12 hours, 
followed by a rapid fall, and a considerable subserous 
cedema in the peritoneal tissues was followed by an 
exudate rich first in polymorphonuclear leucocytes and 
later in histiocytes. The authors favour the amniotic 
fluid as giving the classic sequence of inflammatory 
events, while, for example, the coli vaccine and the 
papain give a distorted response. There does not 
seem to be adequate ground for believing that-the 
“‘ classic ” is any more beneficial in immunity than 
the “distorted.” However, if we assume that a 
quick leucocyte and plasma response without much 
damage to the tissues is required for an increase in 
peritoneal immunity, the amniotic concentrate is to 
be preferred to the coli vaccine. Dogs thus immunised 
were tested by the intraperitoneal inoculation of 
heavy doses of living Bact. coli. The survival rates 
in the various groups were as follows: 7 out of 8 
with amniotic fluid concentrate; 6 out of 9 with 
coli vaccine; and 5 out of 8 controls receiving saline 
as an immunising agent. The samples are so small 
that the figures do not indicate with certainty that 
either the vaccine or the amniotic fiuid concentrate 
are superior to normal saline in immunising value. 


At present the prophylactic value of the concentrate - 
depends on reports of its clinical efficacy. This is - 


very hard to assess and a significant improvement in 
the production of immunity by the use of the con- 
centrate in controlled laboratory tests is required 
before it can be accepted as an agent for general use. 


A NEW INTERNATIONAL CONFERENCE ON 
DANGEROUS DRUGS 


ATTENTION has been called again and again in our 
columns to the appalling extent of illicit traffic in 
narcotic drugs. While the International Opium Con- 
ventions of 1912, 1925, and 1931 have controlled 
and regularised the legitimate trade in drugs of 
addiction, there is indisputable evidence that little 
or no improvement has been effected in suppressing 
clandestine manufacture and contraband commerce. 
At a recent meeting of the Council of the League of 
Nations an important decision was taken in the right 
direction. On the motion of M. de Vasconcellos it 
was resolved to summon a diplomatic conference to 
consider a draft convention which has been prepared 
for the suppression of illicit traffic in dangerous 
drugs. Invitations to the conference will be addressed 
to all States members of the League and also to 
Germany, the United States, Arabia, Brazil, Costa 
Rica, Danzig, Egypt, Iceland, Japan, Leichtenstein, 
Monaco, San Marino, and the Sudan. The Council 


appointed M. Limburg (Netherlands) president of. 


the conference, and the first meeting will be held 
on June 8th of this year. A draft convention, which 
has been twice submitted to the various governments 
for consideration and criticism, will form the basis 
for the deliberations of the conference, but it will be 
open to the delegates to amend or add to it at their 
discretion. Lord Cranborne, the representative of 
Great Britain, took exception to a clause in the draft 
which had been introduced by the committee of 
experts. This clause would bind the High Contracting 
Parties to legislate for the severe punishment of 
those engaged in the “cultivation, gathering and 
production in contravention of national law, with a 
view to obtaining narcotic drugs.” Lord Cranborne, 
while agreeing that to make supervision of the drug 
trafic effective it was necessary to extend it to the 
‘ production ”’ of raw materials, regarded the intro- 


A NEW INTERNATIONAL CONFERENCE ON DANGEROUS DRUGS 


[mance 7, 1936 559 


duction of the clause in question as premature. To 
meet this objection, which was supported by 
M. Massigli, the representative of France, the 
Secretary-General was instructed to ask the various 
governments for their observations on the new 
clause introduced by the experts in time for these 
observations to be circulated before the assembling 
of the conference. It is to be hoped that the 
inclusion of the ‘“‘ production’ of raw materials 
may not lead to the difficulties and abstentions 
which marred the conferences of 1924-25. 


TWIN CORONERS ? 


OUR learned contemporary, the Law Times, has 
published some judicious articles by way of detailed 
comment on the report of the Departmental Com- 
mittee on Coroners. In the third and last of these, 
which appeared last Saturday, it criticises the Com- 
mittee’s recommendation for the creation of a 
disciplinary tribunal for coroners and also the 
proposal to confine appointments to solicitors and 
barristers. On the latter point it observes that the 
Committee on Coroners does not advocate the dual 
qualification in law and medicine. How, asks the 
writer in the Law Times, does the lawyer-coroner 
read the report of a post-mortem examination? He 
may have served for years as a deputy coroner ; 
he may have taken a course in forensic medicine and 
may have studied many text-books. But he will 
never read a post-mortem report with the seeing eye 
of the medical man who has passed through the 
hospitals, conducted his own post-mortem examina- 
tions, and spent years in post-graduate practice. 
The coroner, continues the writer, should be able to 
test the medical evidence out of his own knowledge 
and experience ; otherwise he is at the mercy of the 
medical witnesses. If a patient has died under an 
anesthetic and there has been some carelessness in a 
matter on which both surgeon and anesthetist are 
silent, is the lawyer-coroner likely to detect the 
fault? The critic finds another advantage in 
the medical coroner. In the duties of his office the 
coroner needs to keep in touch with the big hospitals 
and their staffs, the police surgeons, and the general 
practitioners of the district. A coroner who is a 
medical man can talk to other medical men in their 
own language. Codperation will be easier and more 
sympathetic. Coroners have responsibility in the 
choice between pathologists, police surgeons, and 
general practitioners for the performance of post- 
mortem examinations. The proposed institution of 
a Home Office panel of pathologists for this purpose 
is dismissed as inadequate to cope with the wide- 
spread needs and emergencies. If the coroner’s 
choice remains, it is best exercised by one with 
medical qualifications. | ne 

. Having made these points against the Committee’s 
proposals, the writer in the Law Times concludes by 
submitting his own suggestions. As vacancies 
gradually create the opportunity, he would reorganise 
large districts under twin coroners. One of the 
twins would be legally and the other medically 
qualified. The legal member would take over all the 
inquests where no medical issue arose ; the medical 
member, who might be called the ‘‘ medical examiner,” 
would presumably take the difficult medical issues. 
It is suggested that excellent results might be expected 
from the collaboration of the best lawyer and the 
best doctor available for appointment. That may 
well be; but would not the advantages of such a 
partnership be more surely and more smoothly 
obtained if the appointment was given to a single 


560 THE LANCET] 


person who possessed the dual qualification in law 
and medicine? This dual qualification is already 
demanded in some of the most important districts. 
To the General Council of the Bar it is anathema. 
Apparently the Departmental Committee of Coroners 
has in this respect yielded to the organised persuasion 
of the barristers. 


CHARLES NICOLLE 


Dr. Charles Nicolle, a distinguished Bantenoiwiat 
possessing an international - reputation, has died 
in Tunis at the age of 70. He was director of the 
Institut Pasteur de Tunis for more than thirty years, 
from 1903 till 1936, and editor of the well-known 
quarterly Archives of the Institute, which he 
inaugurated in 1906. He wrote extensively on the 
numerous infectious diseases which are endemic 
in Tunis and many of his researches are of general 
importance and of permanent value. Among them 
his greatest achievement was the discovery of the 
mode of transmission of epidemic typhus, in recogni- 
tion of which he was in 1928 awarded the Nobel 
prize for medicine. It had long been known that 
under insanitary conditions typhus fever spread 
rapidly amongst prisoners, soldiers, and vagrants, 
whereas in well-appointed hospitals the disease did 


not spread. Only those members of hospital staffs ` 


were attacked who were occupied in the recciving- 
rooms or manipulating the patients’ clothes and 
garments, while the clean patients could safely be 
attended in the general ward. These facts led 
Nicolle to suspect the body-louse as the vector of the 
virus and in 1909, in collaboration with Ch. Comte 
and P. Conseil, he succeeded in proving the correct- 
ness of his conclusion by experiments on monkeys. 
Body lice (Pediculus corporis), which had sucked the 
blood of a monkey infected by the inoculation of 
blood from a typhus patient, were shown to be capable 
of transmitting the disease to other monkeys on which 
they were subsequently allowed to feed. The far- 
reaching importance of this discovery was demon- 
strated in an overwhelming manner during the war, 
when all the armies adopted louse destruction as the 
essential means of combating epidemic typhus. 

= From 1909 and until his very last days Nicolle 
continued bis typhus researches, studying the experi- 
mental disease in various animal species and the 
conditions under which it is transmitted. As a 
result of his experiments with typhus virus and tame 
rats and mice he formulated a conception of the 
so-called ‘‘inapparent infection,” which he defined 
as an acute infection with periods of incubation and 
evolution, followed by cure and immunity, though 
distinguished from the ordinary type of infection 
by complete absence of general clinical symptoms. 


In Nicolle’s own view this conception is the most 


important of his discoveries, applicable not only to 
typhus but also to other infectious diseases (measles, 
relapsing fever, dengue). Unfortunately his 
numerous and varied attempts to evolve an efficient 
method of active immunisation against typhus 
infection remained unsuccessful. He found, however, 
in collaboration with Conseil, that serum from typhus 
convalescents was of prophylactic value, and in 1918, 
‘again in collaboration with Conseil, he made the 
important discovery of the prophylaxis of measles 
by means of inoculation of serum from convalescents. 

Charles Nicolle’s fame will not rest merely on his 
fundamental researches on the transmission of 
typhus fever by an insect vector, to wit, the louse. 
This will certainly remain his paramount achieve- 
ment, in spite of the fact that recent years have 


CHARLES NICOLLE.— MEASUREMENTS OF RED CELL SIZE 


[marcu 7, 1936 


revealed the existence in various parts of the world of 
many clinical types of typhus-like diseases, spread 
by a variety of insect vectors. Outside his typhus 
work, however, must be placed to his credit and that 
of his school a surprising number of notable findings 
and observations in the field of preventive medi- 
cine. We may note, for example, his studies on 
Mediterranean fever, on kala-azar and oriental sore, 
on trachoma and soft sore, not forgetting his careful 
observations on the behaviour and fate of the relapsing 
fever spirochete in the body of the louse. An 
indefatigable worker, he’enjoyed the happy collabora- 
tion of a band of highly trained experts. The Tunis 
Institute, in fact, made it its business to illuminate 
and so to control just those diseases and plagues 
by which it found itself surrounded. His office of 
director of a Pasteur Institute, affiliated with the 
mother institute in Paris and sharing the latter's 
traditions, he rightly magnified. Only a month 
ago there appeared in the Archives of his institute a 
long and reasoned article from his pen on the 
responsibilities of the ideal director of an institute 
for research in experimental medicine. How is the 
ideal person to be selected and by whom? By a 
committee or by a person ? When selected and placed 
in office, what should be his guiding principles in 
every sphere of his relationships? A pathetic and 
perhaps prophetic interest attaches to his concluding 
hints on the training of a successor, a duty that no 
director, in Nicolle’s view, should shirk, if circum- 
stances permit. So studied and ever-progressive 
should this training in responsibility be, that when the 
chief comes to retire or die, the change over should 
take place almost ‘“‘ physiologiquement.”’ | 


MEASUREMENTS OF RED CELL SIZE 


THE Sidney Ringer memorial lecture was delivered 
at University College Hospital on Feb. 28th on the 
Measurement of Red Cell Size, by Dr. Cecil Price- 
Jones. He outlined his technique of measuring red 
cells and the statistical methods employed to estimate 
the mean diameter, the degree of anisocytosis, and 
the degree of microcytosis and megalocytosis shown 
by the red cells in any sample of blood. He described 
clearly the normal red cell distribution curve, the 
factors, such as exercise, that may influence this 
curve, and the variations from the normal found in 
pathological conditions. 

In introducing the lecturer Dr. Charles Bolton 
voiced a general feeling in saying that, like Sidney 
Ringer, Price-Jones had made a remarkable and 
fundamental contribution to medical science. Ringer’s 
solution and Price-Jones’ curves had both become 
familiar and essential aids to further knowledge of 
certain physiological and medical problems. Price- 
Jones has not only devised an invaluable method of 
studying abnormalities in red cell size but has also 
determined what the limits of normal variation 
may be both in size and anisocytosis. These limits 
are calculated on sound statistical principles and 
are not the result of a small group of observations 
only. The method of Price-Jones is admittedly time-, 
if not temper-, consuming, but it has the extreme 
advantage over most other methods that the limits 
of normal variations in cell size determined by the 
method are known. Mean corpuscular volume can 
also be used as a measure of cell size. Price-Jones and 
his colleagues! have recently determined the normal 
limits of variation in cell volume by the method of 


1 Price-Jones, C., Vaughan, J. 


M., and Goddard, H. 
Path. and Bact., 1935, X1., 503, 


: Jour, 


THE LANCET] 


Wintrobe. The method is quick, accurate, and easily 
carried out. It will probably prove the method of 
choice in the future for estimating cell size in routine 
investigations. It has however the great dis- 
advantage that it gives no expression to the degree 
of anisocytosis present in the sample. Increase in 
anisocytosis is a more delicate measure of variation 
from the normal than increase or decrease in mean 
corpuscular size. For research purposes a method 
that estimates both cell size and anisocytosis is 
essential. Pijper? claims that his new diffraction 
apparatus will give reliable measurements both of 
diameter and anisocytosis; its great advantage is 
the speed with which results can be obtained ; 
should be a useful aid in the routine laboratory, 
especially when the limits of normal variation by 
this technique have been determined on statistical 
principles. No diffraction method, however, will 
give mathematical expression to the degree of micro- 
cytosis and megalocytosis present. Though diffraction 
methods of a refined type and estimations of cell 
volume may have their value in routine blood 
examinations, at present the Price-Jones’ technique, 
especially when used in conjunction with Wintrobe’s 
method of volume estimation, stands alone as a 
method sufficiently accurate for research purposes. 
It has already achieved, in the hands of its originator, 
results of fundamental importance. 


FOG AND FILTHY AIR 


THE public is loudly exhorted in the daily press to 
become air-minded ; and we hope that its new air- 
mindedness will include concern at the condition 
of the air. The twenty-first annual report on 
investigation of atmospheric pollution, issued by the 
Department of Scientific and Industrial Research,?® 
shows that the air over the country generally is not 
becoming cleaner; at least it is not becoming 
cleaner at those places where deposit gauges have been 
installed long enough for comparisons. Out of 57 
such places only 5 show improvement during the 
year ended last March. Nor is this the whole tale ; 
for a survey by Mr. B. H. Wilsdon shows that in the 
past twenty years the amounts of insoluble matters 
deposited have shown no progressive improvement, 
although the soluble matters lessened during the 
first eight years of the investigation. Last year the 
incidence of days of fog haze, when the soot stain 
produced by filtering air through paper reached a 
depth corresponding to over 2 lb. of soot in a cube 
of air with 100-yard sides, was very variable in places 
where Owens’ air filter records were taken. In 
London only 19 such “Z” days were recorded at 
South Kensington and Westminster Bridge, whereas 
at Victoria-street 52 were noted and at Westminster 
City Hall 115. At Kew there were 15, at Cardiff 
none, at Coventry 22, at Stoke-on-Trent 141, and at 
Edinburgh 68. The irregular distribution over the 
small area of London covered by filter records is 
consistent with common experience of the patchy 
incidence of fogs. 

Particular attention has been devoted of late years 
to the sulphur content of the air, determinations 
being made at many stations of either the actual 
volume ratio of sulphur dioxide in air—which is of 
the order of less than 1 in a million—or of the weight 
of active sulphur dioxide absorbed by an area of 
100 sq. cm. of a lead peroxide surface exposed under 
a hood protecting it from rain and renewed after a 


3 Pijper, A.: THE LANCET, 1935, 1i., 1152. 
3? London: H.M. Stationery Office. 1936. 5s. 


FOG AND FILTHY AIR 


[marcu 7, 1936 561 


month’s exposure. In all places the variation from 
month to month is conspicuously seasonal, sulphur, 
like all polluting matters except those which are 
insoluble, being in greater amount in air in winter than 
in summer ; but in London, as well as other towns, 
the amounts in both summer and winter are large, 
suggesting either that the domestic coal fire is widely 
continued through the summer or that the south- 
ward movement of industrial undertakings is having 
its effect on London air. This latter view is put 
forward by a member of the research committee, ` 
Mr. J. H. Coste, chemist to the London County Council. 
Whether it adequately explains the high sulphur 
content of London air it is difficult to judge; but 


‘the annual consumption of coal in the metropolis | 


is very large and there is little reason to suppose that 
this coal is of specially low sulphur content. So 
far as we know, the undertakings in London which 
take steps to remove sulphur from flue gases can 
be counted on the fingers of one hand. — 


EARLY DIAGNOSIS OF PULMONARY 
TUBERCULOSIS 


A: FEW months ago we referred! to the work of 
Dr. Jacques Arnaud, medical director of the Sana- 
torium Grand Hôtel du Mont Blanc. It may be 
recalled that his prescription for the early diagnosis 
of pulmonary tuberculosis was systematic, periodical 
radiographic examination of the whole community. 
The same plan is now recommended independently 
by another tuberculosis specialist in another country. 
In Tidsskrift for den Norske Laegeforening for Feb. Ist, 
Dr. H. J. Ustvedt passes in review 321 patients 
examined in the Ullevaal Hospital in Oslo, and gives 
the duration of the symptoms of these patients before 
they submitted to a medical examination. It seems 
that only 83 of them came to examination within a 
fortnight of the first appearance of symptoms, and 
that the latent period was three months or more in 
the case of another 83. Though cough and fever 
may mark the onset of the disease for the patient, 
they represent in the eyes of the clinician and patho- 
logist comparatively late stages of an infection which 
may date back many months, and the disease will be 
recognised early only when it is sought among persons 
believing themselves to be perfectly well. Ustvedt 
therefore recommends Pirquet tests followed by 
X ray examination of the positive reactors. This 
system has already been started tentatively in the 
homes of the tuberculous in Norway, and in Oslo 
medical students are thus systematically examined 
with the same object. The procedure is- shortly to 
be extended to other groups so that students in all 
the faculties can enjoy its benefits. With regard to 
tuberculin tests, it is curious that whereas in Denmark 
and Sweden the Pirquet reaction has been found to 
be so inferior to the Mantoux reaction that the 
latter is now given the preference in wholesale tuber- 
culin examinations, Norwegians still cling to Pirquet, 
being convinced that, when it is practised lege artis, 
it yields figures within 90-95 per cent. of Mantoux 
figures with 1 mg. of tuberculin. In the other 
Scandinavian countries comparisons of the two 
reactions have been much less flattering to Pirquet. 
These intra-Scandinavian discrepancies may reflect 
want of uniformity of technique, or, as Ustvedt 
believes, the fact that bovine tuberculosis exists in 
Denmark and pycoee but is‘almost non-existent in 
Norway. - 


1 THE LANCET, 1935, ii., 1123. 


562 THE LANCET] 


[marca 7, 1936 


PROGNOSIS 


A Series of Signed Articles contributed by invitation 


XCI.—_ PROGNOSIS IN SPINAL CARIES 


PROGNOSIS in spinal caries depends (1) on the natural 
resistance of the patient, (2) on the method of treat- 
ment adopted, and (3) eventually on complications 
and the degree of deformity remaining. The disease 
may occur at any age and is most dangerous in weakly 
infants with bad family history, in whom the danger 
of tuberculous meningitis or general dissemination 
is very real. There is much controversy as to the 
relative values of extreme conservatism without 
operation and conservative treatment assisted by 
bone-grafting or bone-fusing operations of that 
part of the spine affected. The position is, briefly, 
that properly applied conservative treatment with 
rational orthopedic measures but without operation 
is certain of considerable success, but that treatment 
may be shortened in selected cases by operative 
measures. Immediate mortality is undoubtedly least 
when careful non-operative conservative treatment 
is alone applied. Patients with severe deformity, 
which incidentally should never arise if early treat- 
ment is undertaken, have a lessened hope of longevity 
from mechanical reasons which predispose to death 
from complications such as pneumonia. Such patients 
however can hardly be helped by operative treatment. 

Below are tables giving mortality statistics of all 
my own cases treated at Treloar Cripples’ Hospital 
from September, 1908, to March, 1935, but excluding 
cases in private practice or treated at any other 
hospital with which I am associated. 


SPINE 
Total number of cases admitted during the 
period -. 1666 
Cases discharged to March 31st, 1935 .. 1582 
Deaths to March 31st, 1935 bits 61 (3°8%) 
Average stay in hospital of fatal cases .. 410 days. 
Causes of Death 
Miliary T.B. and meningitis Se aa 32 (2-02 %) 
Sepsis and amyloid Sigean As e% F 16 (1°01 %) 
Other causes ; . Pes a Pay 13 (0°82 %) 
Diphtheria .. 1 Pneumonia A 1 
Morbus cordis 3 Broncho- pneumonia 1 } 3 
Nephritis «e 1 Influenza] pneumonia 1 
Ketosis oe sec L Intestinal obstruction ae | 
T.B. carditis é 1 Heemorrhagic measles 1 
Post-operative shock i 
(laminectomy) .. 1 
Average Miliary Sepsis 
Age- D Other 
- eaths.| stayin T.B. and and . 
periods. days. |meningitis.| amyloid. | “USes 
1- 5 26 257 19 2 5 
6—10 26 592 11 8 7 
11-16 9 466 2 5 2 


Relative Frequency of (a) Miliary T.B. and Meningitis, and 
(6) Sepsis and Amyloid Disease as Causes of Death at 
Different Age-periods in Spinal Caries 


Ag e ee ee 1-5 ee 6-10 11-16 
Miliary T.B. and meningitis 

(per cent.) 73-1 ie 42 sa 22-2 
Sepsis and amyloid (per 

cent.) ; TT ae 30 ais 55°6 

Summary 
Total Total Total Average stay Death 
admitted. discharged. died. fatal he percentage. 


Spine 1666 .. 1582 .. 61 .. 410 a 38 


Mortality is highest in the age-period 1—5 and the 
commonest cause of death in this age-period is menin- 


gitis and general tuberculous dissemination. As age 
increases the danger of meningitis diminishes, but 
deaths from sepsis increase. Other causes may be 
almost disregarded, as they are incidents arising in 
any child’s life though naturally more serious in a 
child already infected with tuberculous disease. 

This comparatively low mortality in children, 
many of whom arrive for treatment with advanced 
disease, often complicated by abscess or sinus forma- 
tion and sometimes paraplegia, may be ascribed 
to the rigid conservatism practised under exceptionally 
good climatic and hygienic conditions. In children 
I am definitely opposed to stabilising the spine by 
bone-grafting or fusing while the disease is active 
and consider such operations not generally indicated 
when the disease is arrested. An exception to this 
rule occurs in the case of children of poor musculature 
where it may not be possible to supervise eflicient 
splinting over a sufficiently long period after discharge. 
In such cases rapid increase of deformity may arise, 
which might be avoided by osteo-synthesis. 

In adolescents and adults Albee’s operation (or some 
modification) for stabilising the spine is increasingly 
popular amongst many surgeons as an alleged means of 
reducing the period of treatment for and the danger 
of later increase of deformity or recurrence of the 
disease. The mortality is undoubtedly raised in 
those submitted to operation unless patients are 
carefully selected, guarded from intervention in the 
acute and progressing stage of the disease, and made 
to take adequate rest over a sufficiently prolonged 
period. | 

These operations will not with certainty arrest 
the disease and in the course of my work I have been 
impressed by the large number of patients I see 
who had been discharged too soon and in whom 
abscesses or paraplegia had compelled return to 
institutional treatment, often without the knowledge 
of the surgeon who performed the operation. 


COMPLICATIONS 


The presence of a closed tuberculous abscess 
associated with a tuberculous lesion of the spine is 
of little moment if it can be successfully aspirated 
and secondary infection or sinus formation avoided. 
If secondary infection occurs the outlook is grave. 
Free drainage is essential and immediate treatment 
with autogenous vaccines at this stage is helpful. 
All too often, however, fever and toxzemia enfeeble 
the patient, the course of treatment frequently 
becomes long and tedious, and amyloid disease may 
follow. In the latter case, the prognosis is definitely 
bad, though I can recall a few such patients who have 
recovered. Secondarily infected sinuses often heal 
with extreme difliculty, some never heal, and then 
the patient may recover or survive for many years 
with discomfort and often, though not necessarily, 

in a state of chronic invalidism. 

An abscess is a serious complication when it forms 
in the region of the spinal canal and when by reason 
of the pachymeningitis it produces, or by direct 
mechanical pressure, it involves the spinal cord. 
The mid- and upper dorsal regions of the spine are 
the commonest situations. Of 134 cases of para- 
plegia occurring at the Treloar Cripples’ Hospital, 
14 are still under treatment, 5 died, 6 were removed, 
24 were unimproved, and 85 were discharged walk- 
ing after conservative treatment. 


THE LANCET] 


THE SERVICES 


[maRcH 7, 1936 563 


Paraplegia from true tuberculous pachymeningitis 
is a late manifestation; its onset is insidious, it 
tends to progress rather than resolve and the 
prognosis is bad. Of 26 such cases included in the 
total of 134, 12 recovered, 11 were unimproved, 
2 were removed, and 1 died. 


DEFORMITY 


The prevention of deformity, or its correction, if 
that is possible, should be an essential aim in treat- 
ment. Both may be ensured in a large number of 
cases if the patient is immobilised, hyperextended, 
and treated at first and for many months in the 
dorsally recumbent position. The cervico-dorsal 
region of the spine is the most difficult one in which 
to prevent or correct deformity, and if much deformity 
exists before effective treatment is initiated, correction 
is almost impossible. The prevention or attempted 
correction of deformity should be urged not only on 
esthetic grounds, but because with much kyphosis 
there is embarrassment and displacement of the 
viscera, especially the thoracic viscera, with con- 
sequent distress to the patient and liability of inter- 
current, especially respiratory, disease. A strong 
dorsal musculature is of great assistance in maintain- 
ing the spine erect, and for that reason open-air 
treatment and back-raising exercises with the patient 
prone are of especial value in the last stages of institu- 
tional treatment. Efficient after-care and well-applied 
and fitting spinal jackets are of immense importance 


at this period, and in cases of weakened muscles 
spinal osteosynthesis has its most important indication. 


ASSOCIATION WITH OTHER TUBERCULOUS LESIONS 


Occasionally, though rarely, one finds patients 
who will fail to respond to any form of treatment 
and in whom other lesions develop. For these, 
prospects of recovery are poor, though, at times, 
from some reason, possibly a suddenly acquired 
immunity, progress of the disease is checked and 
recovery follows. 

In children, multiple lesions associated with 
spinal caries lengthen the period of treatment required 
but do not usually jeopardise cure. Associated 
pulmonary tuberculosis is a serious but not unconquer- 
able complication, and I have known adults who, 
as the result of acquiring spinal caries following 
pulmonary tuberculosis, have recovered completely 
from both, largely as the result of the enforced rest 
which the spinal lesion necessitated. 


I am indebted to Mr. H. H. Langston, R.M.O., at the 
Treloar Hospital, for collecting and analysing the 
incorporated statistics, and to Dr. Churchill, late R.M.O. 
to the hospital, for the analysis of the paraplegia cases 
which is discussed fully elsewhere (St. Bartholomew’s 
Hosp. Jour., October, 1935). 


HENRY GAvvVAIN, M.D., M.Chir., F.R.C.S., 
Medical Superintendent of the Lord Mayor Treloar 
Cripples’ Hospitals. Alton and Hayling Island, 
and of the Morland Clinics, Alton. 


THE SERVICES 


ROYAL NAVAL MEDICAL SERVICE 


Surg. Comdrs. H. H. Babington to Pembroke, for 
R.N.B., Chatham, and as Ophthalmic Specialist ; M. Brown 
to Victory for Haslar Hospl.; and O. D. Brownfield, 
O.B.E., to Pembroke for R.N. Hospl., Chatham. : 

Surg. Lt. (D) S. R. Wallis to Pembroke for R.N.B. 

ROYAL NAVAL VOLUNTEER RESERVE 

Surg. Lt.-Comdr. R. B. H. Wyatt placed on the 
Retd. List. 

Surg. Lt. C. J. T. Watson to Curacoa. 

Surg. Sub-Lts. J. A. Shepherd to Royal Sovereign, and 
R. F. B. Bennett to Victory for R.N. Hospl., Haslar. 

Proby. Surg. Lts. to be Surg. Lts.: A. B. Concanon, 
W. G. Gill, and N. A. Vernon. 

Proby. Surg. Sub-Lt. G. S. Irvine to be Surg. Sub-Lt. 


ARMY MEDICAL SERVICES 
Lt.-Col. S. W. Kyle, R.A.M.C., to be temp. Col. whilst 


empld. as A.D.M.S., 5th Div., Jan. 10th, 1936. (Sub- 
stituted for notification in the Gazette of Feb. 4th.) 


ROYAL ARMY MEDICAL CORPS 


Short Serv. Commissions: Lt. B. €E. Barclay to be 
Capt; Lt. (on prob.) A. H. T. F. Fullerton is restd. to 
the estabt. and is confirmed in his rank; and R. E. 
Waterston to be Lt. (on prob.). 

REGULAR ARMY RESERVE OF OFFICERS 

Col. E. W. Powell (late R.A.M.C.), having attained the 
age limit of liability to recall, ceases to belong to the 
Res. of Off. 

TERRITORIAL ARMY 

Capt. A. N. B. Odbert to be Divl. Adjt. 46th (N. Mid.) 
Div., vice Maj. H. A. Rowell, M.C., vacated. 

Lt. P. Spence to be Capt. 

The King has conferred the Efficiency Decoration upon 
the undermentioned officers under the terms of the Royal 
Warrant dated Sept. 23rd, 1930: Lt.-Col. J. P. Clarke, 
Lt.-Col. J. B. Scott, M.C.. Maj. A. H. D. Smith, M.C., 
Maj. A. G. Williams, O.B.E., Maj. P. Lloyd-Williams, 
Maj. C. W. Healey, M.C., and Maj. James Duncan Hart, 
M.C. (deceased). 


TERRITORIAL ARMY RESERVE OF OFFICERS 


Lt. A. Menzies, from T.A. Res. of Off. (9th Bn. A. and 
S.H.), to be Capt. | 
ROYAL AIR FORCE 


Squadron Leader T. J. X. Canton to R.A.F. Station, 
Manston, for duty as medical officer. 

Flight Lt. J. Hutchieson is promoted to the rank of 
Squadron Leader. 

Wing Comdr. J. Rothwell is placed on the retired list 
at his own request. 

Flying Officer S. R. C. Nelson to No. 6 Flying Training 
School, Netheravon. 

Dental Branch.—Flight Lt. J. E. Willoughby, L.D.S., 
relinquishes his non-permanent commission on account of 
ill-health. 

INDIAN MEDICAL SERVICE 


Capt. G. J. Joyce to be Maj. 


DEATHS IN THE SERVICES 


The death occurred at Tunbridge Wells on Feb. 27th 
of Surgeon Captain Joan Epwin Coan, R.N., retd. He 
qualified M.B. Durh. 1885 and M.R.C.S. Eng. 1886, 
having been educated at Newcastle-on-Tyne and St. 
Thomas's Hospital, London. In 1887 he resided at York 
and soon after joined the Navy. In 1899 he was appointed 
Staff Surgeon in Barracouta, a twin-screw cruiser, Cape 
and West Africa Service, attained the rank of Fleet 
Surgeon in February, 1903, and retired with the rank of 
Surgeon Captain in July, 1917, receiving a medal for 
war service. 


Lona RECORD oF HONORARY SERVICE.— At a 
meeting of the executive committee of Worcester Royal 
Infirmary to consider the appointment of a successor 
to Mr. Mark Bates, who is an honorary surgeon but is 
undertaking other work at the hospital, it was stated that 
the Bates family had in all given 77 years of honorary 
service to the hospital. The late Mr. Tom Bates gave 
37 years’ work, his son, the present senior surgeon, has 
given 27 years, while Mr. Mark Bates has given 13 years. 


564 THE LANCET] 


IVAN PETROVITCH PAVLOV 


DuRING the last twelve months of Pavlov’s life 
probably more people who were interested in his 
work had the privilege of seeing him and hearing 
him speak than in any other year. The summer 
of 1935 is memorable both because of his visit 
to this country for the International Neurological 
Congress and because of the holding in Russia of 
the International Physiological Congress. The name 
of the great physiologist dominated these gatherings, 
which were attended by representatives from all 
over the world, and their chief interest to many 
lay in the opportunity to ‘‘see Pavlov.” Those 
who met him on these 
occasions must count 
themselves fortunate, 
for he died in Leningrad 
on Feb. 27th, at the 
age of 86. 

Pavlov was born in 
September, 1849, in the 
small city of Riazan in 
Russia. His family were 
poor, but his father was 
a country priest and the 
foundations of his educa- 
tion were laid in the 
church school from which 
he passed to the theo- 
logical seminary. It 
seems that this differed 
from other schools in 
that the boys were 
encouraged to develop 
their natural inclinations 
instead of being forced 
up to the same standard 
in all subjects. Pavlov 
became interested in the 
natural sciences, and at 
the age of 21 entered what 
was then St. Petersburg 
University, and studied 
under Mendeleef and 
other eminent teachers. 
Later, in the Medico-Chirurgical Academy, he came in 
contact with von Cyon whose stimulating personality 
had much to do with determining his future career ; 
and after graduation in 1879 he continued research 
work in the Military Medical Academy under the 
physician Botkin, obtaining the degree of M.D. in 
1883 for a thesis on the efferent nerves to the heart. 
In 1884 came the opportunity to go abroad, and when 
he returned to his former position two years later 
his experience had been enriched by work done in the 
laboratories of Ludwig and Heidenhain. 

Thereafter followed his classical contributions to 
the physiology of digestion, and by 1897, when he 
published a monograph on the subject, his reputation 
was international. Meanwhile, at the age of 41, 
he had been appointed professor of pharmacology 
in the Medical Academy, and then to the chair of 
physiology in the new Institute of Experimental 
Medicine, built by Prince Alexander of Oldenburg. 
In 1897 he obtained the chair of physiology in the 
Medico-Chirurgical Academy, relinquishing his pro- 
fessorship of pharmacology, but he still retained 
his other two posts when, in 1907, he was appointed 
one of the four scientific members of the St. Petersburg 


SPECIAL ARTICLES . 


medical science will perpetuate his name. 


[MARCH 7, 1936 


Academy of Sciences, and therefore had charge 
of three laboratories. Most of his personal research 
was done in the Institute, now known as the All- 
Union Institute of Experimental Medicine, of which 
he was latterly honorary director, as well as director 
of physiological laboratories in the Russian Academy 
of Sciences. 

Although Pavlov emerged after the revolution 
in more or less the same posts as he had held 
previously, he suffered more than a change of titles 
during that difficult time. “Like other scientists 


he suffered much .. . having to carry on his experi- 
ments without heat or light, and drawing his main 
food supply from a little patch of potatoes which he 
tended himself. 


But his only complaint was that, 
with other members of the 
Academy of Sciences, he 
had to take his turn in 
guarding firewood stacked 
outside the Academy for 
six hours at a stretch.” ! 
Pavlov, however, was no 
stranger to hardship and 
was enabled to survive 
this period of drudgery 
‘and want which must 
have recalled his earher 
struggles. Until he 
obtained his first pro- 
fessorial post his life had 
been a continual battle 
with poverty and diffi- 
culties which to a lesser 
man would have been 
insurmountable. The 
animals he used for his 
researches into the circu- 
lation and for his earlier 
experiments on digestion 
were tended by himeelf 
and his wife in their own 
home, and comfort was 
sacrificed to the thorough- 
ness upon which he 
insisted in every branch 
of his work. During his 
second period of adver- 


sity he made no secret of his disapproval of the 
prevailing régime and its principles, but he was 
treated with tolerance and later received at the 
hands of Lenin every encouragement and opportunity 
to pursue his important work. 
generous to analyse the motives for this policy, which 
was never varied up to the time of Pavlov’s death. 
Last year, on his 85th birthday, he was given a pension 
of 20,000 roubles, and a million roubles for 
laboratories. 
as such, and it is said rarely read a newspaper. 
criticised the government in so far as they made 
academic appointments on political grounds, and 
more fundamentally because he believed the philo- 
sophy they adopted to rest on a faulty biological 
basis ; nevertheless, in his welcome to the Physio- 
logical Congress last year he fully identified himself 
with the policy of his country. 


It would be un- 


his 
He had but little interest in politics 
He 


Long after these details of Pavlov’s eventful 
career have been forgotten his contributions to 
In the 
space of ten years he reduced the unexplored field of 


digestive secretion to an orderly pattern of reflexes, 


2 The Times, Feb. 28th, 1936. 


THE LANCET] 


IVAN PETROVITCH PAVLOV 


[marcou 7, 1936 565 


and definitely established the value of applying to 
physiology the methods of aseptic surgery.’ His 
fistula were carefully made, and the scrupulous after- 
care of the animals enabled him to keep them alive 
until they were, to all intents and purposes, restored 
to normality. The influence of experimental condi- 
tions upon his observations was reduced to a minimum. 
The importance of his famous operation for separating 
off a pouch from the stomach, in which the gastric 
secretion could be studied uncontaminated with food, 
rested upon the ‘‘normality’’ of the pouch. Its 
nerve- and blood-supply were left intact, and no 
detail was overlooked which would serve to make it 
in all respects a faithful miniature of the stomach 
itself. Pavlov never made the mistake of forgetting 
that the organ he was studying was but a part of the 
whole animal, and that if this was not in perfect 
condition the conclusions would be subject to all 
manner of reservations. He worked out in great 
detail the responses of the salivary and gastric glands 
to the sight, smell, and taste of food, and showed 
how the type and quantity of secretion could vary 
with the kind of food administered. 


THROUGH PHYSIOLOGY TO PSYCHOLOGY 

It is noteworthy that although Pavlov’s work 
had been directed up to this time towards problems 
concerning the circulatory and digestive systems, 
he approached them from the point of view of their 
nervous control. In 1902 Bayliss and Starling 
demonstrated the copious secretion of the pancreas 
in response to the hormone secretin, and Pavlov 
had to revise many of his conclusions in view of this 
hitherto unsuspected mechanism for codrdination. 
He foresaw that development for the next few years 


would be likely to be along chemical lines, and it is- 


probable that his disinclination for this type of work 
was one of the factors which turned his attention to 
the nervous system itself. 

At all events, the next thirty years saw a direct 

attack on the physiology of the cerebrum whose 
results transcended in importance anything which 
Pavlov had yet done. He noticed that an organ 
could be activated reflexly not only by its normal 
stimulus, but, under certain circumstances, by all 
kinds of stimuli not usually associated with it. Thus 
if a dog was always fed in a routine manner by the 
same attendant, dressed in the same way, it would 
begin to secrete saliva before tasting the food, and 
also when the attendant came without food. In 
other words an entirely new reflex—a conditioned 
reflex—had been laid down, the sight of a particular 
person becoming an adequate stimulus for the secre- 
tion of saliva. A salivary fistula enabled Pavlov 
to assess the quantitative value of the response by 
measuring the: rate of secretion, and he showed how 
this could be brought about by stimuli applied to any 
sense-organ. Once the method of producing condi- 
tioned reflexes had been established, the next step 
was to investigate their properties—how they were 
modified by intercurrent stimuli and the laws 
determining how they could be reinforced, destroyed, 
or inhibited. The fruitfulness of experiments on 
inhibitory phenomena alone was surprising, and 
Pavlov showed, among other things, how inhibition 
could be built up so strongly as to produce sleep. 

The technique of the experiments is further 
illustrative of Pavlov’s genius in obtaining reliable 
information about a single organ from the intact 
animal. This time the problem was not surgical, 
but rather one of designing apparatus and perfecting 
routine. The brain was ‘‘isolated’’ by keeping the 
animal under absolutely constant conditions and 


ensuring that the experimental stimuli to which it 
was subjected were the only unusual events in its life. 
This required extraordinary precautions including 
the building of special laboratories and the rigid 
training of assistants. It might have been contended, 
with some show of reason in regard to his earlier 
experiments on digestion, that Pavlov owed his © 
success to his amazing manual dexterity and opera- 
tive technique, which were the envy of his assistants. 
In considering his work on conditioned reflexes, 
however, it becomes apparent that the factor determin- 
ing the outcome of his researches was always his 
method of attacking a problem. His life was literally 
devoted to the search for truth, and in achieving 
his ends he used no instrument which he had not 
perfected to the highest possible degree. “A 
superb experimenter, combining the talent of a 
magnificent surgeon and a shrewd observer; a 
dynamic lecturer, surpassed only perhaps by Maximot 
in logic and the use of language ; a powerful thinker, 
never interested much in priority, never influenced by 
any authority, he understood only the logic of facts.” 2 

It is unnecessary nowadays to stress the value of 
this objective method of approach in the study of the 
mind. Pavlov believed that all acquired habits and 
training depended on chains of conditioned reflexes, 
and that his experiments on dogs provided the clue 
to the type of activity taking place in the human 
cortex. By comparing the reactions of different 
animals to his experiments, the readiness or other- 
wise with which they formed conditioned reflexes, 
and the subsequent stability of the reflexes, he was 
able to divide dogs into four groups which bore a 
close resemblance to the ‘‘choleric, phlegmatic, 
sanguine and melancholic”? temperaments of man. 
By associating one kind of response with a conditioned 
stimulus of certain characteristics, and an incom- 
patible type of response with a closely related but 
slightly different stimulus, he trained his dogs to 
an astonishing pitch of discriminative ability. If 
overtaxed, for instance by persistently having to 
differentiate between two musical notes varying 
by only a few vibrations, they broke down and became 
definitely neurotic, losing temporarily all vestige 
of their training. Inhibitory reflexes were always 
the greatest sufferers under such conditions. | 

Clearly this was leading Pavlov into the realms 
not only of normal but of abnormal psychology. . 
He related the original “type” of dog to the 
disturbance most likely to develop, and was able to 
produce states analogous to hysteria, catalepsy, and 
many of the neuroses and psychoses. Visitors to 
Leningrad last year were able to see the groups of 
orphan babies whose development he was observing, 
and the patients he was investigating in the 
Psychiatric Polyclinic where he had charge of 25 beds. 

è 


A LEGACY TO SCIENCE 


The logical development of Pavlov’s work has 
never faltered, and at the time of his death he was the 
centre of a vast and still growing organisation of 
research which had sprung from his first modest 
experiments. It is doubtful whether the usefulness 
of the methods he has introduced will ever be 
exhausted, while the results so far attained have 
already made a permanent impress on several branches 
of learning, including some previously immune to 
experiment. 

*Stavraky, G. W.: Arch. Neurol. and Psychiat., 1935, 
xxxiii., 1082. Most of the biographical data in the present 
sketch were obtained from this account of Pavlov’s life. The 


photograph was taken at the AAN Institute, during a visit 
to New York, by Mr. Louis Schmidt 


566 THE LANCET] 


His powerful, yet lovable personality, will not -be 
forgotten by those of the present generation, while 
the intense loyalty and admiration he evoked in all 
who worked with him bids fair to make that 
personality legendary. Known in every civilised 
country in the world, he was awarded many foreign 
and international distinctions, including the Nobel 
Prize in medicine and physiology in 1904. In this 
country he was a foreign member of the Royal Society, 
whose Copley medal was given to him in 1915, and 
an honorary fellow of the Royal College of Physicians. 


MEDICINE AND THE LAW 


The Nottingham Nursing-home Trial 


Nurse Waddingham, an unregistered nurse, was 
found guilty last week of the murder of Ada Baguley 
at a home carried on at Devon-drive, Sherwood, 
Nottingham. In the organs of the dead woman’s 
body 4!/, grains of morphine hydrochloride were found. 
One grain was a possible fatal dose. The jury may 
well have been satisfied that Ada Baguley died on 
Sept. llth of morphine poisoning: they had also 
to be satisfied that the accused administered the 
morphia and administered it with intent to murder. 
A will made by the deceased on May 7th in favour of 
the accused was suggested as a motive. When 
told, on Sept. 24th, that morphia had been found in 
the body, Nurse Waddingham said: “I have never 
given Miss Baguley any morphia: I have never had 
any in the house. ... Apart from the medicine 
prescribed by the doctors and aspirin, she has had 
no other medicine.” 
had morphia, but she said that Dr. Manfield (the 
deceased’s medical attendant) had prescribed it 
and she had not mentioned the fact because he asked 
her not to. This statement Dr. Manfield denied. 
There was a further vital conflict of evidence between 
the accused and the medical attendant. The accused 
said that on August 27th Dr. Manfield gave her 
6 tablets which she knew were morphia. Dr. Manfield 
said that he did not and that there was nothing in 
the patient’s condition which would lead him to 
. leave morphia at the home. Inasmuch as the defence 
contended that the accused administered the morphia 
-to alleviate violent pain, it was important that 
Dr. Jacob, who had attended Miss Baguley previously, 
visited the patient in the third week of August and 
saw no reason to prescribe morphia. The drug 
indeed, according to the accused, was mentioned 
for the first time on August 27th. She said that 
on Sept. 2nd Dr. Manfield gave her 4 more tablets of 
morphia, without being asked and without asking 
whether she had used any of the previous 6. 
Dr. Manfield denied this too.’ Nurse Waddingham 
said she had given the first two tablets to the deceased 
on Sept. 7th. She said Miss Baguley had been poorly 
from some date in August and one of the symptoms 
was a severe abdominal pain. She gave the morphia 
tablets for three nights because Ada Baguley suffered 
sharp abdominal pains, yet on Sept. 10th she cooked 
her a heavy meal of pork (two helpings), baked 
potatoes, kidney beans, and fruit pie. The patient 
died next morning. Dr. Manfield was sent for: 
he found the body still warm : rigor mortis had not 
set in. He certified cerebral hemorrhage as the 
cause of death. This, as the post-mortem examina- 
tion showed, was wrong. Mr. Justice Goddard 
remarked that no blame could here be attached to 
the doctor for the error. If a patient dies of a stroke, 


MEDICINE AND THE LAW 


Later she admitted that she - 


{mance 7, 1936 
the doctor can act on what he is told and he can 
but ask those who were present at the death and 
form his own opinion. The doctor was dealing with 
a patient suffering from a disease with which 
apoplectic disorders could be connected, and he was 
told that she had suffered from strokes before. ‘There 
were, as the judge observed to the jury, many points 
at which the evidence was in Nurse Waddingham’s 
favour. The inconsistencies in her story and the 
conflict between her evidence and that of Dr. Manfield 
seem to have established her guilt. 

One point of special significance was the introduc- 
tion of evidence that Ada Baguley’s mother, an 


inmate of the same home, had apparently died of a 
poisonous dose of morphine. Dr. Roche Lynch 
described the discovery of pseudomorphine in her 
exhumed body. How was this evidence of another 


death legally admissible on the charge in respect of 
Ada Baguley alone? We noted in this column a few 
weeks ago the case of R. v. Mortimer, where a soldier 
who stole a car ran down a girl on a bicycle and was 
charged with murder. Although strictly the witnesses 
should have spoken only of this incident, the court 
admitted evidence that, earlier and later, the soldier 
had driven the car at other people on bicycles. These 
facts were held to be admissible in order to show 
systematic purpose and to negative the defence of 
accident. So also in the Baguley trial the evidence 
of a parallel case was allowed in ‘order to prove 
intent. The jury was warned (for what such warn- 
ings may be worth) that the evidence of Mrs. Baguley 
having died of morphine poisoning was not to be 
accepted by them as showing that Nurse Waddingham 
was a woman who poisoned other people. The 
evidence of the mother’s death was material, said 
the judge, only in this way—if the jury thought the 
administration of morphine to the mother might 
not have been innocent, they could ask themselves 
whether the giving of the drug to the daughter 
was done with the innocent intention to relieve 
pain or with the criminal intention of taking life. 
Whether juries can master these subtleties or no, 
such is the law. The same point arose in the 
Armstrong case in 1922. On a charge of murder 
by arsenical poisoning in the month of February, 
it was proved that the prisoner had arsenic in bis 
possession both before and after that date. His 
defence was that death was due to suicide and that 
his possession of arsenic was for the innocent purpose 
of killing weeds. Evidence that he tried to poison 
somebody else with arsenic in October was held 
admissible as tending to show that the possession 
of the weed-killer at the earlier date was not for an 
innocent purpose. 

There is to be an appeal in R. v. Waddingham. 
It has been stated in the daily press, on the authority 
of the solicitor for the defence, that one ground of 
appeal will be the fact that the judge told the jury 
it was either murder or nothing and did not deal with 
the possibility of manslaughter through the negligent 
administration of morphia to the patient. The 
discussion on this and other points must be awaited. 


Hospital’s Liability for Child Patient 

A verdict of £500 damages (with costs) was entered 
last week against the Rochester and Chatham Joint 
Hospital Board, as managers of St. William’s Hospital. 
Rochester, in an action for damages for personal 
injuries to a child patient. A boy of 7 was received 
in the scarlet fever ward on the ground floor. On 
the afternoon of his first day in the ward, having 
been placed in a bed a few feet from a window, the 
lower part of which was open, he somehow sustained 


THE LANCET] 


injuries by falling out of the window to the ground 
below, a distance of about 17 ft. He suffered from 
shock and was kept three weeks longer in. hospital ; 


his forehead was disfigured and both feet are now < 


flat and require special supports. The boy’s father, 
who brought the action, said the hospital and its 
staff were negligent in leaving the patient unattended 
near the open window. The defendants denied the 
allegation and alternatively contended that, if they 
had been negligent, the child had jumped out of the 
window in the endeavour to return home, taking 
the risk of the jump and contributing by his own 
negligence to any harm which he received. The 
verdict of the jury indicates that they did not accept 
the contention of contributory negligence. 

There are interesting legal decisions on the question 
whether, or how far, a child is capable of negligence. 
Lynch v. Nurdin (1841) is the classic case. An egg- 
merchant’s cart was left unattended beside the 
pavement in Compton-street, Soho. Children played 
with it. One little boy was climbing into the driver’s 
seat when another little boy tugged at the horse’s 
bridle. The first boy consequently fell and was 
injured; his father successfully claimed damages 
and it was considered that the child had not been 
guilty of contributory negligence but had merely 
obeyed a child’s natural instincts of play. The 
inference is that a child in such cases is to be judged 
as. a child and must not be expected to have the 
mature judgment of a grown-up person. On the 
other hand he may be unable to recover damages if 
he has done what he knew to be naughty. The 
jury must consider his age and his ability to look after 
himself. Where a machine for oil-cake crushing was 
left standing in the street with the handle not fastened 
up and some schoolboys played with it, one turning 
the handle while another thrust in his fingers, the 
owner of the machine was held not liable. This 
decision has been severely criticised. Modern cases 

- are more sympathetic to the child, where the object 
is dangerous in itself, especially when it offers some 
allurement to the infant mind. Special considera- 
tions arise where the child meets its injuries while 
trespassing. The Central London Railway, for 
instance, had a moving staircase in a booking-hall 
close to the street. It attracted children from the 
street, who were frequently driven away. One child 
‘was injured while thus trespassing and the court 
held that the company was not liable. As regards the 
duty of hospital staff to foresee the natural tempta- 
tions of an open window near a child’s bed, the same 
duty would presumably exist in the case of an adult 
patient of known abnormality of mind. 


Fines for Dangerous Drugs Act Offence 


Last week the Marylebone magistrate imposed 
fines amounting to £150, with 30 guineas costs, upon 
@ physician and surgeon for failing to keep records 
as required by the Dangerous Drugs Regulations. 
The prosecution concerned 398 grains of morphine 
sulphate. It was said that the defendant had given 
one woman 190 grains at one time and another 
person 72 tubes. Both these patients were known to 
be drug addicts. It was further said that the 
prescriptions showed that the doctor, rather than 
reduce the dosage, had been increasing it; 1 grain 
had been increased to 7 or 10 grains in a few months. 
Counsel for the defence submitted that the large 
supply in one instance had been for a patient who 
was going on a cruise. The magistrate said it was 
æ case of such gravity that, if the money was not 
paid by the end of the day, the alternative would 
be imprisonment. 


THE IRISH HOSPITALS 


([maron 7, 1936 567 


THE IRISH HOSPITALS 
(FROM OUR DUBLIN CORRESPONDENT) 


AFTER the passing of the Public Hospitals Act, 
1933, the Minister for Local Government and Public 
Health appointed a commission, under the chairman- 
ship of Mr. Michael W. Doran, to investigate the 
hospital and nursing facilities existing in the Irish 
Free State, to advise him as to the improvement of 
such facilities, and generally on any matter relating 
to the administration of the Hospitals Trust Fund. 
The first general report of the commission was issued 
last Saturday, and is attracting much attention both 
from the public and the medical profession. The 
commission has shown industry, insight, and vision 
in its work, and has made a thorough and dis- 
criminating investigation of the whole hospital 
problem. The acceptance or rejection of the recom- 
mendations in the report is a matter for the Minister, 
but the report will always be of value as a historical 
document, both for its survey of the present position 
and its suggestions for the future. It is a closely 
printed volume of over 200 pages and only a brief 
abstract can be given here. 


HOSPITALS IN THE FUTURE 


The hospital system which the commission visualises 
for the future would consist of district hospitals, 
county hospitals, and regional hospitals. The district 
hospitals, of which there might be several in a county, 
would deal with such acute medical cases and receive 
maternity and surgical cases as could properly be 
treated without special services of any kind. The 
county hospitals—one in each county remote from a 
regional hospital—would cater for acute medical and 
surgical cases. Regional hospitals would be at the 
teaching centres of Dublin, Cork, and Galway, and 
also at Limerick and possibly at Sligo. They would 
deal with acute or obscure medical and surgical cases. 


CONDITIONS IN DUBLIN 


A careful survey is given of the existing facilities 
in the several centres, and a discussion follows of the 
improvements and additions considered desirable. 
The problem of Dublin is of most interest. In the 
opinion of the commission the number of general 
hospitals in Dublin is too large, and many of the 
hospitals are too small, the number of beds ranging 
from 40 to 399, excluding the poor-law hospital 
which has 1582 beds. The commission recommends 
that the ten clinical hospitals should be reduced to 
seven by the amalgamation of four hospitals on the 
south side of the city—the Meath, Mercer’s, Sir 
Patrick Dun’s, and the Royal City of Dublin. Of 
these four the three last mentioned have put forward 
a scheme of amalgamation, and in regard to the 
Meath, the commission does not think that its 
obligations are sufficient to exclude it from the 
scheme, and advises against any large expenditure 
on it should it remain independent. St. Vincent’s 
Hospital has considered removal from its present 
site in St. Stephen’s Green to a site on the outskirts 
of the city, and should be considerably enlarged. 
The commission is not concerned with the Adelaide 
Hospital which has not applied for any grant from 
the Hospitals Trust Fund. The commission does 
not recommend any interference with Dr. Steevens’ 
Hospital, the only remaining hospital on the south 
side of the city, its location and the nature of its 
activities rendering its inclusion in a scheme of 
amalgamation inadvisable. On the north side of the 


568 THE LANCET] 


city the Richmond Hospital and the Mater Miseri- 
cordiæ Hospital should both be considerably enlarged. 
The Charitable Infirmary (Jervis-street Hospital) 
should remain to carry on its work as at present,” 
being in fact the principal accident hospital of the 
city. To sum up, the scheme provides for four 
hospitals of 550 beds each, two on the north side 
and two on the south, together with Dr. Steevens’ 
and Jervis-street, and presumably the Adelaide, as 
at present. It is further recommended that these 
voluntary hospitals should take over the care of 
such acute cases as are at present given care in the 
poor-law hospital. 
FEVER HOSPITALS—ACCOMMODATION FOR 
TUBERCULOUS CASES 


The commission proposes the abolition of the 
fever wings attached to certain of the voluntary 
hospitals and the abandonment of the present fever 
hospital in Cork-street in favour of a new fever 
hospital to be built in or near Dublin. This proposal 
has already been approved by the Minister who has 
introduced a Bill to the Dáil to give it effect. It is 
not intended to amalgamate the three maternity 
hospitals of Dublin. One of them, the National 
Maternity Hospital, has just completed a new and 
vreatly enlarged building. Enlargement of the 
Rotunda is recommended, and the abandonment of 
the present building of the Coombe with its removal] 
and rebuilding on the site now occupied by Cork- 
street Hospital. 

With regard to hospital accommodation for tuber- 
culosis, the commission declares that there is a 
definite shortage of bed accommodation in the 
country, both for pulmonary and for non-pulmonary 
cases. The report recommends an open-air unit of 
100 beds at Our Lady of Lourdes Hospital, County 
Dublin, and open-air hospitals of 50 beds each at 
Cork and Galway; and also a special tuberculosis 
hospital in Dublin. There is need for further 
special provision for dealing with cancer, but the 
commission is not yet in a position to make a 
recommendation. 


“PROPOSED GRANT FOR MEDICAL RESEARCH 


The commission advises that a provisional grant of 
£10,000 a year should be given to a Medical Research 
Council, at present being constituted, for the purpose 
of medical research. The need for developing the 
social service side of hospital work is strongly stressed, 
and attention is drawn to the need for almoners’ 
departments in nearly all the Dublin hospitals. 

The commission makes a clear statement of the 
present financial position of the Hospitals Trust 
Fund and of the cost of carrying out the recom- 
mendations now put forward and meeting commit- 
inents already entered into. Considering estimates 
for proposed expenditure and endowment a sum of 
£7,900,000 will be required to enable the recom- 
mendations in regard to voluntary hospitals to be 
realised. Of this "£3, 383,853 is at present available. 
Recent sweepstakes have shown that the share of the 
voluntary hospitals from each sweepstake averages 
some £363,000. It is impossible to prophesy whether 
this return will be maintained or not, but even if it 
should be, it is clear that it will be some four years 
before the necessary fund is accumulated. The 
commission, therefore, believes that caution should 
be exercised in regard to beginning building schemes 
which would require a large capital for their com- 
pletion until it is reasonably sure that sufficient funds 
will be available. With care, however, an advance 
might be steadily made without discrimination 
avainst any particular hospital or undertaking. 


SCOTLAND 


[MARCH 7, 1936 


SCOTLAND > 
(FROM OUR OWN CORRESPONDENT) 


THE CORPUS LUTEUM AND PREGNANCY 


Dr. J. M. Robson spoke to the Edinburgh Patho- 
logical Club last week on his investigations into the 
activity of the corpus luteum in pregnancy. Among 
animals, he said, three types can be recognised: 
(1) those in which ovulation occurs only after mating ; 
(2) those in which ovulation occurs without mating 
but in which a physiologically active corpus luteum 
is not formed unless mating takes place; and 
(3) those in which ovulation and the formation of 
an active corpus luteum occur spontaneously. In 
some species (e.g., man) the duration of activity of 
the corpus luteum of pseudopregnancy is much 
shorter than that of pregnancy, whereas in others 
(e.g., dog) the periods are of roughly equal length. 
In some animals (e.g., the mare) the corpus luteum 
degenerates in the early stages of pregnancy, and 
this raises the question how far it is necessary that 
luteal secretion should continue until term. The 
available data show that in some species the corpus 
luteum is essential during almost the whole of preg- 
nancy, but in others (man, horse, cat, and guinea-pig) 
its removal does not necessarily lead to abortion. 
The luteal hormone in Dr. Robson’s opinion is 
probably secreted by the placenta as well as the 
corpus luteum, and the importance of the latter in 
different species during pregnancy may vary inversely 
with the capacity of the placenta to produce progestin. 
During pregnancy this hormone is essential for the 
preparation of the endometrium after fertilisation, for 
implantation itself, and probably for the subsequent 
nutrition of the developing embryo and placenta. 
It also inhibits the reaction of the uterine muscle to 
oxytocin and controls the spontaneous rhythmic 
activity of the uterus—in these respects antagonising. 
the action of cstrin. When the pituitary is essential 
to the maintenance of pregnancy, its function consists 
in maintaining the luteal secretion, and pregnancy 
can actually be maintained in the hypophysectomised 
rabbit by the administration of the pure hormone 
progesterone. Experiments now in progress, said 
Dr. Robson, further show that the structure and 
secretory activity of the corpus luteum in hypo- 
physectomised rabbits can be maintained by injection 
of gonadotropic hormones. It is possible, he believes, 
that in species in which abortion does not follow 
removal of the pituitary, the secretion of progestin 
by the corpus luteum and/or placenta may be under 
the control of gonadotropic hormones produced by 
the uterine contents. 


MENTAL HOSPITALS AND MENTAL HEALTH 


In presenting the 123rd annual report of the Royal 
Edinburgh Ilospital for Mental and Nervous Dis- 
orders last week Prof. D. K. Henderson said he 
regarded institutional psychiatry as perhaps the 
smallest part of the psychiatrist's task. He has a 
much bigger sphere which involves the prevention 


‘rather than the cure of those who may be nervously 


or mentally ill. The importance of this principle is 
well recognised by the managers of the hospital 
whose many organisations show that they are 
attempting to establish a mental health service in 
direct relation to the community. The clinics at the 
Royal Infirmary, at Jordanburn Hospital, and at the 
University Clinic have formed a chain of medical 
service which offers help.and treatment to all ages 
and for all conditions of the nervous and mental 


THE LANCET] 


health. The number of patients treated shows a 
steady increase and people are no longer unwilling to 
consult a psychiatrist. The clinics are of great value 
in allowing medical students to become familiar with 
every phase of nervous and mentalillness. The student 
is taught to learn to gppreciate how emotional] forces 
can control and modify bodily functions and how 
readjustment can be effected. The importance of 
this is emphasised by the fact that a recent survey 
of a group of insured patients under the National 
Health Insurance Act showed that a third were 
incapacitated as a result of nervous illness of some kind. 
Prof. Henderson said he looked forward hopefully to 
the time when a department for the treatment of 
early forms of nervous and mental diseases would be 
incorporated in every progressive general hospital. 

At Glasgow, in the annual report of the Royal 
Mental Hospital, Dr. Angus MacNiven points out that 
nearly 40 per cent. of the total admissions show a 
depressive reaction. He deplores the lack of under- 
standing among the public of mental disorders and 
mental hospitals, which he describes as a serious 
obstacle to progress. An encouraging feature, how- 
ever, is that more than half of those admitted to the 
hospital came as voluntary patients, using the 
hospital for the treatment of their mental illness as 
they would a general hospital for the treatment of 
a physical complaint. A mental hospital is not a 
place of discipline, but should be regarded more as 
a refuge to the patient in time of trial. He stressed 
the importance of providing facilities for the treat- 
ment of functional nervous disorders. The Lans- 
downe Clinic provided an initial step in this direction, 
but many cases required to be removed from their 
home environment and there is an urgent need for 
the provision of a special hospital or a special depart- 
ment in one of the general hospitals for the treatment 
of functional nervous disorders. 


THE TRAINING OF NURSES IN SCOTLAND 


The report of the Scottish Departmental Com- 
mittee on the Training of Nurses contains some 
important suggestions for the future development of 
the nursing profession in Scotland. After a brief 
summary of the functions of the General Nursing 
Council for Scotland, the committee review the 
essential requirements for a fully trained nurse, 
among which requirements they place experiences in 
the wards of a hospital for infectious diseases. They 
discuss the various interests involved—the nurses 
themselves, the public, the hospital, the doctor, and 
the local health authorities—showing that no scheme 
for the training and provision of nurses can be 
regarded as satisfactory which does not give due weight 
to the just requirements of each. They point out 
defects in the present system and make pertinent 
proposals for remedying them. The most important 
of the 15 recommendations summarised at the end 
of the report is that for the establishment of a 
‘< Central Registry’ to contain the names of nurses 
who are ‘fully trained,’ that is, trained for five 
years, four of them being spent in a medical and 
surgical hospital and in a fever hospital, followed 
by two courses of six months each out of a selection 
offered, such as sick children, tuberculosis, mental, 
orthopedics, chronic sick. Nurses who are entitled 
to have their names on two parts of the register, 
one being the general part, would also, under the 
scheme, be eligible for inclusion in the ‘“‘ Central 
Register.” Other recommendations include provision 
for the examinations in anatomy and physiology, 
hygiene, and. dietetics of the Preliminary State 
Examination, to be taken as a normal procedure 


PARIS 


[manoH 7, 1936 569 


before trainees enter hospital; grants to hospitals 
providing facilities for the training of nurses for the 
“ Central Register’’ and also, in lesser amount, to 
hospitals training in the present system; the 
establishment of a supplementary part of the 
register for tuberculosis nurses; and the revision of 
arrangements for application between hospitals in 
order to secure a greater degree of elasticity. 


PARIS 


(FROM OUR OWN CORRESPONDENT) 


THE NEW FRENCH ACADEMY OF SURGERY 


THERE is nothing in France exactly equivalent to 
the F.R.C.S. Eng. with its searching examinations 
and enviable prestige. There is no special, surgical 
diploma or brevet de chirurgien. A certain cachet 
attaches to membership of the Syndicat des Chirur- 
giens, or to one or other of the Parisian or provincial 
surgical societies, or the surgeon may secure election 
to the Academy of Medicine or the Academy of 
Sciences. But now the old Académie de Chirurgie 
has been resuscitated at the Sorbonne in the presence 
of Mr. Lebrun, President of the Republic, and many 
other notables. Prof. Gosset, who as president of 
the executive committee has taken a leading part in 
this revival, traced in his speech the history of the 
Academy from its birth in the reign of Louis XV. 
Dissolved during the French Revolution it has carried 
on since as little more than a surgical society, its 
members not enjoying the title of academician. It 
has long been felt as a slur on surgeons that the 
Academy of Medicine should monopolise academic 
honours in the profession ; out of a total member- 
ship of 120, only 16 seats are reserved for surgeons, 
though it should be noted that the present occupant 
of the presidential chair is the well-known surgeon, 
Prof. Hartmann. It would have been a delicate 
task to reorganise the Academy of Medicine in such 
a way as to satisfy the legitimate claims of the 
surgeons, and Prof. Gosset is to be congratulated 
on his solution of the problem. 


NEW IDENTITY CARDS 


Steps have been taken to facilitate travel in France 
by the issue of a special identity card to be called 
the ‘‘ tourist card,” and to be valid for six months. 
It will be issued gratis by French consulates, and 
will help to do away with some of the formality 
which has hitherto embarrassed the foreigner wishing 
to pay something more than a flying visit. The 
period of grace, during which identity cards were 
superfluous, has till now lasted only two months 
and aweek. After this interval, visitors had to apply 
to the préfet for a non-worker’s card, for which there 
was something to pay. Under the new regulations 
the foreigner shows his passport, signs a declaration 
to the effect that he will not work in France, and 
that he has sufficient funds to support him during 
his stay. His tourist card he must give up on leaving 
France within six months; if he stays more than 
that he must apply and pay for a non-worker’s card. 
Between now and the end of this year tourists who 
have not received a tourist card before entering 
France must apply for it within 15 days of entering 
French territory at the local prefecture of police. 


PARIS TRAFFIC 


In 1935 there were 237 traffic deaths in Paris 
itself and 226 in its suburbs. This total of 463 


570 


THE LANCET] | 


compares favourably with the corresponding figure 
(498) for the previous year. The victims per cent. were 
pedestrians 56, cyclists 20, employers of various 
other vehicles 23. Responsibility for the accidents 
was divided fairly equally between the killers and 
the killed, 52 against 46 per cent.; in only 2 per 
cent. was there uncertainty which of the parties was 
to blame. The danger was greatest late in the after- 
noon, as many as 141 of all the fatal accidents occur- 
ring between 5 and 8 P.M. There were only 30 fatal 
accidents between midnight and 6 a.m. In 19 per 
cent. the accidents were traced to drivers who were 
‘insufficient masters of their speed.” 


CHARLES NICOLLE 


The death of Charles Richet, man of science and 
man of letters, has now been followed, after only a 


INTRANASAL SUBMUCOUS INJECTIONS OF CALCIUM 


[MARCE 7, 1936 


few weeks, at Tunis, by that of another Frenchman 
distinguished in the world of letters as well as in 
that of science. Charles Nicolle was gifted with a 
restlessly imaginative mind, and there was nothing 
he hated more than the humdrum orthodoxy of most 
so-called seats of learning. It was, therefore, perhaps 
well for him that he was able to spend most of his 
life after 1903 in Tunis where, far from faculties 
and universities and learned societies, he was free 
to scoff at them gently and to go his own way, in 
science as well as in letters. He was never attached 
to the Pasteur Institute of Paris, and the rumour 
that he would succeed Roux at this seat of learning 
proved to be ill-founded. As he remarked whim- 
sically a few years ago, he had too much imagination 
and independence ever to become a conventional 
man of science. 


| CORRESPONDENCE 


INTRANASAL SUBMUCOUS INJECTIONS 
OF CALCIUM 


To the Editor of THE LANCET 


Sm,—During experiments on the local effect 
of subcutaneous injection of salt solutions I observed 2 
that repeated injection led to thickening of the sub- 
cutaneous tissue together with desquamation of the 
epidermis. The thickening is probably due to an 
increase of fibrous tissue (histological examinations 
have not yet been made), and I thought that, if the 
same effect could be produced by submucous injections, 
it might be of therapeutic value in cases where 
excessive serous secretion shows abnormal permeability 
of the vessels (e.g., vasomotor rhinitis and hay-fever). 
This idea gained support from a case in which I 
had made several submucous injections with novocain 
for the treatment of aural tinnitus ?; there appeared 
such thickening of the submucous tissue and dis- 
appearance of the cavernous plexus of the inferior 
concha that further injections were impossible. 

Since then, to patients with increased serous nasal 
secretion, I have given submucous injections of calcium 
salts into the inferior concha, hoping that the constrict- 
ing effect of the calcium ions would considerably 
amplify the non-specific effect of the salt. At first 
I injected 5-10 c.cm. of 1-5 per cent. calcium chloride 
‘solution; later I used stronger solutions, but as 
calcium chloride in high concentration injures the 
tissues, I employed 10 or 20 per cent. Calcium 
Sandoz (gluconate) solution, which was always 
well tolerated. The injection is made with a straight 
needle, at least 5 cm. long, into the anterior part of 
the inferior concha. Very little pain is felt, and 
anesthesia is therefore unnecessary. The needle 
is pushed in for 1:0-1-5 cm., parallel with the concha, 
and 5c.cm. is injected, taking about thirty seconds. 
Only a slight swelling of the concha ensues, since the 
injection is mostly intravenous; indeed, this sub- 
mucous route may be used instead of the ordinary 
intravenous one when the latter presents difficulty. 
During the injection there is a feeling of heat in the 
whole body, but no other side-effects and no pain, 
either at the time or later. When the needle has 
been pulled out, an adrenaline tampon is placed 
in the nose and pressed against the wound; after 
some minutes this can be removed. I repeat the 
injection on the third day and again on four or five 
occasions. Usually I do not inject both sides on the 
same day. In most cases the first injection is followed 


1 Deut. med. Woch., 1932, lxviii., 1560. 
3 Bárány, R.: Acta oto-laryng., 1935, xxiii., 201. 


by reaction with increased secretion, but after the 
later injections this was not observed. In the 
patients thus treated the secretion has diminished 
considerably, and in some cases I have a very good 
therapeutic result with complete disappearance of 
unpleasant hypersecretion. In those with allergic 
rhinitis (principally rhinitis estivalis) the local applica- 
tion of calcium is active not only in its constricting 
effect, but probably also because, at high local 
concentrations of calcium, the antigen-antibody 
reaction passes off without irritation of cells—that 
is to say, without hypersecretion. This has lately 
been shown by P. Kalós and L. Kallés-Deffner 3 
in my laboratory. _—_.” : 

A detailed report will be published later. Here 
I want only to show this new possibility of effective 
therapy.—I am, Sir, yours faithfully, 


ROBERT BARANY. 
Ear, Nose, and Throat Clinic, University of 
Upsala, Sweden, Feb. 29th. 


‘A DOUBTFUL CASE OF TYPHUS FEVER ” 
To the Editor of THE LANCET 


SIr, —It seems to me that the best comment on 
the epithet “‘ doubtful” as applied to the case of 
typhus fever reported on p. 864 of your issue of 
Oct. 12th last is to be found in the following extracts 
taken from the article on typhus fever by Drs. Brill 
and Baehr in vol. i. of Nelson’s ‘* Loose-Leaf 
Living Medicine ” :— 

(P. 200): “The difficulty in diagnosis is increased. 
when a sporadic case of the endemic variety is encountered 
However if one bears in mind the important clinical 
features of the disease . .. mistakes in diagnosis will 
rarely be made. If an incorrect diagnosis is made, it 
may easily be corrected when the critical fall in tempera- 
ture occurs, as the crisis is one of the most important 
differential features of the disease.” 

“ Weil-Felix reaction . . . A negative test cannot be 
accepted as evidence that the disease is not typhus fever.” 

(P. 201): “The authors’ experience is that in cases of 
the endemic type the serum seldom gives a W.-F. reaction 
in dilutions sufficiently high to be of diagnostic value.” 

“... The Widal agglutination test with typhoid 
bacilli was found to be of little differential value. Typhus 
patients who had previously had typhoid fever . . . often 
developed a positive Widal reaction during the second 
week of their disease.” 


To my mind the case reported is a typical instance 
of the sporadic endemic typhus, which is a severe 


3 Klin. Woch., 1935, xiv., 1247. For further information, 
cf. Wojatschek,W., Undrits, V. F., and Drennowa, K. A.: Zeits. 
f. Hals-, Nasen,- u. Ohren., 1933, xxxiii.,191; and Drennowa, 
K. A.: Arch. f. Ohren-, Nasen-, u. Kehlkopfh., 1930, cxxx., 235. 


THE LANCET] 


but seldom fatal illness. As Dr. Brill says in the 
article above quoted (p. 201) referring to the tradition 
in text-books which inclines the student to believe 
that there is any difficulty in separating the two 
diseases (typhus and enteric): ‘“‘the two diseases 


have nothing in common in pathology, etiology or. 


symptomatology.” 

Incidentally, were the two laboratories to which 
the blood-serum was sent stocked with the varieties 
of Bacillus proteus isolated by the Federated Malay 
States Institute for Medical Research (see their 
- Bulletin No. 1 of 1930)? It is difficult to say what 
value can be placed on their reports ‘‘ Weil-Felix 
reaction, negative’’ on a patient who brought the 
disease from the Straits, if they do not report that 
the serum was tested against strains of B. proteus 
appropriate to the case in question. If the Port 
of London health authority reports typhus only 
when confirmatory evidence is supplied by a laboratory 
we should hear more about this, and in a disease like 
typhus it is no use hedging and saying that ‘* bacterio- 
logically the case was considered to be typhoid ”’! 

JT am, Sir, yours faithfully, : 
Hankow, Jan. 27th A. H. SKINNER; 


THE TREATMENT OF VAGINAL DISCHARGE 


To the Editor of THE LANCET 


Sır, —I read Mr. Gordon Luker’s letter in your 
last issue with great interest, inasmuch as his experi- 
ences differ so widely from my own. After eight 
years’ work in a large clinic, I have come to the 
conclusion that the majority of non-venereal dis- 
charges of which women complain is due either to a 
staphylococcal or, more frequently, to a trichomonas 
infection of the vagina. In a small series of 30 cases 
which I investigated some time ago, I found the 
trichomonas— identified by the dark-ground method— 
in 14, or nearly 50 per cent. Its presence was in 
9 cases diagnosed before microscopy by the typical 
frothy discharge. This afternoon I examined the 
first 6 cases that came in, and found trichomonas 
in 2 of them. Advertisement or no, this form of 
infection has yielded more rapidly to Devegan than 
to any previous form of treatment that I have tried, 
and while not for an instant suggesting the applica- 
tion of the remedy to vaginal discharges in general, 
I have found it very useful for what, in my experience, 
is a common infection. 

I am in complete agreement with Mr. Luker on the 
necessity for a thorough examination of the patient 
and the discharge itself, but I must differ from him 
in his opinion of the relative frequency of a tricho- 
monas infection, and the efficacy of devegan in its 
treatment. I am, Sir, yours faithfully, 

Harley-street, W., March 2nd. KEITH DUFF, 


“ NEAR” X RAY THERAPY 
To the Editor of THE LANCET 


Sir,—Consideration of the possibilities of Chaoul’s 
new ‘‘near’’ X ray therapy method (THE LANCET, 
Feb. 29th, p. 482) suggests that these are not limited 
to the special low-voltage short-focus tube, but could 
be extended to a much wider use with any fully shock- 
proof X ray therapy tube. Indeed, many of Chaoul’s 
best results have been attained with a kilovoltage 
of 180, with 0°5mm. Cu. filter at 8cm. distance, or 
with 100kV., 05mm. Cu., Ilem. distance (see 
Tables C and B in Strahlentherapie 1933, xlviii., 
31 (21 cases)). Tests with a 200 kV. shock-proof 
tube have shown that it gives a radiation of 50 r/min. 
at 100 KV. and 30 cm. distance, 0°2 mm. Cu. equivalent 
filter, Approximately at 15cm. the radiation is 


THE TREATMENT OF VAGINAL DISCHARGE 


[manoH 7, 1936 571 


200 r/min., and at 7°5cm. it is 800 r/min. Treat- 
ment at 6cm. seems possible with this tube. I 
doubt if such extremely high intensities as 800 r/min. 
or more have ever been applied to patients: they 
would correspond to that from one curie in a bead- 
sized light applicator to rodent ulcers of minute size 
by Kelly and Burnham for one minute at the end of 
a long rod. a 

After tests of the tube’s emission at from 1 to 
6 M.A. from 60 to 100 kV. (0°2-mm. Cu. filter) and 
from 1 to 4M.A. from 100 to 200 kV. (with heavier 
filters) I have treated several patients with ulcerated 
breasts (primary or recurrent) and a supraclavicular 
metastasis from a parotid tumour. The factors used 
were 12 and 15 cm. distance, 70 or 80 kV., 4 M.A., and 
0.2mm. Cu. filter; 14 and 2 minutes exposure. 
Tests with surgical specula for mouth, tonsil, and 
cervical applications have also been made with 
ionisation and pastille methods. Lead or lead- 
rubber to localise the fields has appeared adequate ; 
special applicators could be put on the market for 
various sizes and distances. 

The daily treatments of from one to four minutes 
contrast agreeably with the opposite pole of method, 
the protracted-fractional of Coutard. The latter 
appears: to act “‘selectively,” powerfully affecting 
abnormal and sparing normal tissues (as radium 
distance applications do) and is thus most valuable 
for deep-lying tumours in vital areas; whereas the 
near method appears to act more “‘ cytocaustically ” 
—as near or contact radium applications (gamma or 
beta) act—thus being more suitable for quite super- 
ficial lesions, specially if already ulcerated. These 
two extremes of method have greatly enlarged the 
field of X ray therapy. The near method, however, 
should be explored to the full possibilities of shock- 
proof tubes and not be limited to the use of the small 
aperture 60 kV. tube specially designed for cavitary 
applications.—I am, Sir, yours faithfully, 


J. H. DOUGLAS WEBSTER, 
Harley-street, W., Feb. 29th. 


ALLEGED NEGLIGENCE IN HYPODERMIC 
INJECTION G 


To the Editor of THE LANCET 


Str,—The article in last week’s issue of THE 
LANCET (Medicine and the Law, p. 500) reminds me 
of an unpleasant experience I suffered about 25 years 
ago. I have before now related the circumstance to 
my students as a warning. 

About five years prior to the incident leading to 
the allegation I had been consulted by a practitioner 
of medicine who had contracted syphilis, and I had 
treated him over a long period. One evening a tele- 
phone message summoned me to his house some four 
miles distant. He was suffering intense pain. Obvi- 
ously morphine was necessary, but upon my sugges- 
tion that I should go home and fetch a syringe and 
drug he replied, “It will take you half an hour” 
(20 mile limit then). “I can’t stand this pain. 
Here is my syringe and morphine.” 

Upon examination of the syringe I noticed that it 
was fitted with a leather washer and remarked that 
it could not be boiled. He persuaded me to use it; 
after rinsing it many times in carbolic acid solution, 
morphine was dissolved in boiled water and injected 
into the arm. Three or four days later I heard that 
the doctor was in a home, and on going to see him 
learnt that he had cellulitis of the arm which needed 
incisions. I expressed regret. The following day a 
letter informed me that he was taking proceedings 
against me, claiming damages for negligence. On 


572 THE LANCET] 


approaching the defence society to which I subscribed 
I learnt that the plaintiff had already communicated 
with the society, and the secretary doubted whether 
in the circumstances the committee of the society 
would arrange for my defence, because I should lose. 
In answer to the question ‘“‘ Why,” he said that in 
cross-examination the counsel would ask me whether 
I had found fault with the syringe, and upon my 
admitting that I had he would say, then you had no 
right to use it. A mutual friend approached the 
practitioner. Years later it came to my ears that 
he had used the argument that the counsel for the 
defence would have asserted that in a normal man 
cellulitis would have not developed, and that the 
plaintiff's resistance had been reduced by syphilis. 
Anyway the charge was withdrawn; a few days 
later a generous patient made me a present which 
I had the pleasure of forwarding to the unfortunate 
practitioner, and this more than covered his expenses. 
I am, Sir, yours faithfully, 
March 2nd. O.L 
STAMMERING 


To the Editor of THE LANCET 


Sır, —I was very interested in the annotation on 
the subject of stammering in your issue of Jan. 25th 
(p. 208) but I was puzzled by the following sentence : 
“For this reason some authorities have dispensed 
with any specific speech training and have con- 
centrated . .. on relaxation.” Since we are not 
bivocal but use the larynx for speech and song 
surely speech ‘training should proceed on the lines 
of training the voice for song. All singers will agree 
that one of the most important factors in voice 
training is to teach the pupil to relax as far as pos- 
sible all muscles in the throat and neck which do not 
assist in the production of vocal tone; in other 
words, to overcome hypertonicity which must be 
overcome not only by a stammerer but by every 
speaker or singer who aims at getting the best results 
from his larynx. 

Miss Kate Emil-Bebnke in her interesting letter 
of Feb. 22nd seems to contradict herself when she 
says, ‘it will yield to psychic handling combined 
with ‘relaxing’ and quiet breathing exercises,” 
and ‘“‘the serious error of adopting elocutionary 
treatment.” If elocution means, as it should, speech 
training and voice training, it must include some 
study of deep breathing (to learn breath control) 
and “relaxing ’’ as described above. If Miss Behnke 
means the type of elocution which merely consists 
in the overstressing of the consonants I am in agree- 
ment with her, because nearly all stammerers already 
overstress the consonants at the expense of the 
vowels, and thus talk in the jerky, staccato manner 
which, in its most exaggerated form, is a typical 
stammer. When singing the vowels must pre- 
dominate, and they should do so to some extent in 
good speech. It is this predominance of the vowels 
which enables the stammerer to sing without difficulty. 
If the stammerer will cultivate a slight predominance 
of vowels over consonants he will learn to speak 
smoothly and will overcome hypertonicity. This 
should be the aim of everyone who wishes to speak 
musically and audibly; it is not a mannerism to 
cure a stammer but the method of getting the best 
results with the least effort. 

Although some knowledge of deep breathing and 
breath control is needed for perfect speech it should 
be clearly understood that taking a deep breath 
before speaking will increase the difficulties of a 
stammerer and of any other speaker. “Little and 
often”? is a good rule. One of the greatest singers 


A SECONDARY REACTION AFTER ANTI-CHOLERA INOCULATION 


[marca 7, 1936 


of all time said, ‘‘ Never take more breath than can 
be easily controlled.” 

The unusual type of stammerer who stammers on 
the vowels as well as “‘ sticking’? on the consonants 
presents a difficult problem to the speech therapist, 
but space will not allow a detailed ex xpl anation 
here. 

The variability of the incidence of a stammer 
proves that it is very largely due to a neuropathic 
condition, but I cannot think of anything more 
calculated to overcome this condition than learning 
the fundamental principles of perfect speech, while 
the success which follows such study will obviously 
allay anxiety. 

I am, Sir, yours faithfully, 
H. St. JoHN RuMSEY, M.A., 


Instructor for Speech Defects at Guy’ 8 Hospital. 
Feb. 22nd. 


A SECONDARY REACTION AFTER 
ANTI-CHOLERA INOCULATION 


To the Editor of THE LANCET 


Sir,—During the last cholera epidemic in the 
Bassi district. in Patiala State mass anticholera 
prophylactic inoculation was done. This produced 
a general and a local reaction which lasted for two 
or three days after the inoculations. To my utter 
surprise, however, about 8—10 per cent. of the persons 
inoculated got another general and local reaction 
on the twelfth, thirteenth, or fourteenth day after 
the inoculation, in the usual form of a pyrexia 
(varying from 100-102° F.) and local redness at the 
site of the injection, along with pain and tenderness. 
But this secondary reaction, as I may call it, was 
milder than the primary one, and no other sign or 
symptoms were observed. It lasted for about 28-36 
hours only, and many of the sturdy villagers took no 
account of it. Those who came to us for advice 
were treated on general lines and symptomatically. 

The only explanation that I could think of at that 
time was that the condition was caused by abscess 
formation due to negligence in our asepsis. But 
among 4000 cases of inoculation done by me in that 
part of the district, there was only one abscess (on 
the sixth day). We had taken every possible aseptic 
precaution throughout and the vaccine, which was 
supplied by the Central Research Institute, Kasauli, 
was used within two or three days of its receipt. 
I consulted my colleagues who too were working 
in the other cholera-stricken areas of the State and 
all of them had also observed the same phenomenon. 
We could find no published information, however, 
concerning the cause or significance of a secondary 
reaction after prophylactic anti-cholera inoculation, 
and I should be glad therefore if any of your readers 
could tell me whether they have seen such a thing 
or can throw light on its origin. 

I am, Sir, yours faithfully, 
M. TEWARI, 


Hon. Clinical Assistant, Rajindra Hospital, 


Jan. 15th. Patiala (State), India. 


AN ADDRESS IN HARLEY STREET 
To the Editor of THE LANCET 


SIR —A distinguished hospital surgeon, not living 
in Harley Street, told me the following story ; ; it is 
very apropos to Mr. F. C. Goodall’s letter in your 
columns last week. The surgeon was asked to see 
in consultation a patient living in the country, when 
it was his duty to tell the husband “ there is nothing 
to be done.” Leaving the house with the family 
practitioner, 


the latter was caled back by the 
husband, and on rejoining the consultant he exclaimed, 


THE LANCET] 


PANEL AND CONTRACT PRACTICE 


[maron 7, 1936 573 


oua a So eee 


“that man said, ‘now let’s have a Harley Street 
man!’”? Mr. Goodall is right. The public should 
learn “ Harley Street is not a degree but an address ” ; 
believe me, they do not realise it, and the owner of 
an address in Harley Street knows its commercial 
value. I am, Sir, yours faithfully, 

March 3rd.- l W. B. C. 


SHORT-WAVE THERAPY 
To the Editor of THE LANCET 


Sır, —The statement in a leading article in THE 
Lancet of Feb. 22nd (p. 436) that “‘Short-wave 
therapy has come to mean treatment by electro- 
magnetic oscillations, &c., requires correction. 
Actually most treatments are carried out by the use 
of the high-frequency electric field. Electromagnetic 
oscillations are not as a rule used for wave-lengths 
shorter than 20 metres. A more serious error, and 
one which is often repeated, is that ‘“‘for each sub- 
stance there is a definite wave-length with which, for 
a given field strength, the heat produced is maximal.” 
It should have been stated that for a given wave- 
length there is a definite conductivity for which 
heating is maximal—a very different statement. 
This effect shows itself even in wave-lengths as long 
as 200 metres. Further, the writer of the article 
states that the kidney of an animal can be necrosed 
without damaging the skin. I have carried out 


experiments on large numbers of animals, using 
4-5m. and 3-4 m., and have never noticed this effect 
unaccompanied by inflammatory changes in the 
skin and superficial tissues. Lastly I would mention 
the fact that as far as I can find in the literature the 
claim for ‘‘specific’’ effects on bacteria has never 
been independently confirmed. A paper was pub- 
lished by Sir Leonard Hill and myself in THE LANCET 
of Feb. 8th, 1936 (p. 311), which showed that we 
could find no evidence for any “specific” effect of 
the high-frequency field on some physiological 
preparations. 
I am, Sir, yours faithfully, 
H. J. TAYLOR. 


St. John Clinic and Institute of Physical Medicine, 
Ranelagh-road, London, S.W., March 2nd. 


*.* We had hardly thought it open to doubt that 
when a number of substances of different conduc- 
tivities and about the same dielectric constant are 
placed in the condenser field. one substance is likely 
to be heated more rapidly, at any given frequency, 
than the others—that one, namely, of which the 
conductivity most nearly satisfies the simple relation- 
ship x = vė (x = conductivity, » = frequency, 
e = dielectric constant). It was made clear in our 
comments that the alleged lethal effects on bacteria 
are frequently disputed ; we are interested to know 
that Dr. Taylor has himself never observed necrosis 
of the kidney without some damage to the superficial 
tissues.— ED. L. © 


PANEL AND CONTRACT PRACTICE — 


Insulin for Seamen 


Two doctors have recently been called to account 
for prescribing insulin, sufficient to cover the period 
of a transatlantic voyage, for seamen whose names 
were included on their lists. Under Section 62 of 
the N.H.I. Act, 1924, a master or seaman is not 
entitled to medical benefit for any period during 
which the owner of the ship is under the Merchant 
Shipping Act, 1894 (as amended by any subsequent 
enactment, or otherwise), liable to defray the expense 
of the necessary advice, attendance, and medicine. 
Section 34 (1) of the 1906 Act, as amended in 1923, 
provides that if the master or seaman suffers from any 
illness (not being an illness due to his own wilful 
act or default or to his own behaviour) the expenses 
shall be defrayed by the owner of the ship, without 
deduction from his wages. It seems that the men 
in question were entitled to treatment during the 
voyage from the ship’s surgeon (in each case the ship 
was a passenger liner) and not entitled to medical 
benefit. Normally the cost of any prescription issued 
by a doctor for a preparation which does not form 
part of medical benefit would be recovered from the 
practitioner by deduction from his remuneration and 
the chemists’ fund appropriately reimbursed. In 
one case the man remained on the ship for only half 
the anticipated period and was entitled to medical 
benefit for the remainder. The insurance committee 
took the view that the doctors had acted in good 
faith, and was disinclined to debit their accounts 
with the cost of the insulin. A warning letter is to 
be issued and, subject to the consent of the Minister 
of Health, the cost of the prescriptions (about 
£3 17s. 6d.) in so far as it is not chargeable to the 
chemists’ fund will be met from the general purposes 
fund. This seems to be a sensible way out of the 
difficulty, but it may be wondered what arrange- 
ments would have been made for the supply of 
insulin to these diabetic mariners if they had joined a 


“dirty British coaster with a salt-caked smoke- 
stack.” Perhaps, if they had divulged their con- 
dition, they would not have been signed on at all. 


‘« Special Skill and Experience ” 


The London insurance committee has just had a 
report on specialist services rendered during 1935 
to insured persons by insurance doctors in the 
county. In each case the local medical and the 
insurance committees agreed that the service rendered 
involved the application of special skill and experience 
of a degree or kind which general practitioners as a 
class could not reasonably be expected to possess, 
and that the practitioner concerned was possessed 
of the necessary skill and experience to enable him 
adequately to carry out such service. Some 2075 
doctors are included in the committee’s medical 
list, and of these 6 charged fees for ophthalmic 
and 12 for other services, the complete list being 


as follows :— 
Cases. 
11 


7 
34 
22 

1 


OPHTHALMIC SERVICES 
Retinoscopy and ophthalmoscopic examination 
Retinoscopy and prescribing glasses 
Refraction—ophthalmoscopic examination ade a 
Refraction under mydriatic—ophthalmoscopic ex- 
amination i ats ea ra a 
Refraction and prescribing of glasses 


OTHER SERVICES 


Ultra-violet rays for: eczema, 2; furunculosis, 2; 
boils, 1; respiratory catarrh, 1; neurasthenia, 4 ; 
sweats and frequent colds—general debility, 2; acne 
of face—debility, 2; arthritis of knees, 1; alopecia, 
1; melancholia, 1. Total sh “ne T 

Infra-red treatment for acute myositis .. 

Course of pelvic diathermy sa Xe 

a es and cervical diathermy Ae 

Diathermic coagulation with local anesthesia .. 

Appendicectomy .. si ica Ex Ds 

Psychotherapy for anxiety neurosis 

Tonsillectomy—dissection of tonsils 

Removal of large Meibomian cyst sa 

Removal of toe for long standing deformity 

Dilatation and curettage for dysmenorrbcea ` 

X ray diagnosis of septic focus in tarsal bone .. 

Radiant heat and massage for intercostal fibrositis 


n 
PEE EEE = 


jad 
þad 
B 


574 ‘THE LANCET] 


Surgery Inspection 


A practitioner who recently applied for inclusion 
in the London medical list intimated that he desired 
to carry on an insurance medical practice at a place 
other than where he resided, the distance between 
the addresses being about a quarter of a mile. There 
was no caretaker at the surgery, no deputy had been 
appointed to act in case of emergency, and there was 
no telephone either at the residence or at the surgery. 
The doctor said he proposed to exhibit at the surgery 
a notice indicating his private address. The insurance 
committee, not being satisfied that the proposed 
arrangements were adequate, asked an ex-chairman 
of the committee, along with the secretary of the 
local medical and panel committee, to visit the 
surgery and report. On the morning on which the 
visit was due to be made a letter was received from 
the doctor to the effect that his surgery premises 
were shortly to be demolished, that he was hoping 
to obtain other premises in the course of a few weeks, 
and suggesting that in these circumstances the visit 
was unnecessary. It was then too late to cancel 
the visit and the report showed that the waiting- 
and consulting-room consisted of a small shop with 
æa screen running partially down the centre. The 


OBITUARY 


[marcy 7; 1936 


screen did not reach from end to end of the room 
nor did it reach the ceiling, there being at least three 
feet between the end of the screen and the further 
wall and a similar gap between the top of the screen 
and the ceiling, so that a waiting patient could hear 
all that occurred in the consulting-room. The com- 
mittee’s representatives informed the doctor that the 
accommodation provided was unsuitable for an 
insurance medical practice; his application for the 
inclusion of his name in the medical list remains in 
abeyance pending the submission of particulars about 
alternative accommodation. Some other premises 
have recently been found unsuitable for their purpose. 
Up to the present time visits have been paid to 
surgeries only when practitioners have applied for 
consent to the employment of an assistant or where 
some special cause has arisen. The insurance com- 
mittee has now referred it to the proper subcom- 
mittees to consider and report on the desirability of 
satisfying the committee in every instance with the 
surgery accommodation to be provided by an 
insurance practitioner before he undertakes insurance 
work. Clause 9 (4) of the Terms of Service lays on 
the insurance committee the onus of seeing that the 
accommodation provided befits the conditions of 
practice. 


OBITUARY 


JAMES BRUNTON BLAIKIE, M.B. Edin. {3 


Dr. James Blaikie, who died on Feb. 26th, received 
his medical education at the University of Edinburgh 
where he was a successful student and president 
of the Royal Medical Society. He graduated as 
M.B., C.M. in 1896 and proceeded to the M.D. degree 
in 1903, and acted as resident physician at the 
Royal Infirmary. In London he held clinical appoint- 
ments at the Hospital for Sick Children, the Victoria 
Hospital for Children, and the Hospital for Skin 
Diseases, Blackfriars. He was appointed physician 
to the Hospital for Consumption in Margaret-street, 
and was assiduous in attendance there, his profes- 
sional work being of a practical order.. He made 
occasional contributions to the Edinburgh Medical 
Journal and to these columns, but his time was 
absorbed in an extensive practice. He was held in 
high esteem by his colleagues and a large section of 
the public, as was evidenced by the attendance at 
the service held in his memory. He had the gift of 
making friends of his patients, and in particular 
earned the gratitude of the mothers whose children 
he had under his care. Such holidays as he spared 
himself were spent in fishing, a sport to which he 
was devoted and about which he wrote pleasantly. 


SEPTIMUS TRISTRAM PRUEN, M.D. Durh. 


THE death occurred on Feb. 19th of Dr. Septimus 
Pruen, for many years a prominent practitioner in 
Cheltenham. He was born at Clifton, Bristol, in 
1859, the son of Dr. William Ashmead Pruen, 
received his education at Bedford School, proceeding 
for medical training to St. Bartholomew’s Hospital 
and the University of Durham. He graduated as 
M.B. Durh. in 1883 with honours and was a medallist 
for his public health work; in the following year he 
took the diploma of M.R.C.S. Eng. He was appointed 
assistant demonstrator in anatomy and physiology at 
Durham and later acted as house surgeon to the 
Cheltenham Hospital. This post he held for two years 
and in 1886 proceeded to Central Africa as a medical 


officer of the Church Missionary Society. He remained 
in Africa for three years and recorded his experiences 
in a short work “Arab and the African.” On his 
return to England he commenced practice in 
Cheltenham and became medical officer at the 
Cheltenham Medica] Workhouse and Provident Dis- 
pensary, and surgeon to the Hospital-for Sick Children. 
About this time the open-air treatment of phthisis 
was being introduced into this country by Otto 
Walther’s pupils and Dr. Pruen collaborated with 
his partner, Dr. J. C. Braine-Hartnell in founding 
the Cotswold Sanatorium on the hill 600 feet above 
the town. The venture was popular and successful, 
and for many years there was a considerable publica- 
tion of ‘useful papers dealing with various aspects 
of hygienic-dietetic treatment. Dr. Pruen was 
local medical officer of the Charity Organisation 
Society and was an energetic member of the British 
Medical Association of which he was a member for 
44 years, being local secretary at the Cheltenham 
meeting in 1901 and later president of the Gloucester- 
shire branch of the Association. 


VINCENT THOMAS BORTHWICK YULE, M.B., 
Ch.B., D.P.H. Aberd. 


THE death occurred on Feb. 17th of Dr. Vincent 
Yule, the M.O.H. for the borough of Peterhead. 
He was born in Peterhead and had a successful 
career at the University of Aberdeen, where he 
graduated as M.A. and took the medical degrees of 
M.B., Ch.B. in 1917 and D.P.H. in 1920. During 
the war he received a commission as Captain R.A.M.C., 
and saw service in East Africa. At the conclusion 
of hostilities he was appointed R.M.O. at the Aberdeen 
City Hospital, after which he accepted an appointment 
in Mexico as medical officer to one of the oilfields. 
On his return he was for three years in practice at 
Maud, Aberdeenshire, when he entered on practice 
at Peterhead and in 1925 was appointed M.O.H. for 
the borough, a position which he held at the time of 
his death. This occurred at the age of 45 after a 
short life of full and varied experience. 


THE LANCET] 


[marcu 7, 1936 575 


PARLIAMENTARY INTELLIGENCE 


NOTES ON CURRENT TOPICS 


Milk and Nutrition Problem 


On March 2nd in the House of Commons Mr. 
RAMSBOTHAM, Parliamentary Secretary to the 
Ministry of Agriculture, moved the third reading of 
the Milk (Extension of Temporary Provisions) Bill. 

Mr. T. JOHNSTON, in moving the rejection of the 
Bill, said that since the previous discussions on the 
measure in the House of Commons there had been a 
remarkable correspondence in the Times on the 
subject of insufficient nutrition among the population 
of this country. Nobody in that correspondence 
denied that at least 10 per cent. of the population 
was living below the British Medical Association’s 
minimum standard. Sir John Orr had said that 
almost one-half of the population in our industrial 
areas were not getting enough to eat, and he men- 
tioned milk as one of the foodstuffs which ought to 
be better and more widely distributed. The Minister 
of Agriculture did not deny that a large proportion 
of the population was under-nourished, and yet the 
right hon. gentleman was using public money for 
the destruction of 27 per cent. of liquid milk through 
its diversion to manufacturing purposes. We were 
spending at least £111,000,000 a year in the treat- 
ment of disease and the policy of organising scarcity 
in such an essential foodstuff as liquid milk was 
against the public interest. 

Mr. ELLIOT, Minister of Agriculture, in reply, said 
that the enormous importance of fresh food such as 
milk in the avoidance of disease was a matter of 
general agreement in the House. His only point of 
difference with Mr. Johnston was when the right 
hon. gentleman said that the Government were 
organising scarcity. The production and consumption 
of milk had increased greatly in recent years. Mr. 
Johnston’s motion, if carried, would bring the milk 
in schools scheme to an end. Steps were outlined in 
this Bill to extend the supply of milk itself, as well 
as that of butter and cheese. 

Mr. JOHNSTON asked whether raising the price of 
milk to children’s hospitals and to poor-law infirmaries 
was doing anything to increase consumption. 

Mr. ELLIOT called on Mr. Johnston to mention 
one child in one hospital who had received a pint of 
milk less because of the steps taken by the Milk 
Marketing Board. 

Mr. JOHNSTON asked whether the Minister of 
Agriculture was aware that a hospital in Glasgow 
had to pay £500 a year more for its milk, and that 
there were threats by the managers of some hospitals 
that they would be compelled to take a lower grade 
of milk. 

Mr. ELLIOT : I challenged the right hon. gentleman 
to name one hospital where one child was having 
one pint of milk less per day and he is totally unable 
to do so. He merely said that in future in some 
hospital a lower grade of milk may be used. I do 
not think he has met the challenge. If the whole 
assistance being devoted to the butter and cheese 
industry were devoted to the liquid milk industry 
it would not mean a reduction of more than a quarter 
of one farthing a pint in the price of liquid milk, and 
no one would say that this would increase the con- 
sumption of liquid milk to-day. The right hon. 
gentleman went on to say that the Government had 
given a breathing space to the industry for which 
they made no apology, and they had given cheap 
milk to schools, for which they did not apologise, 
and this was a Bill to continue those things. 

Mr. T. WoLrrams said that nothing in this Bill 
was calculated to provide more milk for that section 
of the community which most needed it. 

The motion for rejection was negatived by 242 
votes to 110, and the Bill was read the third time. 


Voluntary Hospitals (Paying Patients) Bill 


In the House of Commons on Thursday, Feb. 27th, 
the Voluntary Hospitals (Paying pepe Bill was 
read a second time. 


HOUSE OF COMMONS 
WEDNESDAY, FEB. 26TH 
Newspaper Wrappers and Food Contamination 


Mr. H. G. Wrams asked the Minister of Health if 
he was aware of the practice among retail butchers and 
fishmongers of purchasing old newspapers, which might 
be contaminated and carriers of disease, for the purpose 
of wrapping up meat or fish sold in retail shops; and 
whether he would take steps to make this practice illegal, 
and ensure the use of clean grease-proof paper for these 
purposes.—Mr. SHAKESPEARE replied: My right hon. 
friend is aware of this practice, which on general grounds 
of cleanliness is to be deprecated, but he is advised that 
there is no definite evidence that the wrapping of meat 
or fish in newspapers is a factor in the spread of disease, 
and he would not therefore be justified in taling. the steps 
suggested by my hon. friend. 


Medical Services at Junior Instruction Centres 


Mr. TEMPLE Morgis asked the Minister of Labour 
whether medical inspection and treatment was now avail- 
able for boys and young men attending instructional 
centres in the special areas; and, in that case, by whom 
the cost was provided.—Mr. ERNEst Brown replied : 
I assume that my hon. friend is referring to persons in 
attendance at junior instruction centres and not to adults. 
Proposals submitted by education authorities for the 
establishment and conduct of authorised courses of instruc- 


‘tion, including junior instruction centres, may include 


provisions under which any boy or girl may be referred 
by the superintendent of the course to the school medical 
officer, with a view to such inspection, and, in England 
and Wales, such treatment as may be found desirable. 
I have approved proposals including provisions—of 
varying extent—for medical services from the following 
authorities in the special areas: education authorities 
for the administrative counties of Durham, Northumber- 
land, Glamorgan, Monmouth, Ayrshire, Dunbarton, and 
from the education authorities for the county boroughs 
of Gateshead, South Shields, Sunderland, and Merthyr 
Tydfil. I intend, at an early date, to issue to all authorities 
conducting authorised courses of instruction a memo- 
randum dealing with the provision of medical services 
in connexion with junior instruction centres, and it is 
my hope that this will lead to a marked increase in the 
number and scope of proposals of this kind. 


THURSDAY, FEB. 27TH 
Provision of Food at Junior Instruction Centres 


Mr. GEorcrE Hatt asked the Minister of Labour whether 
he was aware that an examination by the school medical 
officers revealed that 57 per cent. of the trainees at four 
junior instruction centres in the county of Glamorgan 
were suffering from malnutrition ; and whether he would 
take steps to empower the local authorities responsible 
for these centres to supply meals as well as milk to trainees 
in attendance.—Mr. ERNEsT Brown replied: Local 
education authorities have no power to provide ordinary 
meals in junior instruction centres. Free milk is, however, 
being provided in the Glamorgan centres, and I am in- 
formed that the school medical officer expressed the view 
that since any food given at the junior instruction centres 
can only be a casual and temporary addition to the diet 
of the pupils, the milk available is more useful than any 
other food which could be suggested i in the circumstances. 
I am, however, making inquiries into the adequacy of 
the existing arrangements. 


Certification of Cases of Silicosis 


Mr. Lreacnu asked the Home Secretary if he would 
consider introducing further legislation to ensure prompter 


576 THE LANCET] 


PARLIAMENTARY INTELLIGENCE 


[mance 7, 1936 


and easier certification of cases of silicosis in the mining 
and quarrying industry, and to ensure that compensation 
and measures for the recovery of the victims might be 
made more certain.—Sir JoHN Srmon replied: I would 
refer the hon. Member to the reply given on the 13th of 
this month. If the hon. Member will be good enough to 
send me a statement showing where and how it is sug- 
gested that the medical arrangements and the procedure 
under the Silicosis Schemes could be improved, I shall be 
happy to consider it. 

Mr. Leacu: Does not the right hon. gentleman agree 
that both the law and the regulations operate very harshly 
towards these poor fellows ?—Sir J. Simon: It is a very 
complicated subject, but I have the fullest sympathy 
with those who want to have the whole situation cleared 
up and made as simple as possible. 


Death Certifications and Vaccination 


Mr. BANFIELD asked the Minister of Health how many 
of the deaths associated with vaccination on certificates 
of deaths in the years 1933, 1934, and 1935, respectively, 
were or would be classified by the Registrar-General to 
vaccinia; and how many deaths under five and over 
five years of age, respectively, were or would be classified 
as chicken-pox and erysipelas during the years in ques- 
tion.—Sir KINGSLEY Woop replied: The following is the 
statement :— 


Deaths classified to— 


Deaths 

hasn ated Ha i 
, with | Chicken-pox. Erysipelas. 
Year. vaccination . 

and classified 
to vaccinia. Under Over Under Over 
5 years. | 5 years, | 5 years. | 5 years. 

1933 3 31 12 296 895 
1934 5 36 10 231 1227 
1935 4 Not yet available. 


Public Health Legislation 


Sir ARNOLD WIrtson asked the Minister of Health 
whether and, if so, when he proposed to introduce a Public 
Health Amendment Bill which would embody in that 
general law and make generally applicable powers usually 
granted by Parliament as a matter of course in local Acts, 
as recommended by the Select Committee on Private Bills 
in 1930 for reference to a joint committee of both Houses, 
in the same way as Consolidation Bills.—Sir KINGSLEY 
Woop replied: My hon. friend will be aware that a draft 
has been published of a Bill to consolidate with amend- 
ments part of the general public health law. In preparing 
this Bill account has been taken of the relevant provisions 
allowed by Parliament in local legislation. I regret that 
considerations of parliamentary time have rendered it 
impracticable fully to implement the recommendation 
to which my hon. friend refers, but I recognise its import- 
ance and hope it may be practicable to take further action 
in an early session. 


Unemployed Persons and Food-supplies 

Mr. Davip Apams asked the Minister of Health whether, 
in view of the fact that the consumption by families of 
the unemployed of meat, including beef, mutton, bacon, &c., 
and of eggs, was, like that of milk, only about one-third 
that of the average of the whole country, he would take 
the necessary steps, as in the case of milk, to ensure 
cheaper supplies to unemployed of these essential food- 
stuffs, and thus raise the low nutritional standards of 
these citizens.—Sir KinastEy Woop replied: The con- 
sumption of: the commodities mentioned as well as of 
other foodstuffs by various classes of the community is 
a matter which receives the constant attention of my 
Advisory Committee on Nutrition, but the most effective 
steps that can be taken to raise nutritional standards are 
undoubtedly such steps as are being taken by the Govern- 
ment to reduce unemployment and increase purchasing 
power. 

Tuberculosis in Wales 


Sir WILLIAM JENKINS asked the Minister of Health 
what number per thousand of the population of Wales 


were suffering from tuberculosis; what number under 
treatment at sanatoria or other suitable institutions; 
what number of recoveries; and what number of deaths 
under 12 years of age, under 20 years, under 30 years 
and over for the years 1924, 1926, 1930, 1934, and 1935 
giving the figures separately for each county in Wales.— 
Sir KincsLtEy Woop replied: As regards the first three 
parts of the question, the following are the figures for 
which the hon. Member asks, according to the returns 
furnished by the local authorities and the King Edward VII 
Welsh National Memorial Association to the Welsh Board 
of Health in respect of the year 1934 :— 


Tuberculous persons on the registers of medical officers 
of health at Dec. 31st, 1934, per thousand of the 


population of Wales ae oe Sn 9°64 
Under treatment or observation at sanatoria or other ; 

suitable residential institutions on Dec. 31st, 1934 .. 1650 
Number of recoveries recorded during 1934 ~~ 1213 


As regards the fourth part of the question, figures are 
not available for the age-groups specified. The available 
figures of tuberculosis deaths by ages in the 13 Welsh 
counties are published in the Registrar-General’s Statis- 
tical Review, Tables, Part I., Medical, Table 20 for the 
vears 1924, 1926, and 1930, and Table 24 for 1934. Figures 
for 1935 are not yet available. 


MONDAY, MARCH 2ND 
Expectation of Life of War Pensioners 


Mr. MaBANE asked the Minister of Pensions if, for the 
purpose of his estimates, the expectation of life of war 
pensioners was calculated according to a normal table 
or on a table which gave to war pensioners an expectation 
of life shorter than the normal.—Mr. R. S. HUDSON 
replied: The mortality-rate of disabled pensioners is 
and will for some years to come be greater than the normal, 
and in framing the Estimates of the Ministry of Pensions 
this and all other relevant factors are taken into account. 


Convictions for Murder 


Mr. Day asked the Home Secretary the number of 
persons convicted of murder and sentenced to death for 
the five years ended to the last convenient date; the 
number reprieved ; the number of sentences quashed on 
appeal; the number of persons certified as insane and 
removed to Broadmoor; and the number so convicted 
that were recommended to mercy by the jury, and with 
what result.—Sir JoHN Simon replied: The particulars 
are as follows :— 


l 
„È = SER wee o 
AAN | © SES| Sawo | Recommended 
SSese | & | §48/So0e8 to mercy. 
Year. BS aes = 24¢ FEKE 
SESEL] § |ĝoe| SEBE 
SSES | o| “ARS |No Result. 
e 
peene | OE SS PESEE 
1931 18 7 1 1 4 |All reprieved. 
1932 15 6 0 0 5 rs Sai 
1933 19 9| 0 0 LOY) eee 
‘ of | 9 reprieved. 
1934 24 12 2 1 12 t| 3 executed. 
i 6 reprieved. 
1 executed. 
1935 21 8 2 1 8 1 conviction 
| quashed on 
| appeal. 
T39 reprieved. 
Total for |) 6 executed. 
five years j 97 42 5 3 39- | 1 conviction 
1931-35 | | quashed on 
| C] appeal. 


Imported Chilled Meat and Foot-and-Mouth 
Disease 


Brig.-General CLIFTON Brown asked the Minister of 
Agriculture whether, in view of the fact that the virus 
of foot-and-mouth disease survived in chilled meat and 
that this disease was distributed by the use of bones’ 
imported in chilled meat, the Government was taking 
any action to prevent the importation of meat which 


THE LANCET] 


FOTHERGILL TESTIMONIAL FUND 


[mance 7, 1936 577 


might carry the virus from any country in which this 


disease prevailed.—Mr. Exxior replied: So far as I am 
aware, there is no evidence to support my hon. friend’s 
statement that foot and mouth disease is distributed by 
the use of bones imported in chilled meat, but I recognise 
that there is some such risk. Regulations governing the 
exportation of carcases to this country have been in force 
in the South American meat exporting countries since 
1928 and assurances were given as recently as last year by 
the Governments concerned that these regulations are 
being properly enforced. In addition, orders are in force 
in this country directed to preventing the spread of disease 
through pig food and meat wrappers and other similar 
material. 


.Small-pox Deaths 


Mr. BROMFIELD asked the Minister of Health, in view 
of the fact that the published reports of his department did 
not supply full statistics as to the numbers of vaccinated 
and unvaccinated cases of, and deaths from, small-pox 
which occurred in England and Wales during the years 
1922 to 1934, ho would supply a statement in respect of 
each of the years in question, showing, so far as possible, 
the cases and deaths which were recorded in the hospital 
registers as vaccinated, unvaccinated, and doubtful, 
respectively.—Sir Kınesrıey Woop replied: I regret 
that I have no fuller information in respect of the years 
1922 to 1933 than that contained in the annual reports 
of the Chief Medical Officer of my department. The 
appended table gives the vaccinal condition of cases of 
small-pox occurring in England and Wales in the year 
1934 in towns of 150,000 population and over. 


A. = Successfully vaccinated. B. = Unvaccinated. 


Vaccinal condition Vaccinal condition 
at time of at time of 
infection.* infection.* 

Ages Ages 
A B. A B 
Under 1! i years pu 6 
year ! a 1 Pe 2 26t 

1 year ta Nil. 20 ‘9 sig 16 
2 years ! A 1 25 ,; 2 8 
3e A Sa 7 BU. 55 1 4 
4 ,, a 2 35: 2 2 
D> x45 is Nil. 40 ,, 3 4 
6 ,, os 4 OU - ais 4 za 
T 4 i 4 60, 5 
S* ug 6 70 ,, 1 
9 ,, ig 10 80 and 

10 ,, sk 2 upwards 1 

Il ,, | sa 4 

12 ,, 1 6 

13 ,, esa 6 Totals .. 22 119 


* There were no doubtful cases. 
t Including one fatal case in a youth of 16 years. 


Smokeless Fuel and Atmospheric Purity 


Mr. Davip Apams asked the First Commissioner of 
Works, in view of the recent report upon atmospheric 
pollution issued by the Department of Industrial and 
Scientific Research which showed that the general clean- 
liness of the atmosphere was not improving, if he would 
give a lead to the country by ordering the use of smokeless 
fuel in the Government buildings under his department 
in London.—Mr. ORMsBy-GoRE replied: Smokeless fuel 
is already used in Government offices whenever local 
circumstances make it possible without an unreasonable 
increase in cost. 


TUESDAY, MARCH 3RD 
Mental Deficiency Research 


Mrs. TaTE asked the Minister of Health how many 
local authorities had made use of their powers under 
the Mental Treatment Act, 1930, to provide money for 
research into mental disorder and deficiency; and how 
much money they had provided.—Mr. SHAKESPEARE 
replied: Owing to financial considerations, schemes have 
not yet been initiated under the specific provisions 
referred to; but the most recent record of the varied 
and extensive research work proceeding in public mental 
hospitals and mental deficiency institutions will be found 
in Part II. of the Board of Control’s Report for 1934. 


Army Recruits and Defective Health 


The Duchess of ATHoLL asked the Secretary of State 
for War the proportion of men applying to join the 
Army in the last three years who were rejected for 
defective health or physique.—Mr. Durr CooPER replied : 
The percentage of men served with notice papers who 
were rejected for medical or physical reasons during the 
three years ending Sept. 30th, 1933-35, was 52, 46, and 33 
respectively. 

School Dental Service 


Mr. Day asked the President of the Board of Education 
the number of children attending public elementary 
schools in England and Wales in the 12 months ended 
to the last convenient date who were inspected by school 
dentists ; the number who were found to require treat- 
ment; and the number who received treatment under 
the arrangements made by local education authorities.— 
Mr. OLIVER STANLEY replied: Complete information is 
not yet available for the year 1935. The figures for the 
yéar ended Dec. 31st, 1934, are as follows:— | 


_ Children inspected 3,302,838 
Found to require treatment 2,273,508 
Treated šis 1,431,775 


FOTHERGILL TESTIMONIAL 'FUND 


THE following is the third list of subscriptions to 
the testimonial to Dr. E. Rowland Fothergill, received 
in response to the letter published in the British 
Medical Journal and The Lancet of Jan. 18th. 


Amount previously acknowledged, £386 7s. 

A. M. Daldy (Hove), £1 ls.; A. O. (oon (Hove), C. G. 
Schurr (Rove D Parry (Hove), A an Hall, F. H. Lawson 
(Hove), R e Glege (LOWES); $ Thwaites a fohar ath 
G. B. Thwaites (Brighton), E. V. Oan (Hove), I. Turton 
(Hove), D. A. Crow (Hove), Lilias M. Jeffries (Hove), Barbara M. 
Logan (Hove), Florence M. Edmonds (Hove), M. J. Oliver 


(Hove), A. N. Pollock (Hove), Robert Sanderson (North 
Lancing), et M. Wauchope (Hove), Conwy L. Morgan 
(Hastings), F. J. r horie (Bexhill-on-Sea), P. Lazarus-Barlow 


(Bexbill-on-Sea), R. Jaques (Worthing), Dr. Martin, Dorothea 
A. Carew Hunt (Hove), R. C. McQueen (Eastbourne), J. M. 
Anderson Hovey a . Calvert (Eastbourne), A. G. K. Ledger 
(Shoreham), M. Ross Tayler (Eastbourne), Eliot Curwen (Hove), 
A. Burn (Eastbourne), P. S. Eves (Brighton), Duncan D. 
Macintosh (Worthing), Mark Jackson (Bexhill-on-Sea), and G. 
Tolcher Eccles (Hove), £60 ; F. Wattsford (Newcastle) and 
G. R. Fortune (Newcastle), cach 10s. 6d. ; R. Boyd (Manchester), 
£1 1s.; Northumberland Local Medical Committee, £26 5s. ; Derby 
Local Medical and Panel Committee, £5; Stockport and 
Leicester Local Medical and Panel Committees, and Sir Robert 
Bolam (Newcastle), caD £5 5s.; A. Gregory (Manchester), 
F. L. Angior (Wigan), T. H. Gardner (London), J. N. Ferguson 
(York), J. W. King (Derby), E . W. eecdel (London), and 

J. Baildon (Southport), chek £1 138.3 Johnson Smyth 
Donnent). £3 3s.; A. B. Murray (Bm, £5 5s.; Jane 
L. K. Aitken (London), 10s. 6d.; G. J. Awburn (Mottram, 
Manchester), John Clay (Newcastle), M. W. Renton (Dartford), 
and C. E. Douglas (St. Andrews), each £1 1s.; Nottinghamshire 
Panel Committee, £10 10s.; A. R. Berrie (London) and D. Clow 
(Cheltenbam), each £1 15. ; Huntingdonshire Panel Com- 
mittee, £2 2s. ; J. E. Hailstone (Slindon Common, near Arundel), 


R. S. Harper (Hove), A -H.W TS (Horsham), W - Broadbent 
(Hove), H. Herbert (Worthing), E. R. Hunt t Hove), Alice 
Owen (Horsham), F. H. Allfreys ’ (Southwick), W Thwaites 


(Brighton), G. Handcock (Hove), T. S. Taylor Ca ohates 
W. L. Dickson (Brighton), I. Kinsley | Set oa East Kent 
Division B.M.A., F. E. Feilden (Hove), H. J. McCurrick (Hove). 
John Kerr (Bexhill-on-Sea), and J. F. "Atkins (Hove), £55; 
West Riding of Yorkshire Panel Committee, £10 10s.; Bath 
Division B.M.A., £20; Darlington Panel Committee, £2 2s. ; 
Kent Panel Committee, £100; E. Lewis Lilley (Leicester), 
£1 l1ls.; Sheffield Panel Committee, £25; Shropshire Local 
Medical and Panel Committee, £10 ; . G. McGowan (Man- 
chester), £2 28.; East Sussex Medical Committee, £210. Total 
‘£967 8s. 6d. 

Cheques should be made payable to the Fothergill 
Testimonial Fund, and addressed to the treasurer, 
Fothergill Testimonial Fund, British Medical Associa- 


tion, B.M.A. House, Tavistock-square, London, W.C.1. 


ROYAL SURREY COUNTY HOSPITAL.—At present 
this hospital is run at a loss of £2500 per annum 
and two new wards are being added to cope with 
the long waiting-list. To maintain these and the nurses’ 
home an additional income of about £4000 will have to 
be obtained. This means that in all an additional yearly 
income of £6500 or £7000 must be found if the hospital 
is to be clear of debt. 


578 THE LANCET] 


MEDICAL 


[maRcH 7, 1936 


NEWS 


University of Oxford 


On Feb. 29th the degree of D.M. was conferred on 
C. Wilson and of B.M. on J. F. Loutit. 


University of London 


Mr. Wilfred Trotter, F.R.S., has been appointed to the 
university chair of surgery at University College Hospital 
medical school. 

Mr. Trotter, who is 63 years of age, was educated at University 
College where he graduated M.B. with first-class honours and 
was awarded the gold medal in 1896. He also received a gold 
medal and the university scholarship in surgery on taking the 
B.S. degree in 1899, and after obtaining other qualifications 
was appointed surgical registrar and lecturer in surgery at 
University College Hospital in 1901. Five years later he joined 
the honorary staff of the hospital and also of the East London 
Hospital for Children. A subsequent appointment, for a time, 
to the West End Hospital for Nervous Diseasesishowed his bias 
towards neurological surgery and its underlying physiology, 
but he has also worked and reported on the surgery of the 
mouth and pharynx, on goitre, and on other and various subjects. 
His book on ‘‘ Instincts of the Herd in Peace and War,” which 
first appeared in 1916, has won him a collateral reputation asa 
biologist, and his published works include the Hunterian oration 
of 1932 and many lectures and addresses delivered before 
colleges and societies. Mr. Trotter is a member of the council 
of the Royal College of Surgeons of England and served on the 
Medical Research Council from 1929 to 1933. In 1928 he was 
appointed honorary surgeon to King George and in 1932 
serjeant surgeon. He holds honorary doctorates from the 
ios got Edinburgh and Liverpool and was elected 

R.S. in 


The Graham Legacy committee have awarded a gold 
medal to Sir Thomas Lewis for research in connexion 
with the treatment of cardiac disease conducted at 
University College Hospital and medical school. 

Prof. William Bulloch, F.R.S., has been appointed 
. Heath Clark lecturer for the year 1936. 

The title of Fellow of University College, London, was 
conferred on Dr. H. P. Himsworth, Mr. R. J. Ludford, 
D.Sc., Dr. Arthur MacNalty, and Mr. Julian Taylor. 


University of Dublin 


Mr. J. K. Jamieson, professor of anatomy and dean of 
the medical school at the University of Leeds, has been 
appointed to the chair of human anatomy and embryology 
at Trinity College, where he has for some time been 
examiner. He succeeds the late Dr. A. F. Dixon. 


Britisno vostgraduate Medical School 

On March 17th, at 2.30 P.M., Dr. Leonard Colebrook 
will repeat the lecture on puerperal sepsis which he gave 
on March 2nd. The lecture is one of a course on recent 
advances in obstetrics and infant hygiene which is being 


given at the school, Ducane-road, Hammersmith, 
London, W. 


New Ophthalmic Clinic 


The King Edward Memorial Hospital, Ealing, is now 
providing a clinic in connexion with the Voluntary 
Hospitals Ophthalmic Clinic Scheme. It is held on 
Wednesday afternoons, and is open to members of approved 
societies and to contributors to the Hospital Saving 
Association. Those with incomes below a certain scale 
may also attend and are charged a fee of half a guinea 
and the cost of any spectacles prescribed. _ 


Epsom College 

The council of the College will shortly award a St. Anne’s 
scholarship of £60 a year to an orphan girl, not less than 
nine years of age on July 15th, 1936, who is the daughter 
of a medical man who was at least five years in independent 
practice in England or Wales. Application must be made 
by May 15th on a form to be had from the Secretary of 
the College, 49, Bedford-square, London, W.C.1. 

The council will also shortly award a Grewcock pension 
of £70 a year to a retired medical man who from old age, 
permanent incapacity from illness, reduced circumstances, 
or other cause is in need of it. There is no limitation 
as to age, but special consideration will be given to the 
claims of candidates having association with Worcester- 
shire, Lincolnshire, or Carmarthenshire. Forms of applica- 
tion, which must be returned by the middle of May, can 
be had from the secretary. 


Dr. William Warburton Pemberton has been 
appointed sheriff of Cambridgeshire and Huntingdonshire 
for the year 1936. j 


On Monday, March 9th, the offices of the Radium 
Comm's-ion will be removed from 5, Adelphi-terrace, 
W.C.2, to 18, Park-crescent, Portland-place, W.1. 


Institute of Psycho-Analysis 

Dr. Ernest Jones will preside at three lectures on the 
emotional life of civilised men and women which will 
be given at the Caxton Hall, S.W., at 8.30 p.m. on Thurs- 
days, March 12th, 19th, and 26th. The subject of the 
first lecture, by Dr. Sylvia Payne, is Work and its Meaning 
for Us. Tickets may be had from the secretary of the 
institute, 36, Gloucester-place, W. 


Catholic Medical Congress 

The second international congress of Catholic physicians 
meets in Vienna from May 28th to June 2nd, and the 
main subject for discussion will be eugenics and sterilisation. 
Full information may be had from The Oesterreichisches 
Verkehrsbureau, Friedrichstrasse 7, Vienna. 


Nottingham General Hospital 
To commemorate his 70th birthday Mr. W. G. Player 
has given £1000 to this institution. 


Legacy for Swansea General Hospital 

Mrs. Sarah Powell has left the residue of her estate, 
which is expected to amount to some £20,000, to this 
hospital. The money is to be used to build a new ward 
in memory of her brother, the late Sir Samuel Evans, 
and herself. 


Clacton and District Hospital 

The Silver Jubilee extensions to this hospital, which 
was built in 1899 to commemorate Queen Victoria’s 
Diamond Jubilee, will be ready for opening by Easter. 
The extensions have cost about £10,000 and more money 
is needed to equip and furnish them. They include wards 
for abnormal maternity cases, electrical and massage 
departments, and an administrative block. 


Hunterian Society 

The gold medal which this society awards annually 
for the best essay written by a general practitioner has 
for the first time been given to a practitioner resident 
outside Great Britain. The subject set for 1935 was the 
conduct of midwifery in general practice, and the prize 
essay was submitted by Dr. Francis Bennett, of Christ- 
church, New Zealand. The subject chosen for 1936 is 
rheumatoid arthritis, its diagnosis, treatment, and end- 
results, and for 1937 the prognosis and care of heart 
disease in general practice. Further particulars may be 
had from the hon. secretary of the society, Mr. Arthur 
Porritt, 27, Harley-street, London, W. 


Fellowship of Medicine and Post-Graduate Medical 
Association 


Courses arranged for M.R.C.P. candidates are as follows : 
chest diseases, Brompton Hospital (March 10th to 
April 4th); chest and heart diseases at the Royal Chest 
Hospital (March 15th to April 4th). A demonstration 
on the fundus oculi will be given at the West End Hospital 
for Nervous Diseases on Tuesday, March 3lst, at 8.30 P.M. ; 
and a course in orthopedics at the Royal National Ortho- 
predic Hospital from March 9th to 21st; and in infant’s 
diseases from March 30th to April 4th. Week-end courses 
include chest diseases, at the Brompton Hospital (March 7th 
and 8th); clinical surgery, at the Royal Albert Dock 
Hospital (March 14th and 15th); general medicine, at the 
Miller General Hospital (March 2lst and 22nd); and 
urology, at the All Saints’ Hospital (March 28th and 29th). 
Four lectures on diseases of children will be given by 
Dr. Reginald Lightwood at the National Temperance 
Hospital on March 25th, 27th, April lst and 3rd at 
8.30 P.M. Lectures are open only to members and 
associates, and further particulars may be had from the 
secretary of the fellowship, 1, Wimpole-street, W. 


THE LANCET] 


MEDICAL DIARY 


[marcu 7, 1936 579 


Medical Diary 


Information to be included in this column should reach us 
in proper form on Tuesday, and cannot appear if it reaches 
us later than the first post on Wednesday morning. 


SOCIETIES 


ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W. 
MONDAY, March 9th. 


United Services. 4.30 P.M. Squadron Leader R. H. 
Stanbridge: Occupational Selection of Aircraft 
Apprentices. 

TUESDAY. 


Therapeutics and Pharmacology. 5 P.M. Dr. G. Graham 
and Dr. S. Levy Simpson : L Treatment of Addison’s 
. Disease with Salt. Dr. N. Allott: The Effect of 
Treatment on the Blood Chemical Changes in Addison’s 
Disease. Dr. Audrey Baker and Dr. Margaret Wright : 
The Vitamin B, Content of Human Diet. 
PSU ae: 8.30 P.M. Dr. Alfred Meyer: The Selective 
po Vulnerability of the Brain and its Relation 
sychiatric Problems. 
Wena, 
Surgery: Sub-section of Proctology. 5 P.M. Myr. J. P. 
Lockhart-Mummery : . Spindle-celled Sarcoma of 
Buttock Treated by Radium. No Recurrence two 
years later. 2. Recurrence after Local Excision of 
Adenoma of Rectum. Mr. Lionel E. C. Norbury: 
-4. Extensive Papi ome of Rectum Removed by 
Perineal Excision. Extensive Papilloma of Pelvic 
Colon Removed by Soul's Operation. Dr. Cuthbert 
Dukes: 6. Lymphatic Spread of Cancer of the Rectum. 
7. Derivation of Fistule from Intramuscular Glands. 
8. Misplaced Epithelium (possibly Pancreas) within 
the Rectum. Mr. O. V. Lloyd-Davies: 9. Villous 
Papilloma of the EA 


FRIDAY 
Ophthalmology. 5 P.M. (Moorfields Eye Hospital, City- 
road, E.C.), Mr. H. B. Stallard: 1. Sarcoma. 2-3. 
Glioma. 4-6. Coats’ White Rings of the Cornea. 
Mr. F. A. Juler: 7. Congenital Retinal Fold. 8. 
Angioma of Orbit. 
MEDICAL SOCIETY OF LONDON, 11, Chandos-street, W. 

MONDAY, March 9th.—8.30 P.M., Mr. A. Dickson Wright : 

Phicbitis and its Treatment. 
HARVEIAN SOCIETY OF LONDON. 

THURSDAY, March 12th.—8.30 P.M. (Manson House, 26, 
Portland-place, W.), Dr. H. Letheby Tidy: Treat- 
ment of Gastric and Duodenal Ulcer. (Harveian 
Lecture.) 

WEST KENT MEDICO-CHIRURGICAL SOCIETY. 

FRIDAY, March 13th.—8.45 P.M. (Miller General Hospital, 
Greenwich, S.E.), Dr. Harold Crampton: The Unex- 
pected in Aneesthesia. 

SOUTH-WEST LONDON MEDICAL SOCIETY. 

WEDNESDAY, March 11th.—9 P.M. (Bolingbroke Hospital, 
Wandsworth Common), Dr. W. E. Lloyd: Clinical 
Meeting. 

NORTH LONDON MEDICAL AND CHIRURGICAL 
SOCIETY, Royal Northern Hospital, N. 

FRIDAY, March 13th.—9 P.M., Dr. J. L. Livingstone: 

Asthma 
PADDINGTON MEDICAL SOCIETY. 

TUESDAY, March 10th.—9 P.M. (Paddington Tuberculosis 

Unic 20, Talbot-road, W.), Dr. H. W. A. Post: 
X Ray Fi ‘ims. 
BIOCHEMICAL SOCIETY. 

FRIDAY, March 13th.—2.30 P.M. (University College, Gower- 
street, W.C.), Short Communications and Demon- 
strations. 

MEDICAL SOCIETY OF INDIVIDUAL PSYCHOLOGY. 

THURSDAY, March 12.—8.30 P.M. (11, Chandos-street, W.), 
Sir Walter Langdon-Brown : The Place of Psychology 
in the Medical Curriculum. 

NORTH-WEST LONDON MEDICAL SOCIETY. 

TUESDAY, March 10th.—9 P.M. (Regal Rooms, Finchley- 
road, Golders Green), Dr. John Freeman : Immunology 
in General Practice. 

LONDON JEWISH HOSPITAL MEDICAL SOCIETY, 
Sir Edmund Spriggs, 


Stepney Green, E. 
EUND DAK, March 12th.—4 P.M., 

Dr. B. S. Nissé, Dr. J. B. Mennell, and Dr. F. Nagel- 

schmidt : Rheumatism. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 


ROYAL COLLEGE OF PHYSICIANS, Pall Mall East, S.W. 
TUESDAY, March 10th, and THURSDAY.—5 P.M., Dr. R. A. 
McCance: Medical Problems in Mineral Metabolism. 
(Goulstonian Lectures.) 
ROXAT ee OF SURGEONS OF ENGLAND, Lincoln’s 
Inn-fields. 
FRIDAY, March 13th.—5 P.M., Dr. L. W. Proger: 
illustrating Tumours of the Kidney. 
INSTITUTE OF HYGIENE, 28, Portland-place, W. 
WEDNESDAY, March 1ith.—3.30 P.M., Frof. Winificd 
Cullis: Women in Industry. 
ROYAL INSTITUTION, 21, Albemarle-street, W. 
TUESDAY, March 10th. e, 15 P.M., Prof. Edward Mellanby, 
F.R.S.: Drug-like Actions of some Foods. 


Specin ers 


SIR CHARLES HASTINGS LECTURE 

TUESDAY, March 10th.—8 P.M. (B.M. "A. House, Tavistock- 
square, W.C.), Prof. Winifred Cullis and Dr. R. 
Cove-Smith: Keeping Fit. 

rd POSTGRADUATE MEDICAL SCHOOL, Ducane- 
roa 

MONDAY, March 9th.—3.30 P. M., Prof. F. J. Browne: 
Toxæmias of Pregnancy. 

WEDNESDAY.—3.30 P.M., Mr. Eardley Holand: Hæmor- 
Thage of late Pregnancy (II.). 

WEST LONDON HOSPITAL POST-GRADUATE COLLEGE, 
Hammersmith, W. 

MONDAY, March 9th.—10 A.M., Skin clinic. 11 A.M., 
Surgical wards. 2 P.M., Gyneecological and surgical 
wards, gyneccological and eye clinics. 4.15 P.M., 
Mr. Green-Armytage: Fevers of Pregnancy. 

TUESDAY.—10 A.M., Medical wards. 11 ear Surgical 
wards. 2 P.M., Throat clinic. 4.15 P.M., Mr. Simpson- 
Smith: Minor Surgical Problems. 

WEDNESDAY. —10 A.M., Children’s ward and clinic. 11 A.M., 
Medical wards. 2 P.M., Hye clinic, gynecological 
operations. 

THURSDAY.—10 - A.M., Neurological and gynecological 
clinics. Noon, Fracture clinic. 2 P.M., Eye and genito- 
urinary clinics. 4 P.M., Venereal diseases. 

FRIDAY.—10 A.M., Medical wards and skin clinic. 
Lecture on treatment. 2 P.M., Throat clinic. 

SATURDAY.—10 A.M., Children’s and surgical clinics, 
ge wards. 

Daily, 2 P.M., Operations, Medical and Surgical Clinics. 

The lectures at 4.15 P.M. are open to all medical practi- 


tioners without fee. 
FELLOWSHIP OF MEDICINE AND POST-GRADUATE 
MEDICAL ASSOCIATION, 1, Wimpole-street, W. 
MONDAY, March 9th, to SUNDAY, March 15th.—INFANTS 
HOSPIT r vinent RS S.W. Mon., Wed., and 
Fri., 8 , Primary F.R.C.S. course in ‘anatomy and 
phvciolony. =N ATIONAL TEMPERANCE HOSPITAL, Hamp- 
stead-road, N.W. M.R.C.P. Clinical and pathological 
course. Tues. and Thurs. at 8 P.M. Tues., 
8.30 P.M., Mr. T. Holmes Sellors: Thorax. Thurs., 
8.30 P.M., "Mr. R. Coyte: Large Intestine and Rectum. 
M.R.C.P. Clinical and pathological course at 8 P.M.— 
“ROYAL NATIONAL ORTHOPZDIO HOSPITAL, Great 
Portland-street, W. All-day course in orthopedics. — 
BROMPTON HOSPITAL, S.W. Mon., Tues., Thurs., 
and Fri., 5 P.M., M.R. C.P. class.—ROYAL ALBERT 
Dock HOSPITAL, S. 'E. Sat. and Sun., course in clinical 
surgery. —Courses are open only to members of the 
Fellowship. 
SOUTH-WEST LONDON POST-GRADUATE ASSOCIATION, 
St. James’s Hospital, Ouseley-road, S.W. 
WEDNESDAY, March 11th.—4 P.M., Mr. Leonard Phillips : 
Puerperal Sepsis. 
NATIONAL HOSPITAL FOR DISEASES OF THE HEART, 
Westmoreland-street, W. 
TUESDAY, March 10th.—5.30 P.M., Dr. B. T. Parsons- 
Sımith : Cardiac Breathlessness. 
HAMPSTEAD AND NORTH WEST LONDON GENERAL 
HOSPITAL, N.W. 
WEDNESDAY, March 11th.—4 P.M., Dr. H. M. Oddy: Some 
Aspects of Arterial Discase. 
HOSE tA” FOR SICK CHILDREN, Great Ormond-:street, 


WEDNESDAY, March 11th.—2 P.M., Dr. Alan Moncrieff : 
Epituberculosis and Hilum Tuberculosis. 3 P.M., 
Dr. D. N. Nabarro: Human and Bovine Tubercle. 

Out-patient clinics daily ‘at 10 A.M; and ward visits at 2 P.M. 


NATIONAL HOSPITAL, Quecn-square, W.C. 


Noon, 


Monpay, March 9th. —3.30 P.M., Dr. Symonds: Head 
Injuries (I.). 

TUESDAY.—3.30 P.M., Mr. Julian Taylor: Spinal Com- 
pression. 

WEDNESDAY.—3.30 P.M., Dr. Kinnier Wilson: Clinical 
Demonstration. 


THURSDAY.—3.30 P.M., Dr. Riddoch: Cerebral Tumours. 
FRIDAY.—3.30 P.M., Dr. Purdon Martin: Demyelinating 
and Toxic Diseases of Nervous System. 
Out-patient clinics daily at 2 P.M. 
LEEDS GENERAL INFIRMARY. 
TUESDAY, March 10th.—3.30 P.M., Dr. Towers : Faintness 
and Vertigo: Demonstration of Cardiac Cases. 


MANCHESTER ROYAL INFIRMARY. 


TUESDAY, March 10th.—4.15 P.M., Dr. J. Wharton: Iritis 
and Glaucoma. 
FRIDAY.—4.15 P.M., Dr. Crighton Bramwell: Demon- 
stration of Cardiac Cases. 
ANCOATS HOSPITAL, Manchester. | 
THURSDAY, March 12th.—4.15 P.M., Dr. E. D. Gray: 
A Study of Chest Radiograms. 
UNIVERSITY OF DURHAM. 
SUNDAY, March 15th.—10.30 a.m. (Newcastle Genera 


Hospital), Mr. G. F. Duggan: Surgical Cases. 


GLASGOW POST-GRADUATE MEDICAL ASSOCIATION. 
WEDNESDAY, March 11th.—4.15 P.M. (Royal Maternity 
and Women’s Hospital), Dr. R. A. Lennie: Aute- 

natal Care. 


WEST CORNWALL MINERS’ AND WOMEN’S HOSPITAL. 
REDRUTH.—New quarters for nurses were opened at this 
hospital on Feb. 18th. There are five bedrooms, which 
are centrally heated and have hot and cold water. The 
cost of the extension has been about £1000. 


THE LANCET 


580 


NOTES, COMMENTS. AND ABSTRACTS 


[MARCH 7, 1936 


f POISONS FOR RODENTS 


A TECHNICAL discussion on poisons for rodents 
was held at the College of the Pharmaceutical Society 
on Feb. 27th, under the auspices of the University 
of London Animal Welfare Society. Prof. J. H. 
Burn presided. It was made clear that the society 
did not propose to advocate any particular policy 
or to conduct propaganda at this meeting, but merely 
to survey the available information. The object 
of the discussion was to explore the feasibility of 
selecting and devising poisons for rats and other 
rodents which should cause as little suffering as 
possible. Mr. J. G. Wright, lecturer in surgery and 
materia medica at the Royal Veterinary College, 
summarised the pathological effects of hydrocyanic 
acid gas, and bait poisons including arsenic trioxide 
or potassium arsenite, phosphorus, strychnine, salts 
of thallium, barium carbonate, and red squill. AN 
except the last two of these figure in Part I. of the 


list of poisons drawn up by the Poisons Board, and . 


barium carbonate is in Part II. of the list, so that 
only red squill would be available for unrestricted 
distribution to the public. All the prohibited 
poisons produced severe and prolonged suffering. 
Red squill, when freshly and correctly , prepared, was 
perhaps the least inhumane of the poisons that could 
be effectively used. It was specific for rats, more 
toxic for females than for males, and had little effect 
on domestic animals or man. The toxic principle 
contained in red squill was different from and addi- 
tional to the glucosides which gave the drug thera- 
peutic value. The essential action was upon the 
central nervous system. Symptoms were delayed 
for several hours after ingestion and began as a 
paralysis of the hind limbs, which progressively 
became more generalised, and were accompanied by 
convulsions of varying intensity, during which the 
animal might throw itself about. Death occurred 
in from one to three days from asphyxia following 
paralysis of the respiratory centre. Mr. Wright 
suggested as a useful line of research the search for 
a narcotic that could be combined with red squill, 
in order to provide unconsciousness during the 
onset of painful symptoms. Hydrocyanic acid, used 
for fumigating rabbits and rats in burrows, was 
the most rapidly acting poison known. 

Mr. J. D. Hamer, consultant chemist to the Orient 
Line, put the poison question in due perspective by 
describing first the urgent reasons for combating 
the rat menace and secondly the normal methods 
employed for this purpose. The most important 
of these were rat-proofing of premises, elimination 
of nesting sites and supplies of food and water, and 
fumigation with hydrogen cyanide (which in view of 
its toxicity required skilled handling except in the 
open air). Traps and poison baits were relatively 
inefficient ; if any were to be used he preferred red 
squill. Bacterial poisons he rejects as unsafe. 
Mr. T. Howard described the technique of the methods 
of baiting requisite to outwit the extremely high 
intelligence of the rat. He favoured a quick-acting 
poison of high toxicity, but such poisons could not 
be sold to the general public and were available only 
to the professional rat-catcher. 

In the course of the general discussion which 
followed, a suggestion was made that research should 
be undertaken with the object of identifying the 
rat-toxic principle of red squill and of synthesising 
a kindred compound which by acting more rapidly 
would cause a more humane death. 


THE COMMON COLD AGAIN 


ANOTHER symposium on this vexed and vexing 
problem appears in the Health Examiner (published 
by the New York Academy of Medicine) for January, 
1936. The authors are Dr. Russell L. Cecil, Dr. Yale 
Kneeland, Jun., and Dr. Walter L. Niles, all of New 
York. Dr. Cecil’s foreword does not carry us far. 


Having stated confidently that exposure to cold is 
the surest way to catch a cold, he devotes the rest 
of his article to a discussion of the treatment of 
pneumonia. Dr. Kneeland’s contribution is more to 
the point. He holds the rational and modern view 
that the causa causans of the common cold is a 
filtrable virus which is, or may be, subsequently 
aided and abetted by the common pathogenic 
organisms present in the respiratory passages. 
support of this view he quotes the work of T. H. Paul 
and H. L. Freese on the inhabitants of Spitzbergen 
who, during the seven months of the year in which 
they are ice-bound and so isolated from the rest of 
humanity, do not suffer from colds. In Dr. Knee- 
land’s opinion, the solution of the problem lies in 
effectively immunising the human race against the 
virus. Dr. Niles suggests that the way to avoid 
colds would be to live in regions where they are 
infrequent; but would not the result of following 
such advice be to introduce colds into those happy 
regions ? He holds that the public are still insuffi- 
ciently alive to the seriousness of the cold as a com- 
municable disease which, he thinks, should be handled 
in a manner similar to measles or scarlet fever. With 
regard to treatment he has nothing very new to offer. 
Many will agree with him when he says that there 
is a tendency to over-treat infected mucous mem- 
branes with ephedrine or cocaine. He is inclined to 
look with favour on the treatment of the cold by 
morphia or other alkaloids of opium as advocated by 
Diehl and certain French physicians. 


DEFENCE AGAINST AIR RAIDS 


THE air raid precautions department of the Home 
Office has issued a circular to local authorities on 
‘* Anti-gas Training,” and a leaflet on ‘‘ Rescue Parties 
and the Clearance of Debris.’’ These are obtainable 
from H.M. Stationery Office at ld. and 2d. respec- 
tively. The circular states that a civilian anti-gas 
school will shortly be established at Eastwood Park, 
Falfield, Gloucestershire, and that local authorities 
and other responsible bodies will be expected to 
arrange for instruction to be given in their areas by 
persons who have obtained certificates after under- 
going a general course of at least a fortnight at this 
school. Specialist one-week courses will also be given 
to doctors and nurses and to suitably qualified 
chemists. The first five courses at the school will 
be devoted to police and fire brigade instructors, 
but vacancies can be provisionally allotted for the 
whole of the first year. The memorandum on rescue 
parties forms part of a considerable series of official 
pamphlets and handbooks now in course of pub- 
lication. 

We have also received a copy of a monthly review 
described in a covering letter as the only journal in 
Bulgaria devoted to chemical warfare and the treat- 
ment of poison gas casualties. Its title, in French, 
is Défense de Gaz. et lV Aéronautique, and it is pub- 
lished from Boulevard Ferdinand 90, Sofia. 


MINISTERING ANGELS ON HORSEBACK 


THE condition of rural midwifery in the United 
States still leaves much to be desired. A recent 
report! on Brunswick County, Va., expresses the 
opinion that many of the rural midwives there are 
physically and mentally unfit to practise. No such 
criticism, however, is true of Kentucky where 
Mrs. Mary Breckinridge founded the Frontier Nursing 
Service in 1925. This service now covers an area 
of more than 700 square miles. There are nine 
nursing centres and some fhirty nurses who, owing 
to the nature of the country, have to travel about 


ı U.S. Public Health Reports, Dec. 27th, 1935. The Rural 
Midwife: Her Social and Economic Background and Her 
Practices as Observed in Brunswick County, Va. By Josephine 
L. Daniel, Research Worker in Child Hygiene and Public Health 
Nursing; and William M. Gafafer, Senior Statistician, United 


States Public Health Service. 


THE LANOET] 


on horseback. The service also includes a medical 
director, an 18-bed hospital, and, during the summer 
months, a dentist. In addition there are a social 
worker, a statistician, and a volunteer courier service. 
Though midwifery was the first and remains the 
primary function, the work has expanded and now 
includes the care of the sick of both sexes and all 
ages, social service, and education in preventive 
medicine and child welfare. Up to May, 1931, 
costs worked out at the remarkably low figure of 
$10.92 a year per patient. During the great drought 
of 1930, which brought dysentery, typhoid, small-pox, 
diphtheria, pneumonia, and influenza in its train, 
the nurses covered an area of 1000 miles, tending the 
sick and chlorinating wells. This admirable service 
is an example of what can be done by courage and 
enterprise in remote areas. 


A GUIDE TO INCOME-TAX PROBLEMS 


THERE exist full-dress text-books on income-tax 
for experts, heavy loads of information usually at 
a heavy price, containing every word of the Income 
Tax Act and of the amending sections in annual 
Finance Acts, annotated with every decided case. 
The “ Income Tax Guide,’ by Mr: John Burns,! 
is of less formal character: a convenient summary 
which the tax-payer can study for himself, clearly 
written and inexpensive. In the new edition, 
miraculously shorter even than its predecessor, the 
main change is the substitution of the new scale of 
reliefs under last year’s Finance Act. Chancellors 
of the Exchequer have promised simplification of the 
law. The committee of experts, set up by Mr. Winston 


Churchill several years ago, has its report and its - 


draft code in type; it is possible that the existing 
enactments will be consolidated in an improved 
form in a year or two. Meanwhile there are few tax- 
payers who do not need guidance; within its own 
range Mr. Burns’s little book will be found serviceable. 
It contains pages of special interest to doctors and 


dentists. 
NEW PREPARATIONS 


‘‘Tozo’”’ WHITE STAINLESS IODISED OINTMENT 
contains 6 per cent. of potassium iodide and 3 per 
cent. of methyl salicylate in a neutral saponaceous 
base. It leaves no mark on the skin and is recom- 
mended for external application in cases of rheumatic 
pain, chilblains, cuts, bruises, burns, and other 
conditions. The makers are Christopher, Stanley and 
Co., Ltd.; Thames House, Millbank, London, S.W.1. 


PETEIN is a whooping-cough vaccine, for intra- 
muscular injection, prepared by Schering- Kahlbaum 
A.G., of Berlin, and sold in this country by Schering 
Ltd., 188, High Holborn, W.C.1. About 60 distinct 
strains of Hemophilus pertussis, collected in various 
epidemics, are used in its composition, and care is 
taken to preserve their activity. The principal 
advantage claimed for Petein, as compared with 
other whooping-cough vaccines, is that the bacterial 
toxin has been removed from the bacterial cells, 
which makes it ‘‘ entirely innocuous ” even in large 
doses. The detoxication of each batch is verified 
by intradermal inoculation into guinea-pigs or rabbits, 
and is considered satisfactory if the animal shows 
no reaction after receiving double the maximum dose 
employed in man. The course advised is four injec- 
tions, administered on alternate days, ranging from 
0°25 to 1'0c.cm. (total 2°5c.cm.=—50 million organisms). 
According to the manufacturers such a course is 
useful not only for prophylaxis but also for the treat- 
ment of whooping-cough, as late as the early stages 
of the convulsive phase of the cough. The benefit is 
observed 3-4 days after the last injection ; at this 
point ‘‘the severe paroxysms of coughing and the 
vomiting cease abruptly,’’ though occasionally the 
paroxysms may have been aggravated for a time 
during the actual treatment. The only other unto- 
ward effect noted is that rarely the fourth injection 


1 Income Tax Guide. 
Writer to the Signet. 
Pp. 214. 5s. 


Ninth edition. By John Burns, 
London: Sir Isaac Pitman Ltd. 1935. 


NOTES, COMMENTS, AND ABSTRACTS.—VITAL STATISTICS 


_ fever, 


[MAROH 7, 1936 681 


leads to a slight rise of temperature with some local 
pain, both being attributed to the protein present 
in the vaccine. In support of their claims Messrs. 
Schering quote observations by E. Krüger (1934) 
and M. Richter (1934); but these are suggestive 
rather than conclusive. 


A-B-D CAPSULES, made by Abbott Laboratories 
Ltd., of Montreal (524, Wigmore-street, London, 
W.1), are soluble gelatin capsules containing a pre- 
paration of fish-liver oils and yeast rich in vitamins 
A, B,, B,, and D. It is stated that each is equivalent 
in A and D content to at least three teaspoonfuls of 
cod-liver oil (U.S. Pharmacopeia, 1934), and in B, 
content to about an ounce of moist compressed 
yeast. Expressed more accurately each capsule 
supplies not less than 6200 units of vitamin A and 
900 units of vitamin D (U.S.P.), and not less than 
45 Sherman units of vitamin B, and 10 Sherman 
units of vitamin B,. Since these factors are ‘‘ often 
obtained in inadequate amounts from the diet” 
Messrs. Abbott maintain that their administration 
is ‘‘ essential for good health and well-being.” The 
average dose proposed is 1 to 3 capsules daily or 
more during pregnancy and lactation. 


BROM-NERVACIT, described as a nerve tonic, 
consists of potassium bromide 4 per cent., sodium 
phosphate 0°1 per cent., barbitone 0°33 per cent., 
phenazone 0°67 per cent., and alcohol 7°5 per cent.. 
with flavouring of saccharin caramel, orange, and 

uinine. The manufacturers, Brom- ‘‘ Nervacit ”’ 
Ltd. (47, Crogsland-road, London, N.W.1), claim that 
their mixture has a soothing and curative influence 
on nervous disorders without unpleasant or harmful 
after-effects. 


A CORRESPONDENT inquires whether any con- 
valescent home is known to our readers which would 
admit a hospital patient with a suprapubic cystostomy 
between the two stages of an operation for enlarged 
prostate. | 


INFECTIOUS DISEASE 


IN ENGLAND AND WALES DURING THE WEEK ENDED 
FEB. 22ND, 1936 


Notifications.—The following cases of infectious 
disease were notified during the week: Small-pox, 
0; scarlet fever, 2536; diphtheria, 1265; enteric 
fever, 29; acute pneumonia (primary or influenzal), 
1621 ; puerperal fever, 50; puerperal pyrexia, 110 ; 
cerebro-spinal fever, 31; acute poliomyelitis, 11 ; 
encephalitis lethargica, 7; dysentery, 34 ; ophthalmia 
neonatorum, 71. No case of cholera, plague, or 
typhus fever was notified during the week. 

The number of cases in the Infectious Hospitals of the London 
County Council on Feb. 28th was 4910, which included: Scarlet 
975; diphtheria, 1062; measles, 1498; whooping- 
cough, 720; puerperal fever, 18 mothers (plus 14 babies): 
encephalitis lethargica, 283; poliomyelitis, 4. At St. Mar- 


garet’s Hospital there were 28 babies (plus 14 mothers) with 
ophthalmia neonatorum. 


Deaths.—In 121 great towns, including London. 
there was no death from small-pox or enteric fever. 
78 (11) from measles, 10 (1) from scarlet fever, 
37 (12) from whooping-cough, 39 (8) from diphtheria, 
59 (15) from diarrhcea and enteritis under two years. 
and 119 (10) from influenza. The figures in paren- 
theses are those for London itself. 

The mortality from influenza has risen a little, the total 
deaths for the last twelve weeks (working backwards) being 
119, 97, 85, 98, 104, 89, 110, 110, 80, 67, 62, 45. The deaths 
this week are scattered over 56 great towns, Manchester report - 
ing 8, Leeds 6, Blackburn and Birmingham each 4, Ilford, 
Southgate, Blackpool, Hull, Sheffield, Coventry, and Notting- 
ham each 3, no other great town more than 2. Liverpool! 
reported 16 deaths from measles, Manchester 14, Warrington 3, 
Bradford, Salford, and Bristol each 4. Deaths from diphtheria 
were reported from 20 great towns: 3 each from Bradford. 
Hull, and Warrington, 2 each from Leeds, Newcastle-upon- 
Tyne, Oldham, Sheilield, Wallasey, and Birmingham. 


The number of stillbirths notified during the week 
was 283 (corresponding to a rate of 45 per 1000 total 
births), including 37 in London, 


582 THE LANCET] 


VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS 


[mance 7, 1936 


Appointments 


CULLINAN, E. R., M.D., F.R.C.P. Lond., has been appointed 
Hon. Physician to the Gordon Hospital, Vauxhall Bridge- 
road, London. 

FINLAYSON, D. I. C., M.B., F.R.C.S. Edin., Resident Medical 
Officer and Registrar at the Birmingham Maternity Hospital. 

HEALEY, F. H., M.D. Birm., D.P.M., Senior Assistant Medical 
Officer at the Somerset and Bath Mental Hospital, Cotford. 


V acancies 


For further information refer to the advertisement columns 
Aberdeen koyal Infirmary.—Surgical Registrar. £200. 
Altrincham General Hospital.—sSen. H.S. At rate of £150. 

Aylesbury, Bucks Mental Hospital. Stone.—Sen. Asst. M.O. 

£600. Also two Jun. Asst. M.O.’s. Each £350. 
Bath and Wessex Children’s Orthopedic Hospital, Combe Park.— 
H.S. At rate of £120. 
Bath Royal United Hospital.—H.S. At rate of £150. 
Beckenham, Bethlem Royal Hospital, Alonks Orchard.—Two Res. 
H.P. 5) Each £175. 
Bolfast, Roual Maternity Ilospital.—Res. H.S. At rate of £100. 
Pum ugla City.—Asst. M.O. for Maternity and Child Welfare. 


Birmingham, Erdington House.—Deputy M.O. £800. 

Birmingham, Little Bromwich Hospital for Infectious Diseases.— 
Jun. Res. M.O. £300. 

BRUL ae. ee Hospital for Women, Windlesham-road.— 

Bristol City and County, Child Guidance Clinic.—Psychiatrlst. 
At rate of £500. Also Social Worker. £275 

Bren pee ceuale ADLedical School. —Two Cas. 0.’s. At rate 
o 

Buzton, Devonshire Royal Hospital.—H.P. At rate of £150. 

CanterburY, Kent Corny Mental Hospital, Chartham Down.— 
Med. Supt. £1000, 

Cardiff Royal Infirmary. —H. S. to Ophth. Dept. At rate of £40. 

Central London Throat, Nose, and Ear Hospital. Gray’s I nn-road, 

.C.—Two Hon. Assts. for Qur -patient Dept. 

Chadderton, U.D.—M.0.H., &e. £80 

Chester, Barrowmore Hall, Great Harrow. —H.P. At rate of £150. 

City of London Hospital’ for Diseases of the Heart and Lungs, 
Victoria Park, Ek.—Physician to In-patients. 

Colonial Medical Service-—Med. Supt. for Colonial Hospital, 
Port of Spain. £1100. 

Croydon, Mayday Hospital. Jun. Res. Asst. M.O. £300. 

Derby, Bretby Hall Orthopadic Hormat, near Burton-on-Trent .— 
Asst. M.O. At rate of £150 

Dewsbury and District General I nfirmary. —Second H.S. £150. 

Dudley, Guest Hospital.—H.S. £200. 

Eastbourne, Princess Alice Memorial Hospital.—Res. H.S. £150. 

Edinburgh, General Board of Control.—Deputy Commissioner. 


7 
araro E Eye Infirmary.—Res. H.S. Also Res. Asst. H.S. Each 


Gloucestershire Royal Infirmary.—H.S. to Ear, Nose, and Throat 
Dept. At rate of £150. 
reaL P Cr a Medical Fund Society, Swindon.—Chief 


Guildford, Royal Surrey County Hospital.—Res,. Surg. O. £250. 

Hampstead General and N.W. London Hospital, Haverstock Hill, 

ie N.W.—Cas. M.O. for Out-patient Dept. At rate of £100. 

Harrow Urban District.—Asst. M.O. £600. 

Hertford County Hospital.—Hon. Clin. Asst. 

Hospital for Sick Children, Great eee street, W.C.—Res. H.P. 
and Res. H.S. Each at rate of £100. 

Huddersfield County Borough.—Asst. M. O.H. £500. 

Huddersfield Koyal Infirmary. —ĦH.P. and Res. Anæsthetist. 
Also H.S. Lach at rate of £150. 

Institute of Medical Psychology, M alet- pluce; W.C.—Part-time 
Psychotherapist. At rate of £20 

Institute of Ray Therapy, &c., Darde: road, N.JV.—Part-time 
M.O. At rate of £100 

Kent County Council. —Res. Asst. M.O.’s for County Hospital. 
Each £250. 

Kent Education Committec.—Asst. M.O. £500. 

Lancaster County Mental Hospital.—Asst. M.O. £500. 

Leamington Spa, Warneford General Hospital.—Res. H.S. to 
Cas. and Spec. Depts. At rate of £150. 

Leyton Borough, Education Committee.—Part-time Orthoptic 
Worker. 15s. per session. 

Lincoln County Hospital.—Jun. H.S. At rate of £150. 

London County Council.—Temp. District M.O. At rate of £290. 

London Hospital, E.—Med. First Asst. and Reg. £300. 

London University.—University Chair of Biochemistry. £1000. 
Also University Readership in Anatomy. £600. 

Macclesfield General Infirmary.—Second H.S. At rate of £150. 

Maidenhead Hospital.—lion. Ophth. Surgeon. 

A ONE, County Pathological Luboratory.—Asst. Pathologist. 


Maidstone, West Kent General Hospital.—H.P. £175. 

Manchester, Ancoats Ilospital.—H.S. At rate of £100. 

PENIS St. Mary’s Hospital.—Four H.S.’8. 

£5 

Mansfield, Harlow Wood Orthopedic Hospital.—Two H.S.’s. 

| At rate of £200 

Middlesex County Council.—Asst. M.O. £600. 

Mount Vernon Hospital, Northwood, Middlesex.—Asst. Radio- 
logist. £350. 


Each at rate 


Ne ae ee Royal Victoria Infirmary.—Jun. Surg. 
g. £150, 
Neno, Mon, Royal Gwent Hospital.—Asst. Cas. O. Also 


two H.S.’s and H.P. Each at rate of £135. 


Northampton General Hospiial.—H.P., H.S.’s, also Cas. O. Each 
at rate of £150. 

Northumberland County Council.—Asst. County M.O.H. £500, 

Norwich, Jenny Lind Hospital for Children.—Res. M.O. £120, 

Nottingham General Hospital.—H.S. for Fracture and Ortho- 
pædic Dept. £300. Also H.S. to Ear, Nose, and Throat 
Dept. At rate of £150. 

Plymouth, Prince of Wales’s Hospital, 
At rate of £150. 

Plymouth, Prince of Wales’s Hospital, Greenbank-road.—H.S, 


Lockyer-street.—H.S., 


At rate of £120 

Port Said. British Hospital. —Principal M.O. £700. 

Preston, OT oR Hospital, Appley Bridge. —Jun. Asst. M.O. 
£20 


Princoss Elizabeth of York Hospital for Children, Shadwell, B.— 
H.P. At rate of £125. 

Queen’s Hospital for Children, Hackney-road, E.—Clin. Asst. to 
Ophth. Dept. 5s. per session. . 

Rochdale Infirmary and Dispensary.—Second H.S. £150. 

Ross Institute of Tropical Hygiene, Keppel-street, W.C.—M.O.’s 
for Kast Africa, &c. 


Rotherham Hospital.—Cas. H.S. £150. 
Royal College of Surgeons of England..—Examiners. 


Royal National Orth: pæ dic Hospital, 234, Great Portland-street, 
W.—H.S. At rate of £150. 

Royal Northern Hospital, Holloway, N.—H.S. At rate of £70. 
St. Alban’s and Mid Herts Hospital.—Res. H.S. £150. 

St. Andrew’s Hospital, Devons-road, Bow, E.—Asst. M.O. £350. 
Salisbury General Infirmary.—H.S. At rate of £125. 
Scarborough Hospital and Dispensary.—Two H.S.’s. Each £175. 
Sheffield Children’s Hospital.—H.P. At rate of £100. 


Sheffield, J ¢ SSOP Hospital for Women.—Res. .M.O. Also two 
H.S.’s. At rate of £150 and £100 respectively. 

Sheffleld University, Dept. of Bacteriology.—Jun. Asst. Bacterio- 
logist and Demonstrator. £300. 

South Shields, Ingham Injfirmary.—Jun. H.S. £150. 

Stockport Infirmary.—H.P. £150, 


Sunderland Royal Infirmary.—H.P. £120. 

Taunton and Somerset Hospital.—H.S. At rate of £100. 

University College Hospital, Gower-street, W.C.—Asst. Radio- 
logist. £200 

Uxbridge, Hillingdon County Hospital.—Jun. Res. Asst. M.O. 
At rate of £250. . 

Warrington Infirmary and Dispensary.—Third Resident. At 
rate of £150. 

West London Hospital, Hammersmith-road, W.—H.P. and H.S. 
to Spec. Depts. and Res, Cas. O. Each at rate of £100. 
Non. Res. Cas. O. £250. Also Physician. 

eet See County Council, d:c.—Asst. County M.O.H., &c. 

800 

Wolverhampton Royal Hospital.—H.S. 
Fracture Dept. At rate of £100. 

Wrerham and East Denbighshire War Memorial Hospital.— 
Two Res. H.S.’s. Each at rate of £150. 

The Chief Inspector of Factories announces vacancies for 
Certifying Factory Surgeons at Walton-on-the-Naze 
(Essex), Calvert (Buckingham), Croydon (Surrey), and 
Swanscombe (Kent). 


Births, Marriages, and Deaths 


BIRTHS 


ANDERSON.—On Feb. 26th, at Braintree, the wife of Dr. David M. 
Anderson, of a daughter. 

CAUGHEY.—On Feb. Raru at Collingham-gardens, S.W., the 
wife of Dr. F. W. . Caughey, of a daughter. 

FERGUSON.—On March iat, 1936, at York-place Nursing Home, 
Manchester, to Kathleen (neé Wilson), wife of Fergus R. 
IFerguson—a son 

PEREIRA.—On Feb. 28th, at Aloxandra Park, N., the wife of 
Dr. Harold Pereira, of a daughter. 

REEVES.—On Feb. 27th, at Southsea, the wife of Dr.R. K. Reeves, 


of a son. 
MARRIAGES 


CLEGG—Eason.—On Feb. 22nd, at Southwark Cathedral, 
William Bernulf Clegg, M.R.C.S. Eng., of Wilmslow, 
Cheshire, to Diana Clare, daughter of the late Hon. Mrs. 
Eason and of Mr. H. L. Eason, Superintendent’s House, 
Guy’s Hospital. 

CoPpLAND—DouGLaAs.—On Feb. 27th, at the Caledonian Hotel, 
Edinburgh, James George Copland, M.D. Aberd., of Hud- 
derstield, to Margaret Cruickshank Douglas, M.B., D.P.H., 
younger daughter of Mr. Joseph and the late Mrs. Douglas, 
Colinton, Edinburgh. 

ELLMAN—SAMUELL.—On Feb. 27th, at the Liberal Jewish 
Synagogue, London, Philip Ellman, M.R.C.P. Lond., of 
Harley-street, W., to Betty, elder daughter of Mr. and 
Mrs. Albert L. Samuell, of Cumberland-terrace, Regent’s 


Park, N.W. 
DEATHS 


BURNETT ON Fob. 26th, at’ Keswick, John Ridley Burnett, 

M.D. Edin. 

Coap.—On Feb. 27th, at cunbrides Wells, John Edwin Coad, 
Surgeon Captain, R.N. (retired). 

CoPEsTaAKE.—On Feb. 29th, at Peckham Rye, London, Thomas 
Goodall Copestake, M.B. Glasg. 

Hopson.—On Feb. 26th, at Canterbury Eleanor Hodson, 
M.B. Edin., Chevalier Légion d’Honneur, Médaille d’Hon- 
neur, elder daughter of the late Mr. and Mrs. Hodson, of 
Mickleover, Derbyshire. 

TAYLOR.—On Feb. 27th. at Deepdale, Scarborough, Edward 
Muscroft Taylor, L.R.C.P. Edin., aged 78. 


N.B.—A fee of 7s. 6d. is charged for the insertion of Notices of 
Births, Marriages, and Deaths. 


for Orthopedic and 


THE LANCET] 


[Maron 14, 1936 


ADDRESSES AND ORIGINAL ARTICLES 


THE NUTRITION QUESTION 


By Rogert Hurcuison, M.D., LL.D. Edin., 
F.R.C.P. Lond. 


CONSULTING PHYSICIAN TO THE LONDON HOSPITAL 


THE subject of nutrition is at present much to the 
fore ; it may, indeed, be regarded as the public health 
“stunt” of the moment though maternal mortality 
runs it close. Unfortunately, too, it is a subject 
which has got badly mixed up with politics with the 
consequence that much of the writing about it in 
the lay and even in the medical press is of a tendentious 
character. This is a pity, for nutrition and its 
relation to health is a more complicated matter than 
is. often realised and there is no subject which more 
requires cool and clear thinking. 


What is Meant by Nutrition 


At the outset we are met with the difficulty of 
defining our terms. According to the dictionary, 
nutrition is “the action or process of supplying or 
receiving nutriment,” but this does not carry us 
very far. Perhaps one might describe normal 
nutrition as a state in which the intake of energy 
balances the output; in which the food contains 
enough protein and mineral matters for the purposes 
of growth and repair and in which the supply of the 
accessory food factors is adequate to prevent disease. 
But the “nutrition” of any individual is not a 
fixed and static thing; on the contrary it is, like 
health, capable of various degrees. If, for example, 
æa man gains 5 lb. in weight is he necessarily better 
nourished than he was before? Or if he loses 51b. 
is his nutrition necessarily worse? What, in short, 
is the optimum level of nutrition? Should we aim, 
as some enthusiasts would have us do, at feeding 
children in such a way as to produce the maximum 
growth and development of which each child is 
capable? If we succeed in this are we sure we have 
benefited the child? Does maximum growth make 
for health and longevity? There is certainly some 
experimental evidence that it does not and general 
experience seems to show that the tallest people 
are not the most robust and that the well-developed 
athlete is not necessarily a better “‘life” than the 
more fragile man. May it not be that the smaller 
and more wiry type fits in better with the conditions 
of urban life and a machine age ? 

These are only some of the questions to which 
there are as yet no agreed answers and although 
it might be true simply to say that optimum nutrition 
is that condition in which the body is at its highest 
pitch of vitality, there exists unfortunately no means 
of measuring that quality. 


Assessment of Nutrition 


There is, in fact, no accepted standard of nutrition 
in spite of many attempts to find one,? no “ yard- 
stick ”—to use Prof. Cathcart’s term—by which 
‘we can measure exactly what the state of nutrition in 
any individual is. The Quetelet Index or the relation 
of weight to height is, of course, of some help and 
it is probably true that if a child under 12 is less 
than 10 per cent. below or 20 per cent. above the 
average weight for his height he may be regarded as 
normal (Holt), But only quantitatively normal, 
oe ee may be badly wrong in quality although 

7 


the body-weight is perfectly correct. We are thus 
driven to the conclusion that the state of nutrition 
can only be estimated in the same way as that of 
health ; it is essentially a clinical problem to be 
determined by clinical methods. Unfortunately, 
however, it is just in the use of such methods that 
wide experience is most required and the personal 
equation of the observer counts for so much. It 
is not surprising therefore that the estimates by 
school medical officers of the amount of ‘‘ malnutri- 
tion ” in their districts vary considerably. 


Assessment of Diets 


It is sometimes assumed that although we cannot 
easily determine what optimum nutrition is, at least 
we can tell the kind of diet both in quantity and 
quality which can be guaranteed to produce it. 
Much of the criticism of present-day diets is based 
on this assumption, but is it correct? If we look at 
such a comparatively simple problem as energy 
requirement we find that three different committees 
of experts, appointed in recent years by the Ministry 
of Health, the British Medical Association, and the 
League of. Nations respectively, have each recom- 
mended a different calorie value to maintain efficiency. 
There is even less agreement about the optimum 
protein intake. It was originally fixed by Voit at 
120 g., and this figure was generally accepted at 
the beginning of this century until challenged by 
Chittenden. It is now often put at the round figure 
of 100 g., but we have the authority of Sir Gowland 
Hopkins for the statement ? that Cambridge under- 
graduates (not surely an under-nourished class) 
do not on an average consume more than 80 g., 
although a very high proportion of this is probably 
“first class.” But here again we lack scientific 
guidance. There are some who say that half of the 
intake of protein should be of this superior kind, 
whilst others content themselves with recommending 
about a third. The point is one of importance, for 
first-class protein, being mainly of animal origin, 
adds greatly to the cost of the diet and yet there 
is no scientific justification for any positive pronounce- 
ment as to the exact amount of it required for 
optimum nutrition. If this is true of protein it is 
equally true of the mineral matters in the diet and of 
the “‘ accessory factors’’; estimates of the quantity 
of these required to maintain health are largely a 
matter of guesswork. If one adds to these uncertain- 
ties the inconstant composition of most foods and the 
doubtful allowance which has to be made for ‘‘ waste ” 
in the case of different individuals or households 
one sees on what shaky foundations our conception 
of an “‘optimum diet ” is based. 

In spite, however, of this absence of mathematical 
certainty in our criteria it is useful to distinguish 
between (1) “‘ under-nutrition,’? meaning by that a 
state of things brought about by an inadequate 
intake of energy (calories), and (2) “malnutrition,” 
a condition due to an ill-balanced diet or one deficient 
in building material or some of the accessory factors. 
Such a distinction, though convenient, is of course 
quite artificial, for in practice under-nutrition and 
malnutrition more often than not coexist. 


Effects of Under-nutrition 


It is commonly said that the effects of an insufficient 
intake of energy in the form of food is to lessen 
first activity and then resistance to disease. Such 
a statement needs qualification. It is amazing 

L 


584 THE LANCET! 


how much activity some grossly under-nourished 
persons exhibit—patients with anorexia nervosa 
for instance—and, as regards resistance to disease, 
clinical experience tends to. show that under- 
nourishment must be very pronounced before any 
general lowering of resistance is brought about. 
There is only one disease, indeed, to which beyond 
all doubt under-nutrition, even of moderate degree, 
predisposes, and that is tuberculosis. It was the 
supervention of tuberculosis that one dreaded in the 
casé of young diabetics who were treated in the pre- 
insulin days by Allen’s starvation plan and that 
one dreads still in patients with anorexia nervosa. 
In Germany, during the food shortage of the war, 
the death-rate from tuberculosis rose enormously 
whilst that from diabetes (a disease of over-nutrition) 
fell. Even in this instance, however, there is some 
evidence that it is not a shortage of calories as such 
(i.e., under-nutrition) that weakens resistance but 
poverty of the diet in fat (i.e., malnutrition), though 
whether it is the fat itself that is important, or a 
vitamin of which fat is the vehicle, is undetermined. 
As regards other infections, there is little evidence 
that under-nourishment, at least in moderate degrees, 
favours their development. It does not seem to do 
so, for instance, in the case of acute rheumatic 
infection in childhood, or the common acute specific 
fevers, or B. coli infections or acute poliomyelitis, or 
infection by pyogenic organisms ; indeed Dr. Friend * 
records that at Christ’s Hospital the health of the 
boys, as regards septic infections and possibly in 
some other respects, “‘ was actually better during the 
period of restricted food supplies.” There is more 
doubt about respiratory infections other than tuber- 
culosis; at least there was an increased mortality 
from these in Germany during the time of food 
shortage just as there was from tuberculosis itself. 
On the other hand Chable,® in an investigation in a 
Swiss canton where there was a large amount of 
unemployment, found no deterioration of health in 
spite of restricted rations, indeed it was better at all 
ages, and curiously enough there was even less 
tuberculosis. He attributes these results to the 
cessation of heavy manual work so that the diminished 
intake of food sufficed. 


_Effects of Malnutrition 


If the effect of a moderate degree of uwnder-nutrition 
in predisposing to disease is uncertain, it is even 
more difficult to estimate the consequences of mal- 
nutrition. Take, for instance, the case of protein. 
‘What, if any, are the ill-effects of living habitually 
on a protein minimum? We have no clear evidence 
to guide us to a decision. Some persons seem to be 
able to live normally for very long periods on a 
protein intake which is only about half the generally 
accepted standard, whilst others on the same allow- 
ance have complained after a time of ‘impaired 
health,” lack of energy, and shortness of breath.® 
The condition known as war cdema has also been 
attributed, rightly or wrongly, to protein shortage, 
but as regards the effect of the latter in predisposing 
to disease we really know very little. The same 
is even more true of the mineral constituents of the 
diet. That these are essential to life is of course 
beyond dispute, but as regards the consequences to 
health which follow the consumption of them in 
quantities below those fixed by dietitians as 
“standards ” we really know very little. Shortage 
of iodine in the diet seems to produce goitre and 
lack of iron is sometimes—though usually (except in 
infancy) only in the presence of habitual losses of 
blood—a cause of anemia, but is there any clinical 


DR. ROBERT HUTCHISON : THE NUTRITION QUESTION 


[marcu 14, 1936 


condition other than rickets and osteomalacia which 
can be attributed to a diet poor in calcium ? Even 
these diseases, moreover, are usually brought about 
not by lack of calcium itself but of a sufliciency of 
vitamin D to enable the calcium to be utilised. 

And what of malnutrition due to deprivation of 
the accessory factors (vitamins)? We know of 
course that absence of these (avitaminosis) results in 
the appearance of certain specific diseases—xeroph- 
thalmia, rickets and osteomalacia, beri-beri, scurvy. 
But what is the effect on health of ingesting only 
minimal quantities of vitamins (hypovitaminosis) ? 
About this there has been a good deal of vague talk, 
emanating from experimentalists rather than from 
clinicians, so it will be as well to consider each 
vitamin separately. 

Vitamin A has been proved to prevent xeroph- 
thalmia and night-blindness. Green and Mellanby ’ 
found that a lack of it in the diet of experimental 
animals led to broncho-pneumonia, and they also 
advanced some evidence to show that its adminis- 
tration lessened the risk of puerperal infection in 
women. It was therefore labelled, rather hastily, 
the ‘‘anti-infective’’ vitamin, and began to be 
prescribed in concentrated form in all sorts of infec- 
tions. The results, however, were not impressive, 
and subsequent clinical investigation on a large 
scale with adequate controls has shown that, in fact, 
vitamin A has no general ‘‘anti-infective’’ power 
except possibly as regards some mild infections of 
the skin. 

Vitamin B, of course, is not a single vitamin but 
a complex of more than one. One fraction of it has 
been proved to protect against beri-beri and another 
may possibly play a part in protecting against 
pellagra, but beyond these there are no definite 
diseases in man associated with a lack of it. Experi- 
mentalists have ascribed ill-defined disorders of the 
intestine to a shortage of this vitamin, but it may 
safely be said that no such association has been 
recognised by clinicians. Only the other day I was 
asked by a commercial traveller to believe that an 
artificial preparation of the vitamin-B complex 
which he was trying to sell was “‘ good for neuritis.” 
On cross-examination, however, he proved quite uncer- 
tain as to what variety of neuritis was meant. This 
is a good example of the way in which the vitamins 
are being exploited commercially on the strength of 
the most flimsy evidence. 

Vitamin C protects against scurvy—that is proved— 
and the fact that scurvy, other than the infantile 
form, is now almost extinct in this country shows 
that our ordinary diet contains enough of it; much, 
probably, in that popular article, the potato. 
Here again attempts have been made to show that 
there are conditions of ill-health short of actual 
scurvy due to a scarcity of vitamin C in the diet, 
and some evidence has been brought forward that 
an increased fragility of the capillaries can be demon- 
strated in such circumstances. But do clinicians 
often see such cases, which would of course be bound 
to display themselves by bruising and extravasations 
on slight provocation? I think not. Even less 
convincing to the pediatrist I fancy will be the 
recent attempts to make out that deficiency of 
vitamin C plays a part in the production of acute 
rheumatism. | 

As a matter of fact the striking thing about ascorbic 
acid (vitamin C) is the very negative effect it seeme 
to have on bodily functions and metabolism even 
when given in massive doses. °® 


Vitamin D prevents rickets and some of its com- 


THE LANCET] 


plications in the growing child, and may also, though 
less certainly, help in the building up of sound teeth, 
so during the early years of life a sufficient supply of 
it in the diet is of great importance. To the adult 
it is much less essential. Osteomalacia may be the 
consequence of a deficiency, but that is a very rare 
disease in this country, and there is no other clinical 
condition, so far as I know, which results from a 
shortage of it in the diet as distinct from a failure 
to ‘utilise it. 


The So-called Protective Foods 


The term ‘protective foods ° has been applied, 
rather unfortunately, to dairy products, green vege- 
tables, and fruits on the ground that they protect 
us against disease and, as thought-saving catch- 
phrases so often do, it has caught on. But this 
group of foods is really no more deserving of the title 
‘protective’? than sugar and the other calorie-rich 
foods which, after all, protect us against starvation. 
The protective foods do prevent the development of 
a few specific maladies (though meat which is not 
included amongst them does so too), but there is no 
proof whatever that they protect us against any 
of the great. killing diseases to which most of the 
mortality in this country is due. 


Over-nutrition and Under-nutrition 


The existence of any widespread under-nutrition 
in this country (always a priori unlikely, except 
perhaps in the ‘distressed areas”) most official 
information contradicts, and the experience of practi- 
tioners in close touch with the poorer classes will 
probably confirm the contradiction. Against it also 
is the fact that diseases such as tuberculosis which 
are associated with under-nutrition are steadily 
declining, whilst the incidence of diabetes and cardio- 
vascular disorders, which are associated with good 
nutrition, is increasing. Enthusiasts for feeding-up 
the community should take note of this, for over- 
nutrition has dangers to health almost as great as 
those of under-nutrition, though of a different kind, 
and hypervitaminosis is beginning to be recognised 
as well as hypovitaminosis. 

Moreover, of the under- or mal-nutrition which 
exists a very large part is almost certainly not due to 
inability to get enough food of the right kind but to 
such factors as lack of appetite, the consequence of 
indoor occupation and urban life; to educational 
over-strain amongst children; and, as J. C. Spence 
found in the Newcastle district, to infective disease 
in early life (possibly favoured by overcrowding), 
recovery from which had never been complete. To 
these must be added nervous wear and tear and 
psychological factors in many instances. Sheer 
poverty, in short, is only one cause, and that prob- 
ably not a common one of present-day malnutrition. 

It may well be, of course, that expenditure upon 
food is often unwisely directed, and that there is 
much unnecessary waste. There is room here for 
educative propaganda, but he is a sanguine man who 
believes that it is easy to change by this or any other 
means the food habits and prejudices of a people. 


Summary 


I might summarise the purport of this paper in 
the statement that it is intended to be a protest: 
(1) against the pessimistic view, apparently so com- 
monly held, that defective nutrition is widely pre- 
valent in this country; and (2) against the undue 
optimism which believes that a great improvement 
in the public health can be brought about by altering 
the national diet. 

(References at foot of next column) 


DR. DANIEL DAVIES: PEPTIC ULCER 


[marcu 14, 1936 585 


SOME OBSERVATIONS ON 
PEPTIC ULCER * 


By Danie T. Daves, M.D. Wales, F.R.C.P. Lond. 


ASSISTANT PHYSICIAN TO THE ROYAL FREE HOSPITAL, 
LONDON 


(Concluded from p. 526) 


Gastric Secretion in Cases of Ulcer 


Since experiment demonstrates that active gastric 
secretion is essential to the development of peptic 
ulcer in animals, it is difficult to explain the 
coexistence of achlorhydria and an active ulcer. 
We should expect to find in ulcer patients a juice 
possibly more copious and an acidity often higher 
than which is seen in normal people. Clinical 
experience unquestionably supports this view. Indeed 
it is well recognised among the more surgically 
minded that the higher the acidity the more the 
danger of further ulceration. While a gastro- 
enterostomy for carcinoma never results in secondary 
jejunal ulceration, this complication is not a rare 
sequel to operation for peptic ulcer, especially when 
the patient is young and the juice high in volume and 

acidity. 

In an able review of 1435 ulcer patients, Emery and 
Monroe *4 were able to recall “no instance in which 
an ulcer gave characteristic symptoms in the absence 
of HCI.” Brown?> also recorded hyperacidity in 
75 per cent., normal acidity in 22 per cent., and an 
acidity below 20 units in only 3 per cent.—an observa- 
tion from a total of 1224. Palmer 2° likewise found 
free acid in all but 1 of 1004 ulcer patients. Hurst,?! 
Bennett,?7 and Venables,?® have also drawn attention 
to the high acid secretion. More recently Pyrah 2° 
recorded the presence of free HCl in all but 1 of 197 
duodenal ulcers. 

Scott Polland and Bloomfield 30 31 in their accurate 
studies of gastric secretion maintain that in over 
90 per cent. of ulcer cases there is an increase higher 
than the mean values, both in volume and acidity, 
as a result of histamine stimulation. At the same 
time they point out that while almost all patients with 
ulcer show this high acid and high volume secretion, 
similar values are also found occasionally in persons 
not suffering from this condition. 


*The Bradshaw lecture for 1935, eevee before the Royal 
College of Physicians of London on Nov. 5th. 


(Continued from previous column) 


DR. WUTCHISON : REFERENCES 


1. Is Longevity Compatible with Optimum Growth ? McCay: 
Science, 1933, Ixxvii., 410. 

2. See Panciles of Antenatal and Postnatal Child Hygiene. 
W. M. Feldman, London, 1927, p. 646; Critchley, A. M.: 
Brit. Jour. Phys. Med., 1933, vii., 202 ; Discussion on 


Assessment of Nutrition, Proc. Roy. Soc. Med., 1935, 
xxviii., 713. 

. Brit. Med. Jour., 1935, j., 571. 

. The Schoolboy: His Nutrition and Development. Cam- 


bridge, 1935. 

. L’influence de la crise économique sur la santé publique. 
Natrition Abstrs., July, 1935, p. 200. 

. Susskind, B.: Arch. f. Verdauungskr., 1933, liv., 194. 

. Brit. Med. Jour., 1935, ii., 595. 

. For clinical and’ experimental work on the alleged anti- 
infective power of vitamin A, see, inter alia, Mellanby, E. 


OND Cr mo 


Nutrition and Disease, 1934 ; Harris, L. J.: Brit. Med. 
Jour., 1933, ii., 231; Hesa, Lewis, and Barenberg: Jour. 
Amer, Med. Assoc. "1933, ci., 657; Ellison, J. B.: Brit. 


Med. Jour., 1932 708 ; Mackay, Helen: THE LANCET, 
1934, ii., 1462 ; Sütheriand. R.: (Thesis, 1933) Nutrition 
‘Abstrs. . 1933, iii., 819; Blackfan, K. D., and Wolbach, 
S. B.: Jour. "of Pediatrics, 1933, iii., 679; Tress, G. M.: 
Nutrition Abstrs., 1935, v., 906; Richards, Marion : 
Brit. Med. Jour., 1935, i., 99. 

9. Armentaro, L., and others: Zeits. f. d. ges. exp. Med., 1935, 
xevi., 321 (Nutrition Abstrs., October, 1935, p. 497). 


L2 


586 THE LANCET] 


Recently Osterberg and Vanzant*? have drawn 
attention to the high pepsin values which are specially 
found in duodenal ulcer when the symptoms are 
somewhat difficult to control. They also were able 
to show that highly nervous individuals with the 
ulcer syndrome but without an actual lesion showed 
similar high readings in the gastric secretion. 

Gastric secretion varies with age. According to 
Vanzant °° (in a study of 3746 records) gastric acidity 
reaches its maximum between the age of 20 and 40 
in the male, but there is little fluctuation in the acid 
values in the female. Over the age of 60 there is a 
decline and an increasing incidence of anacidity. 
It is of interest to recall that the maximum incidence 
of benign ulcer is between 30 and 40 years, and that 
the male suffers more often than the female. 


TABLE VI 
Gastric Analysis in Ulcer 
G.U. D.U. Total. 
Hyperacidity .. sa 37 os 76 113 (60 %) 
Normal acidity.. te 47 os 27 za 74 (39%) 
Achlorhydria ee ee — or ae 1 oe 1 


Among my patients 188 had gastric analyses, 
many of them repeatedly. We found hyperacidity 
in 60 per cent. and an acidity within the range of 
normal in 39 per cent. (Table VI.). 

Only 33 of the 188 showed a resting juice volume 
below 40 c.cm., and 70 per cent. of the gastric and 
92 per cent. of the duodenal cases showed a resting 
juice volume of above 40 c.cm. (Table VII.). In 


TABLE VII 
The Volume of Resting Juice 


C.cm. | — 40 40 | 60 | 80 | 100 | 120 | 160+ 
Gastric ulcer 27 | 25 | 19 | 12 aj 1 
Duodenal ,, 6 | 37 |/28/ 9] 8] 4 9 

Tse pata [aps | a 


- 


44 per cent. of the gastric and in 55 per cent. of the 
duodenal the resting juice was more than 60 c.cm. 
in volume, This increased volume of resting juice 
is readily apparent during aspiration, and the ease 
with which the juice is withdrawn from an ulcer 
patient contrasts with the frequent difficulty of 
obtaining 20 c.cm. in a normal person. 

Special attention has been paid to the possible 
finding of achlorhydria. One woman with pyloric 
stenosis showed achlorhydria on first analysis which 
was later replaced by a normal acidity. Three 
women who complained of pains after food and who 
showed achlorhydria were reported as showing 
small gastric ulcer craters. 


1. Aged 27. Pain after food for 20 months. Small 
crater reported on the lesser curve. Both the crater and 
symptoms disappeared. The resting juice volume was 
48 c.cm., and histamine resulted in the secretion of 24 units 
of HC) as well as pepsin (256 units). 

2. Aged 40. Pain after food for 8 years. Ulcer 
crater reported on posterior wall. ‘“‘ Crater ’’ disappeared 
in one month, but symptoms persist. Achlorhydria to 
histamine. Resting juice 46 c.cm., pepsin 256 units. 

3. Aged 56. Pain after food for 12 months. “‘ Saucer- 
shaped’ crater on posterior wall. Radiological signs 
and symptoms disappeared in 3 months. Achlorhydria 
persistent to histamine. Resting juice 54 c.cm., pepsin 
256 units. 


These brief records have been incorporated to show 
their unconvincing nature. In only the one with 
free HCl to histamine was the ulcer crater found in 


DR. DANIEL DAVIES: PEPTIC ULCER 


[marnon 14, 1936 


the usual situation ; in the other two it was described 
as on the posterior wall—an uncommon site. Although 
the symptoms were apparently relieved by medication 
in two, it is doubtful whether they should be included 
as patients suffering from peptic ulcer. In all 
probability they are examples of gastritis in which 
the radiological findings are not a little uncertain. 

A more interesting example of achlorhydria is that of 
a man, aged 34, who first appeared complaining of vague 
indigestion in 1933. A barium meal disclosed no organic 
disease, but on gastric analysis achlorhydria persistent 
to histamine was discovered. Some symptomatic treat- 
ment was advised and he was well until the beginning 
of 1935. Pain, but of a more definite character and 
periodicity, returned. A further barium meal now showed 
a lesser-curve ulcer, and when a second gastric analysis 
was done a normal acid secretion was found. The crater 
and symptoms disappeared in two months. In this case 
the appearance of an ulcer crater was associated with 
the presence of free HCl in a person who previously had 
shown achlorhydria. 

It is generally agreed that a high acidity is more 
often found in benign ulcer than in any other state. 
Within recent years attention has also been drawn 
to the dyspepsia of “‘nervous origin,” in which the 
gastric secretion is copious in volume and of high 
acidity—the ulcer syndrome without an actual 
ulcer demonstrable. The exact mechanism of this 
hypersecretion is still sub judice. Some investigators 
attribute it to pyloric spasm and the absence of free 
alkaline regurgitation from the duodenum, while 
others believe that the hypersecretion is a manifesta- 
tion of a constitutional type—the hypersthenic 
gastric diathesis of Hurst—a more or less permanent 
state.?8 It is very difficult to reconcile success 
in treatment with a belief in the persistence of hyper- 
secretion and hyperacidity, if we are at the same time 
to attribute an essential part to gastric juice in the 
development of ulcer. Ulcers should only heal 
with difficulty and rarely, but the reverse is true. 
Is it possible that the hypersecretion and hyper- 
acidity do diminish under certain favourable 
conditions ? 

j TABLE VIII 


Gastric Analysis in Recurrences 
GASTRIO ULCER 


Time 
ea) Type of Time, type of Recur- 
Seely ait secretion. further analysis. rence. 
1 lst mth. H., 12th mth. N. 20 c.cm. 
RJ 76 c.cm. 2nd yr. H.26 ,, + 
2 Ist 99 H., 2ndmth. N. 30 DD 
R J 64 c.cm. 6th ,, H.84 ,, + 
3 6 wks. N., 4th yr. H. 98 + 
R J 84 o.cm. ve a 
4 Ist mth. H., 12th mth. N.15 ,, 
RJ 45c.cm. 4th xr. H.76 ,, + 
5th ,, H.58 ,, + 
5 lst wk. H., 6th mth. H. 41 ,, C.T 
R J 60 c.cm. | 18th ,, H.60 ,, 
3rd yr. N.38 ,, 
C.T.=Crater persisted until 13th month. Treatment 
commenced 12th month. 
DUODENAL ULCER 
1 lst mth. H, 6th mth. H. 86 c.cm. + 
2 | Ist wk. H., 1 yr. N. 32 ,, 
RJ 50 c.cm. 2tyrs. H. 80 ,, + 
3 | 2ndmth. H., 14th mth. N. 32 ,, 
RJ 52 c.cm. 3 yrs. H. 78 ,, ae 
4 | 2nd wk. H., 8th mth. N. 62 ,, 
R J 300 c.cm. | 2 yrs. H. 240 ,, ae 
H.= hyperchlorhydria. J = resting juice. 


R 
N. = normal acidity. 


THE LANCET] DR. DANIEL DAVIES: PEPTIC ULCER [maron 14,1936 587 
FIG. 12 
10.xii.30 11.iv.34 
90 
80 
x 70 
S 60 
Sc a 
© 4 Hp tt 
>30 BCA | | | | 
20 AE Ge ee eee ARSRES 
10 He AINSI I AAST) 
= | | | ane “Reese eS ARR 
Hours Y2 | R 2 232 Yo |. We 2 M Yo | We 2 WM Vo | We 2 M 


The gastric secretion was repeatedly examined over 
a course of three to four years in 52 of my patients, 
and it was found that a definite diminution both in 
acidity and volume was recorded in some of the 
analyses. The initial examination performed during 
the first six months of 
treatment showed the 
following distribution— 
hyperacidity in 42 and 
a normal acidity in 10. 
During the following 
four years only 13 
showed a persistent 
hyperacidity, while as 
many as 39 did at some 
time or other show a 
normal acidity. The 
change occurred at 
varying periods, but 
several showed no 
change in the gastric secretion until the lapse of 
two years. 

We were fortunate enough to obtain several records 
of some who suffered recurrences, both of symptoms and 
a return of crater. Table VIII. shows the types of secre- 


5.iii.32 


N/10 NaOH 


Hours y2 | We 2. 242 


FIG. 14 
14.Xx.32 10.iv.33 
aE) Ease 
GO E 
T Seceseteeeon 
S fo LL LVN 
= 50 MHA R.J.136 c.cm— 
XS 40 
LV 30 fe 
naz NAO 
3 PVC 
Hours Y2 | tle 2 2\2 Yo | We 2 242 


tion and the volume of resting juice in recurrent duo- 
denal and gastric ulcers. Four examples may be given. 


A.—This man showed hyperchlorhydria and a gastric 
Pa in 1930, a normal secretion and no radiological 
abnormality in 1931, and in 1934, with a return of symp- 


FIG. 15 


N/10 NaOH 


ae 
uA 
RE 
RE 
Ea 
SE 
Ne 
An 
i 


Hours 


V2 


toms, a recurrent ulcer and hyperchlorhydria, which has 
now persisted for some six months (Fig. 12). 


B.—This man had hyperacidity and a lesser-curve 
ulcer in 1932, a normal acidity in 1933, and in 1934 a 
return of symptoms and hyperchlorhydria. He was 


26.iii.34 


Ue Ye 2 242 
operated on, but the ulcer had healed and a scar was all 


that was left. In this case both symptoms and hyper- 
acidity returned before the recurrence of the ulcer (Fig. 13). 


C.—The third patient, a woman, had a duodenal ulcer 
ou a high acidity in 1932. This persisted at the time 
of the second analysis 
and had diminished little 
twelve months later. We 
can expect this patient to 
be a ready prey to recur- 
rence unless greater dimi- 
nution in resting juice 
and acidity is recorded 
(Fig. 14). 

D.—In 1933 the fourth 
patient had a duodenal 
ulcer with a characteristic 
acid secretion. Sixteen 
months later the acidity 
was much lower 
(Fig. 15). ; 

The number of repeated analyses is small, but 
nevertheless I think the results are of some significance. 
Under favourable conditions there is a diminution, 
both in acidity and volume, but the improvement 
may not be manifest for a year or more. Even then 
it may only be temporary, to be replaced by a hyper- 
acidity with a recurrence. 

Is this fluctuation in acidity the reason for the 
spontaneous remissions and the long lasting relief 
from symptoms in people who have had the most 
inadequate treatment ? 

The return of hyperacidity i in a recurrence is again 
in keeping with the experimental work on the 
importance of an active concentrated juice in the 
production of ulcer in animals. 


The Emotional Factor 


In the initiation of the ulcer lesion are we to 
believe that the nervous system plays an important 


26,111.34. 


V2 


We 2 2Y2 


588 THE LANCET] 
part ? 
ulcer development, and we know that such periodic 
symptoms are not uncommonly found in people 
under tension.*43> The relief of the tension often 
brings silence in the abdomen. Can we—in a signi- 
ficant proportion of cases—recognise some such 
mental upset in the life of the individual preceding 
ulcer development and preceding a recurrence ? 
From the experimental evidence it would be fair 
to presume that a deep emotional upset would be 
just as capable of stimulating the hypothalamic 
centre as would the more artificial electrical stimu- 
lation, which we already know is capable of producing 
hyperperistalsis and hypersecretion. Continued 
stimulation might be responsible for gastric erosions, 
hematemesis, and even ulceration. 

The constitutional type has been well described 
by a number of observers (Hurst,?1 Ryle,?® Draper,3’ 
Rivers 3%), Robinson ?? has recently described the 
man with ulcer as being in the firing-line of life’s 
struggle, and Draper has convincingly shown that 
the ulcer patient is of a different mould to him with 
a gall-bladder lesion. The angularity of the body, 
combined with the dynamic energy, is characteristic. 
He works under tension with vigour and enthusiasm, 
and he is generally under-weight, an increase in weight 
being always a sure sign of improvément not only 
physical but mental. He is fully conscious of his 
responsibilities, but is reticent to the unfolding of 
his difficulties and anxieties. Ile certainly does not 
like to attribute his disturbed gastric function to 
his nervous system, although he often relates that 
during week-ends and other periods of relaxation 
his stomach is surprisingly silent. 

The majority of my patients were under-weight. 
Table IX. shows that 60 per cent. were under 9 st. 
and 34 per cent. under 8 st. on their first appearance. 
It is difficult to assess and describe the various 


TABLE IX 
Weight of 240 Ulcer Patients 


Stones se —7 —9 
Gastric ulcer .. 28 2T Da re Eg T A — 
Duodenal ,,_.. 9 18 42 26 28 12 — 
= “37 | 45 | 63 | 40 | 42 | 13 |=240 
© Total 145 Total 95. 


(60 per cent.). 


influences which might possibly affect an individual, 
and a mental upset in one might be of little conse- 
quence in another. An attempt will be made to give 
an account of nervous influences more by example 
than by any general description. 


BEFORE THE DEVELOPMENT OF 
DYSPEPSIA 


I.—A man of 33, the father of six children, obtained 
work after a long period of unemployment. He was con- 
siderably upset three weeks later whon he was forced to 
keep to his bed with influenza. In a few days he was 
well and he returned to work, but became greatly dis- 
tressed to find that his post had been filled. Five days 
later he showed a perforated ulcer. 

1.—A man, aged 53, who had always enjoyed excellent 
health, and who had been employed as chauffeur for many 
years, with the customary long hours of waiting, was 
favoured with a legacy on the death of his employer. He 
opened a small business and was soon troubled by financial 
anxiety. For the first time in his life he developed indiges- 
tion, and in ten days’ time had a severe hamatemesis. 
The presence of a peptic ulcer was subsequently verified 
by a barium meal. In this case the man had been accus- 


NERVOUS UPSETS 


DR. DANIEL DAVIES : PEPTIC ULCER 


We know that symptoms often precede 


[mancH 14, 1936 


tomed to security and served in a position somewhat 
free of hazard. Launching out into independence at 
53 years of age resulted in mental anxiety and this was 
accompanied by the development of an ulcer. 

m1.—A woman of 49 had always enjoyed perfect health 


until she witnessed her daughter run over by a motor-car. 

Five days later she complained of indigestion. In a 

month’s time a crater was visible in the duodenum. 
Iv.—A man of 48 suddenly lost, through death, two 


brothers who were partners in his firm. There was much 
financial worry in consequence and he began to suffer 
from severe indigestion. He was seen five weeks after 
the development of dyspepsia, and a large ulcer (Fig. 16) 
was discovered on the lesser curve. He had previously 
enjoyed excellent health. 


NERVOUS UPSET AND RECURRENCES 


During the last five years I have seen 45 recurrences, 
and doubtless this number will increase as the periods 
of observation extend. In 20 of these patients I 
have definite knowledge of some mental upset pre- 
ceding the return of symptoms, and this is a sufi- 
ciently high proportion for us to seriously consider 
whether a deep emotional upset is not capable of 
producing a recurrent ulcer. Table X. shows the 
time of recurrence, and the nature of the upsets 
which preceded it, in the gastric and duodenal ulcer 
patients. Examples of the influence of mental upset 
in recurrence are the following :— 

1.—A male, aged 45, was the manager of a failing busi- 
nessin 1931. The failure became a reality and he developed 


TABLE X 
Nervous Influences and Recurrent Ulcer 
GASTRIC ULCER 


Duration Date of 
Age.| of treat- recur- Remarks. 
ment. rence. 

30 | 12 mths. | 16th mth. | Anxiety about work; put on 
half-pay ; dyspepsia returned. 

49 6 Cb 3rd yr. Illness of daughter; tuber- 
culosis, 

4th ,, Business responsibilities ; staff 

on holiday ; sole charge. 

61 6 Cy, 6th mth. | Sudden illness and death of wife. 

40 4, 6th ,, Legal proceedings pending ; pos- 
sibility of imprisonment. 

26 O. 46 Gth ,, Brother, hematemesis ; much 
anxiety. 

53 So as Sth ,, Daughter, sudden operation for 
hematemesis. Much anxiety. 

34 9 5% 9th ,, Friend killed by car. 

48 6 s Sth ,, Daughter il with puerperal 
sepsis, 

16th ,, Pneumonia in member of family ; 


much anxiety. 


DUODENAL ULCER 


6th mth. | Hyperchlorhydria; anxiety 
about balancing accounts at 
end of year. 

Hyperchlorhydria ; 
ness anxiety. 

Distress from disseminating 
whooping-cough among grand- 
children. 

Separated from wife; care of 
two children: legal case. 

Sudden unemployment : : wife 
pregnant. Five children ; 
hematemesis 4 weeks after 
ceasing work. 

Accident to husband at work. 
Dyspepsia returned 5 days 
later. 

Son knocked down by car 3; much 
anxiety. 

Notice to quit bouse; financial 
embarrassment. 

Symptoms increased after death 
of husband. Responsibilitics ; 
mother of six. 

Following ‘‘intluenza.”’ 

Saw friend killed by cars; return 
of symptoms 3 days later. 

meres worries preceding symp- 
oms, 


Violent quarrel at home ; profuse 
ee 3 days later.’ 


3rd yr. acute busi- 


Sth ,, 


5th ,, 
12th mth. 


3 yTs. 
9 mths. 


18 ,, 


62 6 mths. | 
54 |12 ,, 
70 | 12 , 
18th ,, 
| 


40 Spasmodic. 
42 s3 


el Tr saow 


THE LANCET] 


DR. DANIEL DAVIES: PEPTIC ULCER 


[marca 14,1936 589 


loop was performed, and this operation gave an oppor- 


indigestion. An ulcer was found on the lesser curve and 
treatment brought relief. He was well and working in a 
less responsible position until early in 1934, when his only 
child was diagnosed as suffering from pulmonary tuber- 
culosis. This caused much upset and anxiety at home 
and his symptoms returned. A large ulcer crater was 
discovered and treatment again brought relief. The 
crater disappeared in six weeks and he gained weight 
from 9 st. 6 lb. to 10 st. 8 lb. during the following six 
months. Everything appeared well, and periodic radio- 
logical examination showed no return of the ulcer crater. 
However, in August this year he was again, owing to the 
holidays of other members of the staff, put in sole charge 
of afirm. Work was heavy and he was uncertain whether 
he could cope with it. Dyspepsia returned and a large 
crater became visible on the lesser curve of the stomach. 

2.—Another patient, who had responded well to treat- 
ment, had in his sixth month the misfortune to lose his 
wife, after an operation. His grief was profound. Pain 
returned and an ulcer crater became again demonstrable 
and larger in size than on the initial examination. He 
died from a hematemesis in the seventh month. In this 
case there were undoubted signs of healing, but even 
with complete rest in bed and the strictest medical atten- 
tion, the sudden grief was followed by a recurrence and a 
hzeematemesis closed the scene. 


NERVOUS INFLUENCES IN POST-OPERATIVE 
RECURRENCES 


Surgery does not of necessity confer an immunity 
against recurrences. Of the 15 patients who showed 
active ulceration some years after the initial opera- 
tion for ulcer, 8 gave details which strongly suggest 
the important part played by nervous upsets. 
Table XI. gives the salient features, but two of the 
cases are worthy of more detailed record. 


TABLE XI 


Nervous Influences in Post-operative Recurrences 
Operation.—Gastro-enterostomy for duodenal ulcer 


Date | 


E of op. Present findings. Remarks. 
44 | 1927 | 1929. Recurrence of — 
symptoms ; medi- 
-- cal treatment. 
1932. Perf. jejunal ulcer. — 
1932. Partial gastrectomy. — f 
1935. Recurrence of | Four mths. dyspepsia 
symptoms; ulcer on notice to leave 
crater lesser curve. work, held for 21 
i years. 
47 1927 | 1935. Large ulcer, lesser | Business worries; 
: curve. failure to negotiate 
sale of failing busi- 
l ness. 
58 1928 | 1934. Duod. ulcer crater | Wife ill, heart failure, 


and jejunal crater. much anxiety; 
hrematemesis. , 
Hematemesis on dis- 


solution of partner- 


ship. 
Death of wife. Four 


Jejunal ulcer. 


54 ; 1929 | 1934. Lesser curve ulcer. 
! mths. dyspepsia. 

30 1931 | 1935. Duod. crater. Family quarrels. 

40 | 1934 | 1935. Perf. jejunal ulcer. Sudden illness of 
| mother; return of 
i dyspepsia. 

43 1931 | 1934. Duod. deformity | Son in motor acci- 
i only. dent; return of 

symptoms. 


| 
| 
1 
| 
| 
34 1927 | 1934. 
| 


_————— ee 


A.—A male, aged 34, had a gastro-enterostomy per- 
formed for a perforated duodenal ulcer in 1927. In 1928 
he suffered a mild recurrence of symptoms, but he enjoyed 
very good health afterwards until there was a sudden 
hzematemesis in 1933. The anemia was intense and his 
condition gave rise to much concern. In September of 
that year it was shown that he had a jejunal ulcer as 
well as an active duodenal ulcer. Treatment improved 
his general condition and in the early part of 1934 a 
barium meal demonstrated the disappearance of the 
jejunal crater; but one of the jejunal loops-was found 
to be dilated and barium was held up in this loop for 
an appreciable time. A lateral anastomosis of the jejunal 


tunity to verify the disappearance of the jejunal ulcer. 
A further barium meal a month after the operation showed 
the anastomosis between the two loops to be working 
well. The patient affirmed that he never had been fitter. 
He returned to work after a brief holiday and received 
what he termed the greatest shock of his life when the 
other partner in his firm said that a dissolution of partner- 
ship was imperative because he, the patient, had been 


26.ix.35 


FIG. 16.—Large ulcer crater in a man of 48 with a five weeks’ 
history. 


23.x.34 


away too much from business. Seven days later he had 


severe hematemesis. 


B.—A man of 44, for whom a gastro-enterostomy for 
duodenal ulcer was done in 1927, enjoyed freedom for 
two years. A recurrence of symptoms was treated medi- 
cally in 1929, and in 1932 a jejunal ulcer perforated after 
five days’ dyspepsia. Six months later partial gastrectomy 
was performed. He enjoyed good health subsequently 
until 1935, .when, following some episode of doubtful 
integrity, he was given notice to leave his work, where 
he had been in constant employment for twenty years. 
Much anxiety resulted as well as considerable disturbance 
in his domestic affairs. Within seven days indigestion 
returned and it continued for four months, when a barium 
meal examination showed that he had a large ulcer crater 
on the lesser curve of the remaining portion of his stomach. 


IMPORTANCE OF THE NERVOUS FACTOR 


There are undoubtedly many influences adverse 
to the healing of an ulcer. Coarse food, long hours 
without food, smoking to excess, violent muscular 
work, and especially fatigue from overwork, all play 
an important part and in all probability recurrences 
are often due to one or more of these factors. My 
own belief is that emotional upsets may also be 
powerful influences in producing a disturbed gastric 
function, and the incidence of such upsets in the 
recurrences of my series is especially high, even in 
those already subjected to operative interference, 
and in whom we could expect a ready regurgitation 
of alkaline juice into the stomach. Draper and 
Touraine 4° drew attention to the high familial 
incidence of ulcer, and suggested that there is a 
weakened or vulnerable alimentary tract which runs 
in families. Exposure to unusual anxieties or stress 
would perhaps be suflicient in susceptible individuals 
to develop an organic gastric lesion. I, wish to 
emphasise that many of the examples which I quote 
were in persons who had already reached mature 
years; yet some change in environment or work 


590 THE LANCET] 


or increased responsibility or anxiety appears sufi- 
cient to produce alimentary symptoms never pre- 
viously experienced. 

Whatever view is taken of the influence of the 
nervous system on ulcer development, it certainly 
calls for a treatment which is wide enough to envisage 
the whole man and his environment. It becomes a 
general problem and not a local one. Furthermore, 
it becomes highly individual, 


and each case needs 


FIG. 17.—Tumour compressing medulla and producing internal 
hydrocephalus. Three hwmatemeses during twelve months 
before signs of increased intracranial pressure developed. 


specific attention. Steering the patient through a 
mental crisis or possibly diminishing his respon- 
sibilities and thereby lessening stress and strain 
may do much in preventing a relapse. This close 
relationship between the organic peptic ulceration 
and nerve influence furnishes an explanation for the 
increasing incidence of ulcer in city dwellers. In 
spite of better food and better hygiene the condition 
is on the increase, and the greater stress and strain 
of living to-day can hardly be dismissed. 


Organic Nervous Disease 


Reference has already been made to the patient 
who showed a tumour compressing the medulla 
oblongata, and in whom a bleeding ulcer attracted 
attention six months before the development of 
nerve symptoms—an example of an organic nerve 
process situated in the line of the vagal tracts, a 
possible cause of the chronic ulcer. A similar case 
came to my notice in 1933. 


A man of 37 had suffered vertigo for 13 months, asso- 
ciated with headache and a staggering gait. Three attacks 
of hematemesis occurred during this period, and two 
radiological examinations failed to reveal any ulcer. 
When he came under my notice there was bilateral 
papillcedema, and he died suddenly two hours after admis- 
sion to hospital. A soft cystic and hemorrhagic tumour 
was situated between the vermis of the cerebellum and 
the medulla, and there was considerable dilatation of the 
fourth ventricle, the medulla being much compressed. 
The tumour was an ependymoma. 


This case is of interest in that three attacksof hemat- 
emesis occurred during the period when the patient’s 
nerve symptoms were extremely mild, and a year 
elapsed before these symptoms became obvious 
enough to attract any serious attention. Here is, 
therefore, another example of an organic nerve 
lesion giving rise to gastric symptoms. Fig. 17 
shows the tumour with the dilated ventricles. 


DR. DANIEL DAVIES: PEPTIC ULCER 


[MAROH 14, 1936 


Ambulatory Treatment 


It is still held by some clinical observers that rest 
in bed is an essential part of the treatment of peptic 
ulcer, although Blackford and Bowers *! have pub. 
lished reasonably satisfactory results with ambula- 
tory treatment. Hospital accommodation is limited, ` 
and during the past five years I have been forced to 
see what could be done in the way of ambulatory 
treatment. There is some advantage in this, in that 
the patient is encouraged to remain at his work. 
Of 351 gastric and duodenal ulcer patients, I admitted 
for medical treatment only 37. The period of obser. 
vation does not extend beyond five years, and what. 
ever claims I make on the treatment it must be at 
the same time emphasised that only 122 of my cases 
have been seen for more than three years (Table XII.). 


TABLE XII 
Duration of Observations 


PAER 2 yrs. 3 yrs.'4 yrs. 5 yrs. 
25 31 19 42 


Duodenal ,, 


— 


=! 
Gastric ulcer Ea 


Under treatment symptoms disappear extremely 
quickly, and as Goodall 4? remarks, the ‘“‘ alkaline 
smile’’ is at once apparent. The patient gains in 
weight, and the ulcer, if it is a lesser-curve ulcer, 
can be seen to disappear, usually within 2-3 months. 
From Table XIII. it can be seen that 97 of 130 


TABLE XIII 
Results of Ambulant Treatment of Ulcer 
GASTRIO 
Cases. 
Symptom-free and no radiological abnormality .. 76 } 97 
ee »» but conmemation ie 21 
but ulcer crater persisting . ei 7 
Recurrence with no crater demonstable. .. ee 
i; » return of crater .. ee -- | 20 
130 
DUODENAL 
Cases 
Symptom-free `.. as ia 128 
Recurrence of symptoms mae Te 25 
Persistence ,, es ss se 10 
163 


gastric ulcers gave rise to no further symptoms, 
and 128 of 163 duodenal ulcers showed an equally 
good response. The total of known recurrences was 
45 out of 293, but we can expect as time passes that 
the number of recurrences will be increased. How- 
ever, the results reasonably justify ambulatory 
treatment. Even the recurrences do not show any 
increased diffculty in healing. 

Two of the patients died of hemorrhage while 
under treatment; one was a woman in her sixth 
month of treatment, the other a man in his seventh 
month. Four suffered from melena during treat- 
ment, but the four recovered. 

It is generally conceded that carcinoma develops 
on an ulcer in not more than 2-3 per cent. of cases. 
Two of my patients unfortunately died of cancer 
of the stomach, and in both the lesion was a lesser- 
curve ulcer; it was originally dispelled by medical 
measures, but a recurrence at a later date became 
carcinomatous. One case may be given in detail. 


The patient, a woman of 41, gave a five years’ history 
of indigestion. She had a large ulcer crater on the lesser 
curve of the stomach, which disappeared within six 


~ 


r 


? 


THE LANCET] 


DR. DANIEL DAVIES: PEPTIC ULCER 


[maron 14, 1936 591 


months of treatment. There was immediate sympto- 
matic relief and a gain in weight from 8 st. 4 lb. to 
10 st. 6 Ib. Gastric analysis showed hyperchlorhydria 
and a large volume of resting juice. In the sixteenth 
month the patient had a return of her symptoms. The 
ulcer crater again became visible, and on this occasion 
there was an adjoining area which failed to transmit 
peristalsis. Alkalis brought no relief and the patient 
lost weight. The hyperchlorhydria was replaced by 
hypochlorhydria and altered blood. Operation was 
advised, but unfortunately secondary deposits were 
present in the liver. | 


It is somewhat disturbing to realise that a lesser- 
curve ulcer can actually disappear, and the patient 
gain weight and relief from symptoms, and yet in 
so short a time there may be a recurrence ending in 
cancer. This should impel us to submit all patients 
treated for peptic ulcer to periodic X ray examina- 
bie however benign the initial appearance of the 

cer. 

One of my patients suffered from a perforated 
ulcer six months after receiving treatment for a 
duodenal ulcer, which had apparently healed. Unfor- 
tunately I know no more than this, nor of the history 
which preceded the perforation. Three others 
developed acute attacks of appendicitis during the 
first few months of medical treatment, and I cannot 
help wondering whether the alteration in diet, and 
the purgation sometimes caused by an alkaline powder, 
may not light up an appendix which is already in a 
state of chronic inflammation. The three did well. 

It has often been stated that all septic foci should 
be eradicated as an essential part of medical treat- 
ment. There is really little experimental proof for 
this statement. For the past five years I have delib- 
erately withheld any advice regarding attention 
to septic foci, and since relief from symptoms and 
healing of crater occurred in such a high proportion 
of the patients—most of whom came from the out- 
patient class among whom oral sepsis is certainly 
not uncommon—it is difficult to believe that sepsis 

plays any part in the initiation of a peptic ulcer. 

Efficient treatment nowadays involves periodic 
radiological examination, and it is wise to continue 
its repetition until a restitution to normal is obtained. 
It is hardly fair to the patient, while such exact 
information is obtainable, to continue treating him 
without such knowledge. The change from hyper- 
secretion to a more normal secretion is also an indi- 
cation that he is on safer ground, while a persistent 
hypersecretion and hyperacidity should indicate 
the need for continued care. 

The best therapy should include not only exact 
knowledge of local gastric affairs, but also the fullest 
knowledge of the patient. His active coöperation, 
so essential a feature of successful treatment, can 
only be realised when he is fully aware of the method 
of approach and its rationale. Moreover, the influence 
of his work, his anxieties and worries should be 
made known to him. Indeed, if a mental storm 
becomes inevitable, advice to buffer his acid juices 
all the more thoroughly with frequent feeds and 
alkalis may avert a catastrophe such as a perforation 
or bleeding. He should also realise that his stomach 
is his most vulnerable point, and the possibility of 
forestalling trouble would not be impossible. 

The symptoms which precede ulcer development, 
and which are so amenable to treatment, should also 
be recognised. We are inconsistent if we diagnose 
the person with pain relieved by alkalis, who shows 
no local lesion, as a mere ‘‘functional dyspeptic,” 
with all that this carries, and change our front at a 
later date when an ulcer has appeared to give the 


patient all the care of an ‘“‘organic lesion.” The 
former is the precursor of the latter, and they deserve 
the same attention. Prevention of ulcer should be 
our aim, and to attain this our advice may perforce 
extend into fields far removed from gastric function. 


General Conclusions 


Although much is still obscure in the, etiology of 
peptic ulcer as seen in man, experimental surgery 
has shown that a chronic ulcer can be readily pro- 
duced, and that active gastric juice is by itself 
sufficient to produce this lesion in the intestine. 
Experiment has also shown that there is a centre 
high up in the nervous system. which, when stimu- 
lated, produces profound disturbance, both of 
motility and secretion, in the stomach, a centre which 
is undoubtedly influenced by higher levels. There 
is indeed close agreement on many points between 
clinical experience and these experimental findings. 
An attempt has been made in this study to show that 
a benign ulcer forms and heals rather readily, and 
that the hypersecretion and hyperchlorhydria— 
findings which are known to be more common in this 
condition than any other—do diminish and in time 
are replaced by a more normal gastric secretion. 
It has also been demonstrated that bodily rest is not 
essential for the healing of an ulcer crater, and that 
this healing occurs in some cases while the patient 
remains at his work. | 

The idea that peptic ulcer is a local manifestation 
of nervous disturbance in susceptible individuals is 
not new. Von Bergman wrote extensively on this 
hypothesis in 1914, and the further knowledge that 
has accumulated during the intervening years has 
supported this conception. The frequency of nervous 
bombardment in recurrence and in initiating symptoms 
is further evidence of the importance of these nervous 
influences. Efficient treatment must, therefore, be 
not only highly specific to the individual but also 
wide enough to encompass the whole man and his 
environment. As much prominence should be given 
to a consideration of his anxieties as to his diet. 

With the advent and growth of pathology, during 
the latter part of Jast century, the profession felt 
confident in being able to distinguish between func- 
tional and organic disease. The line of demarcation 
was clear-cut. To-day we seem less certain of that 
demarcation, for the influence of mind over matter 
is recognised as a powerful force, capable not only 
of disturbing function but also of producing organic 
structural changes. Is peptic ulcer the end-result 
of such disturbance along nervous pathways, and 
should we not concentrate less on the lesion and more 
on the man and his surroundings ? 


May I tender my sincere thanks to my friends and 
colleagues at the Royal Free Hospital for their unfailing 
help, especially to Dr. D. Staveley and Dr. U. Shelley. 


REFERENCES 


25. Brown, R. C.: Jour. Amer. Med. Assoc.. 1930, xcv., 1144. 
26. Palmer, W. L.: Arch. Internal Med., 1926, xxxviii., 603. 
27. Bennett, T. I.: The Stomach in Health and Disease, 


London, 1925. ao 
. Venables, J. F.: Proc. Roy. Soc. Med., 1929, xxii., 1047. 
29. Pyrah, L. N.: Ibid., 1934, xxvii., 233. 
. Scott Polland, W.: Arch. Internal Med., 1933, li., 903. 
. Bloomfield, A. L., and Scott Polland, W.: Jour. Amer. 
Med. Assoc., 1929, xcii., 1508. 


32. Osterberg, A. E., and Vanzant, F. R.: Proc. Staff Meet. 
Mayo Clinic, 1932, vii., 268. 
33. Vanzant, F. R., et al.: Arch. Internal Med., 1932, xlix. 


345. 
. Rivers, A. B., and Vanzant, F. R.: Med. Clin. N. America, 


1933, xvi., 1449. 
. Hartman, H. R.: Jbid., 1933. xvi., 1357. 


. Ryle, J. A.: THE LANCET, 1932, 1., 327. 
(Continued at foot of next page) 


592 THE LANCET] DR. ELIZABETH HUNT: SKIN AFFECTIONS OF THE VULVA AND ANUS 


SKIN AFFECTIONS 


UNDERLYING PRURITUS OF THE 
VULVA AND ANUS 


A REVIEW OF THREE HUNDRED CASES 


By Evizasetin Ifont, B.A., M.D., Ch.B. 


HONORARY PHYSICIAN TO THE SKIN DEPARTMENT, SOUTH 
LONDON HOSPITAL FOR WOMEN 


THE diagnosis of a skin affection when it is localised 
on or around the external genitalia and anus may be, 
and often is, extraordinarily difficult, for the distinctive 
characters of the eruptions are wont to be modified 
in this moist warm area, and it is sometimes only 
by the discovery of typical lesions at other sites 
that the diagnosis can be' made with confidence. 
The need for accurate diagnosis, and for the differentia- 
tion of the various skin affections which may give 
rise to vulval and anal irritation must be apparent, 
not merely for the purposes of treatment but also 
for the reassurance of the patient and for guidance 
in avoiding recurrences. 

In Table I. the 300 cases on which this brief review 
is based are classified into seven groups. 


TABLE I | 
Analysis of 300 Cases of Pruritus into Seven Groups 


Cases, Cases 

I.—GENERAL SKIN V.—GENERAL CONSTITU- 
AFFECTIONS : TIONAL DISEASES : 
Lichen planus 105 Diabetes .. .. 12 
Seborrheic derma- Secondary anemia. ` 2 
titis -- 69 Disseminated 

Psoriasis oe ox AT sclerosis 1 

eczema ix os 2 

Leucodermia se 4 


VI.—PSYCHIC .. a 8 
I.—DERMATITIS TRAU- 
MATICA ET VENENATA 59 | VIT.—VARIOUS . 
III]L—LOCAL CAUSES ? 
Vaginal discharge .. 3 
Vaginal prolapse 2 
Iæemorrhoids a 2 


( 

Lichenoid eruption 
with oral sepsis.. 2 

Lichenoid eruption 

i with cholecystitis 1 

| Lichenoid eruption 

| with malignant 

| 

| 


—PARASITES : oe 
[Ve TSE ASETES neoplasm of liver 1 


Scabies en a 2 Senile pruritus te 2 
Ringworm (Dhobie Imperfect. hygiene.. 2 
itch) ; s 1 


Undetermined l 3 


The most striking feature of the Table is probably 
the large number of cases recorded as suffering from 
well-recognised skin affections, and in particular the 
excessive proporiion of cases of lichen planus— 
an eruption which may affect skin’ and mucous 
membrane, and which is usually stated to occur rarely 
on the vulva. 


LICHEN PLANUS 


In a recent article! T have drawn attention to the 
similarity both in the clinical and histopathological 
findings between eruptions of lichen planus on the 
vulva and the condition commonly called leuco- 


! Hont, E.: Leucoplakia Vulve, 
Lichen Planus of the Vulva, 
February, 1936, p. 53. 


! Wraurosis Vulve. and 
Brit. Jour. Derm. and Syph., 


DR. DAVIES: REFERENCES 


(Continued from previous page) 
37. Brace G.: The (Philadelphia) , 
1924. 


38. Rivers, A. B.: Arch. Internal Med., 1934, liii., 97. 

39, Bove 5. C.: Amer. Jour. Dis. Dig. und Nut., 1935, 
ii., 333. 

40. Draper. G., and Touraine, G. A.: Arch. Internal Med., 
1932, xlix., 616. 

41. Blackford, J. M.. and Bowers, J. M.: Amer. Jour. Med. 
Sci., 1929, elxxvii.. 51. cos ! 

42. Goodall, A.: Trans, Med.-Chir. Soe. Edin., 1931-32, ms. 
XXXIX., 85 (Edin. Med. Jour., June, 1932). 

43. von Bergman, G.: Berlin klin. Woch., 1913, 1., 2374. 


Human Constitution 


eed 


[marca 14, 1936 


plakia vulve, which, it is stated, affects the skin 
of the vulva and of the adjacent parts. Many of the 
cases here classified as lichen planus of the vulva 
were referred with the diagnosis ‘“‘ leucoplakia vulve,” 
and the existence of lichen lesions at other sites had 
not been observed. 


The type of leucoplakia known as leucoplakia vulve, 
which it is stated affects ordinary skin, differs both 
in its clinical and histological findings, and must be 
carefully differentiated from the affection of mucous 
membrane known as leucoplakia buccalis, which 
occurs more commonly in men, and to which a sinister 
significance is attached owing to the records of cases 
in which malignant changes have been reported. 

The importance of the observation that lichen 
planus of the vulva is indistinguishable both clinically 
and histologically from what is commonly described 
as leucoplakia vulvz, lies in the fact that it is generally 
taught in the English text-books of gynzcology 
that leucoplakia vulve is a precancerous condition 
of the skin, and the serious operation of vulvectomy 
is advised for this condition, even in the absence 
of definite evidence of malignant change. Lichen 
planus is on the other hand definitely not a pre- 
cancerous condition of the skin, so that the outlook 
for the patient must be widely different if a diagnosis 
of lichen planus rather than of leucoplakia vulve 
is established. 

Confirmation of a diagnosis of lichen planus often 
requires the observation and consideration of lesions 
widely remote from one another, and in the cases here 
submitted a diagnosis of lichen planus of the vulva 
was made with extreme reserve unless typical lesions 
of lichen planus were evident at other sites. The 
search for lesions at different sites necessarily involves 
a general examination of the patient, and the study 
of these cases suggests a need for such an examina- 
tion in every case where itching of the vulva and/or 
anus is the chief complaint. 

The manifestations of lichen planus of the vulva 
are more fully discussed in the article to which 
reference has heen made above. 


SEBORRUGIC DERMATITIS 


The number of cases of seborrheic dermatitis 
in the series is also high, and seems to indicate that 
seborrheic dermatitis as a cause of vulval pruritus 
merits more consideration than is usually accorded to 
it. These cases included the youngest patients in 
whom vulval pruritus occurred, as might be expected, 
since the skin of the seborrhaic patient is peculiarly 
liable to develop eruptions from infaney upwards. 
and reacts to a great variety both of exogenous and 
endogenous causes by which the normal person is 
unaffected. Hence in such cases the general skiu 
history needs investigation as well as the local condi- 


tion, and it is to be remembered that the skin in these . 


patients may be adversely affected by the usual anti- 
pruritic applications or even by such apparently 
innocuous causes as the bases of the ointments 
applied. Eruptions in seborrheic patients are fre- 
quently associated with emotional crises, and it is 
not unusual to find subjective symptoms out of all 
proportion to objective signs, and as a result the 
condition in these patients is often extremely 
intractable. 

The eruption is rarely limited to the genitalia. 
Seborrheea of the scalp and trunk are usually present 
and lesions are common on the area covered by pubic 
hair. The eruption may be asymmetrical and one 
labium will be found thickened and erythematous, 
whilst the other is-unaflected. 


- THE LANCET] 


PSORIASIS 


Psoriasis as a cause of vulval pruritus is not 
common. In all the cases here recorded the eruption 
was of old standing and very limited in its distribution. 
The lesions were never found on the internal surfaces 
of the labia, and seldom presented the familiar silvery 
scales of psoriasis but tended to the exfoliative type. 
Symptoms were noticeably aggravated by any mental 
anxiety or disturbance. One case in which excessive 
subjective symptoms were a feature may be quoted. 
In this patient a coalescent band of psoriasis lesions 
was situated on the outer borders of the external 
surfaces of the labia majora and extended over the 
mons. Elsewhere only the nails were affected. 
This patient was the subject of excessive mental 
anxiety and worry, and vulvectomy had been 
suggested, on account of the persistent vulval irrita- 


tion, on an analogy with the treatment advocated : 


for leucoplakia vulvz when the symptoms prove 
‘intractable. 

The contrast between the number of cases of 
lichen planus of the vulva and psoriasis of the vulva 
in this series merits some comment, because the total 
number of cases of psoriasis and of lichen planus 
attending the hospital clinic is approximately the 
same, constituting about 12-13 per cent. of the 
total number of cases of every type of skin affection. 
Of these cases of every type the proportion with vulval 
symptoms is unusually high for a general hospital 
clinic, but may be accounted for by the fact that 
the hospital is entirely officered by women, to 
whom such cases would naturally gravitate. 


ECZEMA 


Eczema as is to be expected was a common diagnosis 
in cases referred to the clinic, but the two cases 
included under this heading seemed to me the only 
two in which a diagnosis of eczema could be made 
with assurance. Both patients were young married 
women with children; both had extensive weeping 
eruptions over the abdomen, genitals, and thighs ; 
one had, in addition, an eczema of the hands, the 
second developed an eczematous rash on the arms 
and trunk following a slight excess of sweets. No 
trace of glycosuria was detected in this case at any 
time. The patient had undergone intensive treat- 
ment for months, including X rays, without relief 
until she was put on a mildly restricted carbohydrate 
diet, when the condition rapidly cleared and she 
has had no recurrence for two years. 


LEUCODERMIA 


The cases of leucodermia showed transient patches 
of de-pigmentation on the labia with a slightly inflam- 
matory border to the lesions, and associated with 
intense irritation. No cause could be detected and 
no other skin lesion was observed. 


DERMATITIS TRAUMATICA ET VENENATA 


The cases grouped under the title dermatitis 
traumatica et venenata include all those in which 
the eruption was traced to injury inflicted by 
deleterious applications, and those others in which 
an individual hypersensitiveness to some particular 
external cause could be traced. In most of these 
eases both the anus and vulva were involved, as 
might be expected, since the usual history obtained 
was of a slight initial irritation of the vulva or the 
anus, which had become steadily worse and spread 
as the patient used one remedy after the other. In 
some the lower abdomen, buttocks, and thighs were 
the site of an acute inflammatory eruption; others 


DR. ELIZABETH HUNT: SKIN AFFECTIONS OF THE VULVA AND ANUS - [MARCH 14, 1936 593 


showed a white dry harsh skin inclined to fissure 
and similar to the conditions seen on the hands as 
the result of the excessive use of alkalis and anti- 
septics, whilst in others there was marked lichenifica- 
tion of the vulva and adjacent surfaces. 

The cause of the initial irritation was often difficult 
to determine. Idiosyncrasy in some cases was the 
factor, as when the onset followed vaginal douches 
of iodine, or coincided with the use of a particular 
soap, or with an alteration in underclothing such as 
the adoption of dyed artificial silk undergarments 
or of the tight woollen garment known as “ panties.” 
A history of recurrent irritation at the menstrual 
period was not infrequent either as a result of the 
type of pad used or from inability to change 
frequently. 

Where the irritation first arose around the anus, 
hemorrhoids and constipation were a common 
finding, but hemorrhoids per se will not cause an 
acute dermatitis of the vulva, nor on the other hand 
will a vaginal discharge or vaginal prolapse directly 
affect the skin of the anal area. The associated 
dermatitis in these cases is more commonly the 
result of frequent applications of different kinds 
which injure the skin. 

Table II. shows the causes which were found to have 
contributed to the production of eruptions with 
persistent irritation in the cases under review. 


TABLE II.—Causes 


No, ` No. 
1.—BATHS WITH : IV.—OINTMENTS AND 
Lysol ae .. 12 LOTIONS ; 
Boric acid and car- Germolene .. 8 
bonate of soda .. Zambuk .. 1 
Carbolic - Sulphur 2 
V.—APERIENTS : 
IIl.— VAGINAL DOUCHES : Liquid paraffin 4 
Strong potassium i Die benag ia 3 
permanganate .. E EEA, 
Iòdiñe 2 Feen-a-Mint 1 
Alum 1 VI.—SOAPS : 
Containing tar 4 
II1.—PHYSICAL THERAPY : Synthetic scent 1 
Radium .. .. 1 | VIL—UNDERCLOTHING : 


X ray os -- 1 Dyed artificial silk 2 
Ultra-violet light .. 2 Wool +s sa 1 


These figures suggest that an excess of cleanliness 
and the indiscriminate use of antiseptics, rather than 
the lack of personal hygiene, are potent causes of 
vulval and anal pruritus in women to-day, and it is 
perhaps significant of the changes in social conditions 
that no case of pubic lice was observed in a series of 
300 cases of vulval and anal irritation in women, 
a majority of whom were seen in hospital clinics. 

With regard to aperients the leakage of liquid 
parafin around the anus is a fruitful cause of anal 
pruritus ; bile beans is a secret remedy, and it is 
not therefore possible to explain why it should be the 
cause of anal irritation. Feen-a-Mint and Ex-lax 
both contain phenolphthalein, to which these patients 
were intolerant, and the eruption and irritation in 
these cases was not entirely restricted to the genital 
area. 

GENERAL CONSTITUTIONAL DISEASE 


Of the remaining groups the largest number of 
cases appear under general constitutional diseases. 
It is common knowledge that vulval pruritus may 
be associated with glycosuria, and routine examination 
of the urine is therefore essential. 

The two patients with a secondary anemia suffered 
from folliculitis, which cleared up with treatment 
of the general condition. The case of disseminated 

L3 


594 THE LANCET] 


sclerosis is of some interest because the patient had 
been given X ray treatment for the persistent irrita- 
tion, though there was no evidence of any skin affection 
and the symptoms were probably the result of changes 
in the sensory nerves. 

PSYCHIC 


Eight cases only have been included in the psychic 
group though the existence of a psychic factor was 
recognised in many cases in addition to the definite 
causes which were found. 

The patients included in this group showed no 
skin changes. One of the patients had become a 
syphilophobe after the discovery of her husband’s 
infidelity. A second, a young married woman, was 
referred after she had been treated for months for 
acute recurrent vulval irritation and insomnia, and 
it was discovered that for a long time she had a child 
in hospital with bladder and kidney trouble. 
suggested to her that her thoughts were in consequence 
concentrated on her own genital area, and that she 
must cease thinking of it, and within two weeks her 
condition was relieved and did not recur. 


METHYLENE DICHLORIDE 
INTOXICATION IN INDUSTRY 


A REPORT OF TWO CASES 


By Howard Co.Liirer, M.C., M.B. Edin. 


READER IN INDUSTRIAL HYGIENE AND MEDICINE IN THE 
UNIVERSITY OF BIRMINGHAM 


Methylene dichloride (CH,.Cl,) is a chlorinated 
hydrocarbon of relatively low flash-point, widely 
used in modern industry as a solvent for cellulose 
esters, fats, oils, resins, and rubber. It forms a 
large proportion of certain proprictary “‘ paint 
removers,” some of which are of German origin, and 
has also been used in the paint trade to raise the flash- 
point of lacquers. 

It is an anesthetic with a pleasant chloroform-like 
smell, slightly more toxic and irritant than chloro- 
form. In commercial use it may be contaminated 
by the presence of methyl chloride (CH,Cl): this 
sometimes might complicate the clinical picture. 
It was formerly used as a general anesthetic by 
Richardson (1867); ‘‘10 fatal cases resulting from 
its use as an anesthetic have been misquoted as 
due to its use in industry.” ‘“‘ Otherwise no definite 
cases of poisoning have been reported,” and Zernik 1 
sums up the existing opinion concerning methylene 
dichloride when he says that “‘ with good ventilation 
its industrial use is practically harmless.” 

In contrast, however, to this opinion may be set 
the practical experience of a manufacturer of lacquers 
who informs me that so far as possible he has 
abandoned the use of methylene dichloride ‘“ because 
of its ill-effects ” upon the workers. ‘‘ It dopes them, 
makes them stupid, they suffer from headache, 
are unreliable at their work and are awfully apt 
to tumble about and to hurt themselves.” The 
same observer remarks upon the curious effect of this 
solvent and of other solvents upon the “ psychology ”’ 
of the workers. He says that “‘they are irritable, 
unhappy and require constant supervision if they 
are to be kept from making silly mistakes.” 

This shrewd observation, coupled with the effects 
of the drug upon the cases recorded below, raises a 
point of the utmost importance in industrial hygiene. 
Whilst it may be admitted—may even be proved— 
that many of these solvents do not (if pure) cause any 


DR. H. COLLIER: METHYLENE DICHLORIDE INTOXICATION IN INDUSTRY 


It was: 


- 


[mancH 14, 1936 


discoverable industrial disease, nevertheless they 
may detrimentally affect industrial health. As 
typical examples of this class of ‘“* physiological, 
non-disease-producing toxins ” we may take methylene 
dichloride or trichlorethylene (which resembles it 
in very many of its pharmacological properties). 
It seems to me that this is a point of the first 
importance to industry. Workers who are constantly 
exposed to concentrations of these solvent gases 
may be rendered inefficient in their work without 
the production of discoverable pathological lesions. 
These cases serve to ilustrate another problem 
which always faces the industrial physician. That 
problem is the almost invariably “‘ mixed >° nature 
of industrial diseases (Alice Hamilton’). It will 
be observed that the first of the cases recorded 
below showed definite signs of chronic lead absorption, 
whilst the other suffered from a definite peptic ulcer 
and had recently fractured his skull. It is more than 
probable in fact that, but for these added disabilities, 
the connexion of methylene dichloride with the 
illness from which these workers suffered would 
never have come to the notice of any medical man. 


THE CASES 


Four painters were engaged during the autumn 
of 1935 in removing paint from the wall of a large 
room. A paint remover containing a high percentage 
(96 per cent. approx. by analysis) of methylene 
dichloride was used for this purpose. The windows 
were closed and rapid evaporation of the solvent 
took place. Jn this work the ‘‘remover’’ softens 
the old paint which is subsequently scraped off the 
wall by hand. All of the workers had been more or 
less exposed to lead absorption for periods varying 
from 6-14 years. They complained that whilst at 
work with the ‘“‘ paint remover” they became faint, 
giddy, and stupid, and stated that “this stupor 
passed off after a few hours,” that they “felt better 
when not at work,” and that “the stuff upset their 
appetite; that they did not care for food °’; and 
that they felt dull and were not interested in things 
which had always interested them before. Of these 
four men, two were sufficiently ill to have to leave 
their work. They were examined by me at repeated 
intervals. 

CasE 1.—A man, aged 42 (a painter for 13 years 
continuous), first seen on Oct. 12th, 1935. Peritonitis 
at 12 years of age. Five years’ army service; double 
pneumonia and empyema at 32. Complaints: (@) irregular 
but severe pains in legs and arms, hot flushes, headache, 
vertigo, stupidity whilst at work with paint remover ; 
could not read at night because his eyesight was not 
clear (? transient diplopia); + anorexia: (b) precordial 
pain, rapid pulse, shortness of breath, great fatigue on 
exertion, and attacks of rapid beating of heart. 

On examination soon after a day’s exposure to the 
‘“‘remover,” a faint “chloroform odour” could be 
detected in the breath. He was pale and nervous in 
manner, would flush up over the face and neck and then 
go pale again. Heart: apex-beat diffuse, outside nipple 
line. Pulse-rate 108 at rest. Arteries palpable, tenuous, 
B.P. 130/90. Respiratory system: old empyema wound 
on right side. No abnormal physical signs in chest. 
Urine normal. Alimentary system normal. Nervous 
system: no distinct abnormality. Special senses: no 
anesthesia or alterations of sensation discovered. Romberg 
sign absent. No muscular weakness of hands or wrists. 
Fundi showed clear evidence of arterio-sclerosis of fundal 
vessels. Blood: red cells, 4,910,000; white cells, 6200, 
Normal differential count, but a punctate basophilia 
of the order of 3500 per million. Punctate granules large. 

Course of wllness.—Six weoks later the general condition 
was much improved and he had put on 1} st. in weight ; 
he still complained of precordial pain, but there was less 
dyspnea. During this time the only change in his 


THE LANCET] 


DR. RITCHIE RUSSELL: INTRASPINAL INJECTION OF ALCOHOL [mMarcH 14, 1936 595 


circumstances were (a) the cessation of work with the 
methylene dichloride, and (b) the taking of half a pound 
of liver a day together with a mixture of ferri et quin. cit. 
He now looked much better and carried a better colour : 
pulse-rate 72 (at rest); apex-beat more distinct; heart 
still dilated; blood pressure 120/86. Blood picture 
normal, no punctate cells observed. The condition 
of the fundal vessels was unaltered. He was now quite 
“alert and clear in his mind.” His eyesight was “ better.” 
Subsequent examinations at intervals up to the time of 
writing show that his condition now remains unaltered 
except for a slow improvement in his general condition. 

The conclusions which I draw from this first case 
are (a) that the patient is suffering from the effects 
of slight chronic lead intoxication, which is shown 
by the state of his cardiovascular system, and (b) 
that he was suffering at the time of the first examina- 
tion from the effects of acute toxemia from methylene 
dichloride. The rapidity with which the acute 
symptoms subsided and the exact correspondence 
between his subjective complaints and those of the 
other workers is too clear to be explained by chance ; 
the condition cannot be attributed (in my experience) 
to lead. The symptoms resemble also those presented 
by workers who are exposed to the vapour of 
trichlorethylene, and in a less extent to other industrial 
solvents of this non-disease-producing class. 

Case 2.—A man, aged 45, a painter for 20 years. 
Examined on Jan. 19th, 1935. Pneumonia at 38 years 
of age. Severe fracture of skull at 40. Irregular attacks 


of gastric pain and “‘ black stools ”? since he was 33. Has. 


had “ gastric ulcer ” on and off for last four years. Has 
used the same proprietary “ paint remover” for two 
years; recently has used it much more extensively and 
used it indoors. This work makes him ‘ drowsy, dis- 
inclined to do anything in evenings; makes him very 
irritable and easily disturbed by trifles.” ‘‘ Has pains 
in the head.” He is highly intelligent. He finds that 
“he is better if he stays away from work.” He has 
noticed “‘ a definite tingling in hands and feet after working 
with this paint remover.” Has now been away from work 
for two weeks. 

On this evidence the patient was admitted to the 
General Hospital, Birmingham, under Dr. Stanley Barnes, 
for observation and the treatment of peptic ulcer. It 
does not appear necessary to detail his clinical condition 
which was that of a typical case of peptic ulcer, except 
to say that a congenital opaque patch was found in right 
disc. Central nervous system: normal. Urinary system : 
normal. Van den Bergh reaction: direct and indirect 
negative. Blood count: hemoglobin, 100 per cent. ; 
red cells, 5,320,000; white cells, 5500; no punctate 
basophilia; differential count normal. Wassermann 
reaction negative. Blood pressure 130/75. Pulse-rate 80. 
Heart and lungs normal. Alimentary system: “ gastro- 
duodenal ulcer.” 

The condition rapidly improved on Hurst’s diet, and he 
was discharged from hospital on Dec. 3rd, 1935. 

The conclusions drawn from this case are that the 
patient had suffered from the effects of methylene 
dichloride intoxication on and off for two years until 
the condition of his alimentary system forced him 
to leave work. The methylene dichloride poisoning 
caused definite and characteristic symptoms which 
were relieved by the cessation of exposure and which 
are remarkably similar to ‘those detailed above. 

It did not prove possible to persuade the other 
workers to submit to examination, but I have definite 
information that they experienced exactly similar 
effects. As their general health was good, they did 
not leave work. 

CONCLUSION 

To sum up therefore, these cases suggest that 
methylene dichloride is a potential source of ill-health 
to those who are exposed to the fumes of it in any 
confined and unventilated space. Those effects are 
to be attributed to its anesthetic action upon the 


nervous system and are largely subjective—viz., 
headache, giddiness, stupor-irritability, numbness 
and tingling in the limbs, and possibly some degree 
of chronic anemia. It seems to be important to 
emphasise that many of the industrial solvents 
(beside the chlorinated hydrocarbons) whilst they 
may not cause ‘‘occupational disease” may be 
real factors in the production of lowered efficiency, 
industrial fatigue, and definite psychological 
abnormalities of feeling and of conduct. It appears 
that this valuable industrial solvent (methylene 
dichloride) can safely be used in industry provided 
adequate ventilation is maintained. 


I must gratefully acknowledge the help of Dr. Stanley 
Barnes, dean of the faculty of medicine in the university, 
and of Dr. Ethel Browning, of the Medical Research 
Council, who has put at my disposal much information 
and many references concerning the known effects of 
methylene dichloride. I must express also my thanks to 
Dr. J. A. Ainscow for permission to see the second patient 
and for his help in providing me with a remarkably detailed 
history. 

REFERENCES 
1. Zernik, F.: Ergebn. d. Hyg., 1933, xiv., 202 


2. Hamilton, A.: Industrial Poisons in the "United States, 
London, 1929, p. 1. 


INTRASPINAL INJECTION OF ALCOHOL 
FOR INTRACTABLE PAIN 


By W. Ritcntge RussELL, M.D., r.R.C.P. Edin. 


ASSISTANT PHYSICIAN TO THE ROYAL INFIRMARY, EDINBURGH 


IN operations for the relief of neuralgic pain it has 
been found that complete interruption of the nerve 
concerned is not necessary, but that partial destruc- 
tion of the nerve-root has the same good effect. 
This led Dogliotti! in 1930 to attempt to damage 
the posterior nerve-roots within the spinal canal 
with alcohol in such a way that the conduction 
of pain would be arrested while little or no sensory 
loss would result. After demonstrating the practica- 
bility of the procedure by animal experiment he 
injected small quantities of absolute alcohol—0:2 to 
0-8 c.cm.—into the cerebro-spinal fluid of patients 
suffering from painful diseases. As alcohol has a 
specific gravity less than that of the spinal fluid, 
he arranged the position of the patient in such a 
way that the nerve-roots he wished to affect lay 
at the highest point of the subarachnoid space as 
near as possible to the site of injection. For example, 
if he wished to affect the sacral nerve-roots, he made 
the injection into the lumbar theca while the sacral 
region was at a higher level than any other part 
of the spine or head. Dogliotti used his method 
in the treatment of conditions such as intractable 
sciatica and tabetic crises, and reported good results 
in a high proportion of the cases treated. Others, 
including Stern,® Saltzstein,s Yeomans,® Greenhill 
and Schmitz? have used this method for the relief 
of the pain of malignant disease, particularly of the 
pelvic viscera, and have all reported many satis- 
factory results. During the past eighteen months 
I have used this method in attempting to relieve 
severe pain in 18 cases, and in several of these the 
result of the injection has been satisfactory.* 


* Since this paper was written I have treated 4 further cases, 
in 3 of which the result was satisfactory. Good results following 
this method of treatment have also been reported again by 
Greenhill and Schmitz (Amer. Jour. Obst. and Gyn.. February, 
1936, p. 290), who find it superior to pelvic sympathectomy in 
cases of carcinoma of the cervix; and by Abbott (Amer, Jour. 
Surg., February, 1936, p. 351). 


596 THE LANCET] 


DANGERS OF THE INJECTION . 


It is in the first place necessary to emphasise the 
dangers of the injection. The most suitable cases 
for treatment are those in which the pain is referred 
to the lower part of the body. The injection is, 
therefore, made into the lumbar theca, and there 
is a danger of damaging the nervous control of the 
sphincters. Further, it should be noted that in 
many cases of pelvic cancer the bladder control is 
already interfered with by disease, and very slight 
damage to the nervous control may cause retention 
of urine. In one such case in the present series the 
injection of 0-8c.cm. of absolute alcohol pro- 
duced retention of urine. Sloane ‘ reports a case in 
which the injection of 1:0 c.cm. caused the same 
complication. 

A second possible danger is that while the injection 
apparently causes no damage to the spinal cord at 
the time of the treatment, slight damage may occur 
which will cause a tendency to degenerative changes 
at a later date. In view of our ignorance of the 
ultimate effect of the injection it seems desirable 
at present to use the treatment only for advanced 
cases of inoperable malignant disease. This is the 
view held by most of those who have used this method, 
though Dogliotti originally injected many cases 
of non-malignant disease. It must, however, be 
noted that Dogliotti used small injections (0-2 to 
0-8c¢.cm.), and it is probable that injections of 
0-4 c.cm. or less can be given safely in any case. 

Most of the cases here reported have been of 
advanced malignant disease, and in some of these 
injections of as much as 1-5 c.cm. have had to be 
given in order to give relief from pain. In several 
cases this amount has been injected without any 
loss of sphincter control resulting, while in others 
a much smaller quantity has caused retention of 
urine. Itis thus evident that the individual suscepti- 
bility to alcohol injections is very variable. The 
safest method, therefore, of giving the treatment 
is to start with a small dose of, say, 0-4 c.cm. of 
absolute alcohol, observe the effects, if any, during 
the ensuing ten days, and, if necessary, repeat the 
injection using a larger amount as is described later. 
If, in cases of advanced malignant disease of the 
pelvis, the bladder is drained by a suprapubic tube, 
and there is a colostomy, the danger of causing 
sphincter disturbance is removed and a larger 
injection can be given at first (0-8 c.cm.) without 
anxiety, provided the technique described is rigidly 
adhered to. 


TECHNIQUE FOR THE RELIEF OF SACRAL PAIN 


In order to relieve any pelvic or other pain 
conducted through the sacral nerves, the sacrum 
must form the highest part of the spinal canal during, 
and for a period following, the injection. Further, 
the side of the body in which most pain is felt must 
be uppermost. The patient lies in the usual position 
for lumbar puncture (Fig. 1), while the operating 
table is tilted or the foot of the bed is raised so that 
the sacrum forms the highest part of the spine; 
a pillow may be placed below the pelvis. It is 
important that the head should always be kept at 
a definitely lower level than the spine so as to avoid 
any risk of the alcohol running up into the skull 
while it is still in a concentrated state. For this 
injection I prefer to make the spinal puncture between 
the third and fourth lumbar vertebre. A few 
cubic centimetres of spinal fluid are allowed to escape, 
and then 0:4¢.cm. of absolute alcohol is slowly 
injected, the whole amount being introduced during 


DR. RITCHIE RUSSELL: INTRASPINAL INJECTION OF ALCOHOL 


([maRncH 14, 1936 


a period of about 20 seconds. Cerebro-spinal fluid 
should not be drawn into the syringe prior to injection. 
The needle is then withdrawn, but the patient is made 
to lie in the same position for about an hour. He 
must on no account raise his head or the upper part 
of his body. He may, however, with advantage, 
turn slightly on his face as soon as the injection is 
completed so that the alcohol may have access more 
to the posterior than to the anterior nerve-roots. 
After lying in the same position for an hour, the 
patient is treated as after an ordinary lumbar puncture. 
Headache followed the injection in only one of my 
cases. 

During the injection the patient often experiences 
a burning sensation referred to that part of the body 
supplied by the nerve-roots that are being damaged 
by the alcohol. Where the sacral roots are being 
treated numbness is often noticed in the buttock and 
foot of the side that is uppermost. Some sensory 
loss may be demonstrated in the sacral and lower 
lumbar distribution, and the ankle-jerk is often 
diminished or abolished. 

` The degree of sensory loss should be tested shortly 
after the injection, for this demonstrates not only 
which nerve-roots have been damaged, but also the 
degree of damage caused. As has already been 
mentioned, the susceptibility of the nerve-roots 
varies from case to case. Within a few hours the 
slight sensory loss and reflex disturbance usually 
disappear entirely. In some cases the pain dis- 
appears at once. In some it remains unchanged for 
several days and then ceases, perhaps ten days after 
the injection. In some it becomes less, but is not 
abolished. If the pain is still severe ten days after 
the injection, the operation may be repeated. If 
the previous injection caused no sphincter difficulty 
and little sensory disturbance, 0°6 to 0-8c.cm. of 
alcohol may be safely injected. As before, the side 
to which most pain is referred should be uppermost, 
but if the pain is central, asin the case of bladder and 
rectal pain, the second injection should be made 
with the patient lying on the side opposite to that 
on which he was placed for the first injection. The 
effect is again observed for a period of ten days, and 
if pain is still severe, and if there has been no sphincter 
difficulty, and little or no permanent sensory loss, 
a still larger injection may be given of 1-0 to 1-3 c.cm. 
of absolute alcohol. Additional or larger injections 
are seldom required. After the treatment distension 
of the bladder should always be looked for and 
promptly relieved by catheterisation. In most 
cases in which sphincter difficulty occurs, the difficulty 
passes off in a few days. The injection for the relief 
of sacral pain is often effective in relieving the 
distressing bladder and rectal spasms which occur 
in malignant disease involving these organs. At 
the same time, the hemorrhage and discharge which 
accompanies these spasms become much less. If 
the pain persists in spite of these injections, the 
case should be reconsidered from the point of view 
of the exact situation of the pain. The above method 
will only relieve pain conducted via the sacral nerves, 
and will therefore not relieve pain felt in the front 
of the thigh or leg, or in the lower abdomen, which 
is conducted by the lumbar and lower dorsal roots 
respectively. | 
METHOD OF RELIEVING LUMBAR OR THORACIC PAIN 

ete l i 

When severe pain is referred to a part of the lower 
extremity supplied by the lumbar nerves, the position 
of tho patient for the injection should be such that 
the upper lumbar vertebræ form the highest part 


THE LANCET] 


DR. RITCHIE RUSSELL: INTRASPINAL INJECTION OF ALCOHOL [marcH 14, 1936 597 


of the spine (Fig. 2). The injection may 
be made between the second and third 
lumbar vertebre. The procedure is 
otherwise the same as described above. 
When the pain is referred to the 
abdomen or chest, the injection is not 
so easy to carry out. The patient is 
placed so that the nerve-roots con- 
ducting the pain are situated at the 
highest part of the spine (Fig. 3). The 
spinal theca is punctured at this level, 
care being taken to penetrate the theca 
the least necessary distance, so as to 
avoid risk of injury to the spinal cord. 
Dogliotti described a method of 
injecting alcohol to affect the cervical 
nerve-roots, but as I have no experience 
of this I shall not refer to it further. 


FURTHER POINTS REGARDING TECHNIQUE 


When the larger injections are being made, it is 
wise to stop for a few seconds after a part of the 
injection has been given to test for the presence 
of gross sensory loss or weakness. Such an obser- 
vation will give the operator some indication of 
the sensitivity to alcohol of the nerve-roots in 
the case he is 
treating. 

Some patients 
with advanced 
malignant disease ii 
are in an emo- i i 
tional and highly | en ya 
nervous state. i | Se N 
In such cases I 
usually give mor- 
phine and hyo- 
scine before the 
injection, the 
amount depend- 
ing on the 
tolerance al- 
ready developed 
for the opiates. 


RESULTS OF THE TREATMENT 


In the following short abstracts of the cases treated 
it will be noted that the injections given were in 
many instances larger than those advised. The 
first injections I gave were small (0-5 c.cm.) but had 
no effect in relieving severe pain, hence in advanced 
cancer cases I have given injections of 1-0 c.cm. 
or more. As however in one recent case this amount 
has caused retention of urine, I am again reducing 
the amount of the initial injection. It should 
be clearly understood that most of the cases treated 
have been advanced cases of malignant disease, most 


} 
; 
} 


EJ 


| haa 7 eS E G Re TT, PE a eE 


FIG. 2.—Position of the patient for injection when the pain is conducted 
through the lumbar roots of the right side. 


FIG. 3.—Position of the patient for injection when the pain is conducted 
through the lower dorsal roots of the right side. 


FIG. 1.—Position of the patient for injection when the pain is conducted, 


through the sacral roots of the right side. 


of which were in the cancer wards of a hospital for 
incurables. l 
Case 1—A man, aged 72, suffered from carcinoma 
of the prostate for which the bladder had been drained 
by a suprapubic tube. He had suffered severe spasms 
of pain in the bladder for over two years with almost 
continual hemorrhage from the bladder. Two alcoholic 
injections were made, one of 0°5c.cm. and a second 
of l-4c.cm. in November, 1934. Considerable relief 
of pain persisted to 
death on Jan. 20th, 
1935. <A striking 
effect of the injec- 
tion was the cessa- 
tion of hemorrhage 
from the bladder, 


3 CASE 2.—A 
Nii. woman, aged 77, 
‘N . ~ suffered from carci- 
noma of the rectum 
which caused much 
rectal pain. 1:0 
c.cm. of alcohol 
was injected on 
Nov. 19th, 1934. 
No sensory loss or 
reflex disturbance 
could be demon- 
strated on the day 
following. Complete relief of rectal pain persisted to 
death on June 4th, 1935. 


CasE 3.—A woman, aged 50, suffered from a huge tumour 
of the sacrum and a pathological fracture of the femur. 
0-6 c.cm. of absolute alcohol was injected in November, 
1934, but no relief of pain resulted. The injection was 
carried out with great difficulty owing to cedema of the 
back and patient declined to have a further injection. 


CASE 4.—A man, aged 60, was seen on Feb. 28th, 1935, 
suffering from severe pain referred to the front of both 
thighs which had been gradually getting worse for a 
period of seven weeks. The pain was very severe on 
coughing and was aggravated by lying down, so much 80, 
that he had been unable to go to bed 
at night for some weeks. Great cdema 
of both legs had developed. On examina- 
tion there was no motor, sensory, or 
reflex abnormality. X ray examination 
showed some abnormality of the tenth 
dorsal vertebra, which was thought to be 
due to malignant disease. The patient 
was rapidly becoming exhausted with the 
severe pain and required large doses of 
morphine to give relief. On Feb. 28th 
0:5 c.cm. of absolute alcohol was injected 
with the patient lying on his right side. 
The cerebro-spinal fluid was yellow and 
contained 400 mg. of protein per 100 
c.cm. The examination of the cerebro- 
spinal fluid showed no other abnormality 
except that the colloidal gold curve was 


598 THE LANCET] 


333322210000. No relief of pain resulted, and on 
March Ist 1:3c.cm. of absolute alcohol was injected 
with the patient lying on his left side. On the day following 
there was some difficulty with micturition which sub- 
sequently passed off. There was also transient weakness 
of the right leg and some senory loss in the sacral distribu- 
tion. For two days after the second injection the pain 
remained severe; thereafter, it quickly disappeared and 
in June, 1935, the patient returned to full work as a sea- 
captain. When examined on Jan. 18th, 1936, seven 
months later, he was still perfectly well, free of all pain 
and able to do full work. The only effect of the injection 
was slight numbness in the fifth lumbar and first sacral 
distribution on the right side. X ray examination of 
the spine showed no conclusive evidence of disease. There 
had been no further difficulty in passing water and the 
area of sensory loss was becoming steadily less. The 
diagnosis in this case remains undetermined. 


CasE 5.—This patient, a man of 65, suffers from carci- 
noma of the rectum. Colostomy was performed in May, 
1934, and suprapubic drainage of the bladder instituted 
in December, 1934. Owing to severe perineal pain 
1-0 c.cm. of alcohol was injected in March, 1935. Pain 
was relieved for two months, after which a further injection 
of 1:3 c.cm. was given to affect the opposite sacral roots. 
Slight sacral sensory loss and absence of the ankle-jerk 
persisted for afew days. Pain was almost entirely relieved 
and the patient’s general condition improved greatly. 
In November, 1935, he was able to walk half a mile. 
Thereafter some discomfort returned owing to the 
progressive reduction of bladder capacity. 


CasE 6.—A woman, aged 59, suffered from carcinoma 
of the uterus which was causing great pain. On March 3rd, 
1935, 1-5 e.cm. of absolute alcohol was injected. Transient 
weakness and sensory loss in one leg resulted. No sensory 
loss persisted, but pain was relieved till death on May 7th. 


CasE 7.—A man, aged 62, suffered fram advanced 
carcinoma of the rectum for which a colostomy had been 
performed. Severe root pains had been roferred to the 
left thigh for many months causing great restlessness 
and for which large doses of opium were required. 
Injection of 1:5c.cm. of absolute alcohol on April 19th, 
1935, abolished the reflexes in the left leg, but caused 
little motor or sensory loss. No further opium was 
required and the patient was free of severe pain till he 
died on May 3rd. 


CasE 8.—A woman, aged 53, had a huge sarcoma involv- 
ing the sacrum and lower lumbar vertebre. She suffered 
very sevore pain on movement and had been obliged to 
lie on her face for three months. On May 25th, 1935, 
with the patient lying on the right side, 2-0 c.cm. of alcohol 
was slowly injected above the first lumbar vertebra, 
the lower intervertcbral spaces being invaded by tumour. 
Little pain was felt on the day following and the patient 
was able to be nursed on her back free of severe pain till 
she died on July 5th. No retention of urine occurred 
and little motor or sensory loss resulted. 


CASE 9.—A man, aged 66, suffered from severe pain 
due to rectal carcinoma for which colostomy had been 
performed. 1-5c.cm. of absolute alcohol was injected 
on June 29th, 1935. Some weakness of the uppermost leg 
occurred with loss of knee- and ankle-jerks and sensory 
loss below the third lumbar supply. Pain was relieved 
but death occurred from gastric hamorrhage on July 2nd. 


Case 10.—A man, aged 77, suffered from cancer of the 
pelvic organs for which a colostomy had been performed. 
1-5¢c.cem. of absolute alcohol was injected on July 13th, 
1935, to damage the left sacral nerve-roots ; but no sensory 
loss, weakness, or reflex disturbance resulted. Great 
relief of pain persisted till death on July 18th. 


Case 11.—A woman, aged 58, suffered from carcinoma 
of the rectum for which colostomy was performed in 
September, 1934. Rectal pain had been becoming steadily 
more severe and was hardly bearable. On July 29th, 1935, 
1-3c.cm. was injected to damage the left sacral nerve- 
roots. As some pain persisted the injection was repeated 
ten days later; on this occasion the right side was upper- 
most and 1-:5c.cm. of absolute alcohol was injected. 


DR. RITCHIE RUSSELL: INTRASPINAL INJECTION OF ALCOHOL 


[MARCH 14, 1936 


Some weakness and sensory loss occurred after both 
injections, but pain was entirely relieved and there was 
no loss of urinary control. The slight weakness did not 
prevent her from walking without difficulty. The patient 
left hospital and returned home on Sept. 5th. 


Case 12.—A man, aged 65, suffering from carcinoma 
of the prostate and severe root pains in the left thigh. On 
August llth, 1935, 1-4 c.em. of alcohol was injected with 
the left leg uppermost. Considerable sensory loss in the 
left sacral distribution and complete retention of urine 
resulted. Severe pain persisted in the second lumbar 
distribution, but the patient declined to‘have a further 
injection. 


Case 13.—A man, aged 66, suffered from advanced 
carcinoma of the rectum for which colostomy was per- 
formed in June, 1935. Recently some urinary difficulty 
had been noticed. On Sept. 14th 1-0c.cm. of alcohol 
was injected. The knee- and ankle-jerk on one side were 
abolished, but some pain in the rectum continued and the 
patient complained of a numb feeling of the leg. Further 
injections were not carried out in view of the urinary 
difficulty. 


Case 14.—A man, aged 60, suffered from advanced 
malignant disease of the left lung. There was severe pain 
referred to the scapula and to the lower part of the abdomen 
on the left side. On Sept. 26th, 1935, after the administra- 
tion of morphine and hyoscine to enable the patient 
to lie comfortably, he was placed on his right side in such 
position that the sixth dorsal vertebra formed the highest 
point of the spine. The subarachnoid space was tapped 
between the soventh and eighth dorsal vertebrae and 
0-6 c.cm. of absolute alcohol was slowly injected. This 
relieved the pain in the left scapula but severe pain 
continued in the left side of the abdomen. A further 
injection was given ten days later of 1-0 c.cm. with the 
eighth dorsal vertebra forming the highest point of the 
spine. This, however, failed to relieve the severe pain 
and further injections were not attempted. 


Case 15.—A woman, aged 75, had been incapacitated 
for the past year with severe arthritis of the knees. On 
Nov. 30th, 1935, 0:5 c.cm. of absolute alcohol was injected 
into the subarachnoid space between the third and fourth 
lumbar vertebre, with patient lying on her right side 
and the third lumbar vertebra forming the highest point 
of the spine. No sensory loss was demonstrated following 
the injection and the reflexes were unaltered. Some relief 
of pain in the left knee resulted. » 


CASE 16.—A woman, aged 48, suffered from an advanced 
stage of disseminated sclerosis with extreme contracture 
of the right leg and considerable flexion deformity of the 
left leg. Flexion spasms of the legs were frequent and 
caused great pain. On Dec. 20th, 1935, 0-5¢.cm. of 
absolute alcohol was injected into the subarachnoid space 
between the second and third lumbar vertebre, the 
patient lying on the right side and the third lumbar 
vertebra forming the highest point of the spine. Almost 
immediately the clonus of the left ankle and knee was 
abolished and the spasnf at the left knee became much 
less. The left knee-jerk was abolished. Considerable 
sensory loss occurred from the second to fifth lumbar 
distribution of the left leg, the sacral segments escaping 
entirely. On Jan. 20th, 1936, considerable pain con- 
tinued in the extremities, but flexion spasms of the left 
leg no longer occurred. The knee-jerk was still absent 
and the ankle-jerk was sluggish. The injection had not 
increased the patient’s slight difficulty with micturition. 


CASE 17.—A woman, aged 47, suffered severe perineal 
pain from carcinoma of the vagina which involved the 
rectum. 1-0c.cm. of absolute alcohol was injected. 
Transient sensory loss occurred in the S1 to S5 distribution 
of one leg. Severe pain was reheved, but the patient 
remained very uncomfortable and slight incontinence 
of urine followed the injection. 


Case 18.—A man, aged 68, suffered from carcinoma 
of the rectum for which a colostomy had been performed. 
Severe spasms of rectal pain with hamorrhage caused 
great distress, 0-Sc.cm. of absolute alcohol, injected 
on Dec. 26th, 1935, to damage the left sacral roots, caused 


THE LANCET] 


MR. A. H. WALTERS : ANKYLOSTOMIASIS IN INDIAN SEAMEN 


[marnoH 14,1936 599 


‘some temporary sensory loss in the left sacral distribution 
and loss of the left ankle-jerk. Complete relief of rectal 
pain resulted, but retention of urine occurred. The 
rectal discharges ceased. 


SUMMARY 


1. The intraspinal injection of alcohol is a dangerous 
procedure unless carried out with great care and 
strict attention to the details of the technique 
advised. 

2. The injection often relieves the severe pain of 
malignant disease. 

3. Eighteen cases which have been treated by this 
method are briefly described. 


REFERENCES 
1. Dogliotti, A. M. : Presse méd., 1931, xxxix., 1249. 
2. Greenhill, J. P., and Se chmitz, H E.: Jour. Amer. Med. 


Assoc., 1935, OY., 
3. Saltzstein, H. C.: Thio, 1934, ciii., 242. 
4. Sloane, P.: ‘Arch. Neurol. and Psychiat., November, 1935, 


p. 1120. 
5. Stern, E. L.: 
6. Yeomans, F. C.: 


Amer. Jour. Surg., 1934, xxv., 


217. 
Jour. Amer. Med. Assoc., 1933, ci., 1141. 


TREATMENT OF 
ANKYLOSTOMIASIS IN INDIAN SEAMEN 


By A. H. WALTERS 
SENIOR TECHNICIAN, ROYAL ALBERT DOCK HOSPITAL 
Under the direction of 
Dr. G. CARMICHAEL Low and Dr. P. H. MANSON-BAHR 


WHILE examining the stools of Indian seamen 
after treatment for ankylostomiasis, it was noted 
that although ova-free stools were finally obtained 
the worms were often never recovered in the fæces. 
Therefore a small series of investigations were carried 
out during the years 1930-34 on such patients admitted 
to the Albert Dock Hospital under the medical 
charge of Dr. Low and Dr. Manson-Bahr to discover 
whether recovery from ankylostomiasis could take 
place without the worms ever being found in the stools 
after treatment. 

All the cases in this series were Indian seamen 
employed in ships running between London, India, 
Africa, and the Far East. In each case the number of 
ankylostome ova per c.cm. of feces was obtained 
by the Clayton Lane direct centrifugal floatation 
method before treatment to obtain an idea of the 
degree of infection. After treatment each stool 
passed was examined by the same method and the 
number of ankylostome ova per c.cm. was noted. 
Where necessary the treatment was repeated until 
ova-free fæces were obtained on at least. seven 
consecutive days.. After the seventh day if ova- 
free fæces were obtained, the patients were discharged 
from hospital to go back to their work on the ships. 
Between 5 and 12 months later, when the men 
returned to London, specimens of faces were obtained 
from them and examined, as before, for ankylostome 
ova. The men were treated with various anthel- 
mintics and the Tables illustrate the work done and 
the results obtained. 

Although the patients returned on their ships to 
tropical countries it is fairly safe to assume that they 
were not reinfected with ankylostomiasis during their 
short stay on shore. A number of interesting points 
may be noted :— 

1. In the stools recovered immediately after treat- 
ment small fragments of what were thought to be 
disintegrated worms were found in about 25 per cent. 
of all cases examined. It is thought that the majority 


of these natives contract ankylostomiasis during 
childhood and that the worms become firmly embedded 
in the convolutions of the wall of the small intestine. 
Anthelmintic treatment by the combined method 
seems to be the most efficacious way of killing these 
worms, but it does not remove them intact. 


TABLE I 
A.—THYMOL 


Ova Presence Days Ore Dee 
Case] Per o.cm. | of ova in| Treat.| before | worms) fæces 
No treat- feecal ments. became passed 5-12 
ment film. ova-free. monts 
TIo EOE 
EFEN ET 
PE A e 
7 46 — 1 6 — — 
8 118 + 2 12 7 — 
B.—OIL OF CHENOPODIUM 

1 32 — 1 5 — — 
2 72 + 2 12 3 26 
3 66 — 2 11 — 

Tina Rr 
6 34 = 1 6 == 56 

C.—CARBON TETRACHLORIDE 

1 62 — 1 5 — _ 
2 45 — 1 3 — 34 
E See eee 
5 26 — 1 5 — 

6 124 + 3 14 12 52 


D.—COMBINED TREATMENT ; CARBON TETRACHLORIDE 
AND OIL OF CHENOPODIUM 


1 32 = 1 4 — = 
2 64 = 1 5 = = 
3 76 = 1 ő = = 
4 54 = 1 5 = = 
5 42 = 1 4 — == 
6 53 == 1 3 = m 
7 83 F 1 5 = Fa 
8 82 + 1 5 = = 
9 135 + 1 6 9 =s 
10 25 = 1 5 = = 
11 47 = 1 4 m = 
12 43 == 1 4 = = 
13 82 + 1 5 2 = 
14 21 — 1 5 = = 
15 47 == 1 4 = = 
16 56 + 1 5 — = 
17 34 = 1 5 ai — 


TABLE II.—Summary of Results 
| 


Men in whom 


: Men 
Tope] treatment. —_[¢guata,| recovered | attor aie 
treatment, | Months. 
AL | Thymol. 8 1 2 
B. | Oil of chenopodium. 6 1 2 
C. | Carbon tetrachloride. 6 2 2 
D. | Combined treatment. 17 2 0 


2. Fæcal films, prepared by the ordinary coverslip- 
saline method, of stools containing ankylostome ova 
do not reveal the eggs as a rule unless the ova content 
is greater than 60 per c.cm. The Clayton Lane 
method is undoubtedly the best for detecting 
ankylostome ova in fæces. 

3. The technique of administering the combined 
treatment is conveniently carried out as follows: 
(a) starve the patient from midnight; (b) at 9 A.M. 


600 THE LANCET] 


give carbon tetrachloride M 40 in two gelatin 
capsules and oil of chenopodium M 15 in two gelatin 
capsules, followed by magnesium sulphate 1 oz. 
in a tumblerful of water. Natives usually experience 
no trouble in taking the treatment, but about one 
in ten are sick after carbon tetrachloride; aspirin, 
grs. 10, relieves this. Stools are passed at the rate 
of about three during the first 24 hours, two during 
the second 24 hours, after which defecation becomes 
normal. . 

4. Although not recorded here, some of the men 
included in this series were also suffering from 
Ascaris lumbricoides, Trichuris trichiura, and Oxyuris 
vermicularis infections. The combined treatment 
seemed to be satisfactory for these helminths also. 


I am much indebted to Dr. Carmichael Low and 
Dr. Manson-Bahr, under whose direction the work was 
carried out, and to Dr. H. M. Hanschell for kindly 
providing laboratory facilities to undertake this work. 


TECHNIQUE OF INTRAVENOUS 
ANAESTHESIA 
By Ronatp Jarman, D.S.C., M.R.C.S. Eng., D.A, 
AND 
A. LAWRENCE ABEL, M.S. Lond., F.R.C.S. Eng. 


Tsis note describes the methods we use for injecting 
intravenous anxsthetics such as Evipan and Pento- 
thal. As we have lately pointed out,! these can be given 
in one of three ways: asa single dose; in repeated 
doses ; and by continuous intravenous infusion. 

1. Single dose.—The sterilised syringe having been 
loaded, a dental prop or Hewer’s mouthpiece is 
inserted between the patient’s teeth. The upper 
part of the arm is constricted, either manually or 
by a pressure armlet, and the needle inserted into an 
antecubital vein. Assuming a dose of 10 c.cm., 
the first 2 or 3 c.cm. of the solution is injected in 
about 15 seconds, during which time the patient is 
asked to count. He usually becomes unconscious 
in 15-30 seconds, and a pause is then advisable, 
for about the same period, so that one may be 
satisfied that his condition is within normal 
limits. If the injection is given too 
rapidly, the pulse-rate rises and the 
respirations become depressed. The 
next 3 or 4¢.cm. should be injected in 
about 30 seconds. After a further short 
pause, provided the patient’s condition 
is satisfactory, the remainder of the 
10 c.cm. dose is given at the previous 
rate. . Both the pulse and respiratory 
rates are constantly observed, a clear 
airway is maintained, and the jaw is 
supported throughout the anesthesia. 

2. Repeated doses.—If a further dose 
is likely to be wanted the needle may 
be left in the 
vein, and the 
syringe re- 
moved, re- 
charged, and 


2? See Jarman 
and Abel: In- 
travenous Anæs- 
thesia with Pen- 
tothal Sodium, 
THE LANCET, 
Feb. 22nd, 1936, 
p. 432. 


ene 
T 


ya = 


DR. JARMAN AND MR. ABEL: TECHNIQUE OF INTRAVENOUS ANESTHESIA 


FIG. 1.—Dickson Wright's apparatus. 


[marcu 14, 1936 


replaced if required. For this purpose Dickson Wricht’s 


splnt,? which controls the forearm, will be found con- 
venient. This has an upper band consisting of a pneu- 
matic bag which can be inflated and deflated by means 


of a bulb with a release valve attached and a lower 


mM 


Mi 


FIG. 2.—<Authors’ three-way syringe. 


band firmly gripping the wrist. The needle and 
syringe are fixed to the forearm and kept in place 
by means of adhesive plaster. 

3. Continuous intravenous infusion.—I wo forms of 
apparatus are available for this :— 

(a) An ordinary intravenous apparatus is used 
to convey normal saline with 5 per cent. glucose 
from a flask container to a vein. The lotion need 


- not be heated. A dripper, controlled by a simple 


thumbscrew, is adjusted to deliver not less than 
20, and not more than 30, drops a minute. The 
limb is with advantage controlled on a suitable splint. 
The needle, attached to the syringe containing the 
intravenous anesthetic, is inserted into the tubing 
near the vein and the injection given as into the 
vein (Fig. 1). 

(b) The authors’ three-way syringe (Fig. 2). A 
10 c.cm. syringe with a three-way nozzle is fixed to 
the forearm with elastic bracelets. With the control 
in the central position, the barrel of the syringe 
communicates directly via the needle to the vein. 
When the contro is turned to the left, the lateral 
feed communicates directly with the needle, and this 
position is used for continuous saline-glucose infusion 
as in the preceding method. When the control 
is turned to the right, the other lateral feed com- 
municates with the barrel, and the syringe can thus 
be loaded with a further dose of anzsthetic, which 
may then be injected through the needle by turning 
the control to the mid-position. 

In serious cases a patient can, of course, have blood 
transfusion throughout the operation with pauses for 
the anwsthetic administration. Similarly, for any 
emergency, the syringe can be used for giving 
stimulants, such as Coramine or Alpha-lobeline ; 
and here an advantage of the apparatus is that only 
the smallest amount necessary of the drug need be 
given, since it is accurately measured 
and reaches the vein direct. We have 
found the administration of con- 
tinuous saline-glucose infusion dur- 
ing operation of the utmost import- 
ance in some of the “poor risk” 
cases. Dehydration is combated 
all the time and shock is largely 
abolished. 


? Wright, A. D.: Technique of Evipan 
Anæsthesia, Ibid., 1935, i., 1040. 


od / Mee 


uta 


CARRE B hny i da dibya 


THE LANCET] 


[marcu 14, 1936 601 


MEDICAL SOCIETIES 


ROYAL SOCIETY OF MEDICINE 


SECTION OF SURGERY 


AT a meeting of this section held on March 4th 
the chair was taken by Mr. W. SAMPSON HANDLEY, 
the president, and a discussion on 


Intestinal Strangulation 


was opened by Mr. IAN AIRD. The mortality of 
operation for this condition, he said, had fallen to 
about 40 per cent. by the end of last century and 
had continued there ever since. The principles of 
optrative treatment could be stated simply: the 
cause must be removed and non-viable bowel excised. 
The only question was where lay the dividing line 
between viable and non-viable bowel. Certain experi- 
mental data threw doubt on the wisdom of returning 
to the abdomen sections of bowel which regained 
their circulation when the strangulation was released. 
Gross venous congestion marked the dividing line. 
While release after a short period improved the 
circulation, sudden release of a congestion long 
maintained had a depressor effect on blood pressure. 
This had been shown by experiments in dogs and 
cats, which Mr. Aird described. In one case the 
fall of blood pressure had been followed by death in 
eight minutes ; in others there had been fall of blood 
pressure after congestion lasting from 6 to 18 hours. 
Shorter periods of congestion produced a rise in 
blood pressure when the congestion was suddenly 
released. 
The causes of death in strangulation were three : 
perforation and peritonitis, loss of blood from the 
circulation, and absorption of toxic elements from 
the strangulated bowel. If the loop strangulated 
were short, the treatment was that of peritonitis ; 
if it were very long, blood transfusion was indicated 
to replace the blood: lost in the loop. In the average 
medium-length loop another factor must be sought, 
and the general treatment must be directed towards 
the toxemia. Loss of blood in these cases was 
an important but not a lethal factor. The transudate 
from the strangulated bowel contained, as a result 
of bacterial growth in the bowel wall, two toxins. 
The first was a euglobulin, perhaps related to the 
complex bacterial toxins; this was the only toxic 
protein fraction. The non-protein element was a 
diffusible substance, perhaps histamine, which was 
present in surprisingly high concentration. 
Artificially strangulated loops of small intestine 
taken from new-born guinea-pigs in which the 
intestine was sterile could be placed in the peritoneal 
cavities of adult cats without harm. This strongly 
suggested that the toxicity of strangulated loops 
depended on bacterial action. Another series of 
experiments had shown that the transudate fluid 
was non-toxic and the seromuscwar coat was sterile 
when the strangulation was only a few hours old. 
After 18 or 20 hours aerobic and anaerobic bacteria 
invaded the bowel wall and the transudate became 
toxic. Animals injected with the euglobulin showed 
spasticity before death and affection of the liver and 
spleen post mortem. Certain bacterial exotoxins 
had the composition of a euglobulin. The success of 
B. welchii preparations in intestinal strangulation 
had never been explained. The new specific anti- 
sera ought to have a field of usefulness in this condi- 
tion. Death from the ‘non-protein substance was in 
every case preceded by respiratory embarrassment. 


Work on the histamine content of transudate was 
still in progress. Transudate protein-free filtrate 
caused an almost identical excitatory effect on guinea- 
pig ileum to that produced by histamine. The 
inhibition of rat and stimulation of guinea-pig uterus 
were similarly comparable. The concentration seemed 
to be between 1/10,000 and 1/20,000. Proteolytic 
organisms were present in the bowel wall in enormous 
quantities and the conditions were ideal for histamine 
production. Vagopressor substances therefore seemed 
indicated in treatment. 


Dr. Davm Stome described experiments by Mr. 
G. C. Knight and himself. The fluid-loss factor in 
long-loop strangulations had been determined by 
weight comparisons. It had varied from 1:4 to 
2:2 per cent. of body-weight and so was insufficient 
to account for death. The initial fall in blood pressure 
could be attributed to the fluid loss, but the failure 
to recover and gradual decline leading to death 
must be attributed to some other factor. Cross- 
connexion experiments in two animals had shown 
that strangulation lowered blood pressure, although 
the fluid loss was all sustained by the other animal. 
In the non-viable type of strangulation the animals 
were all dead within 48 hours. The survival-time 
was definitely related to the severity of the strangula- 
tion, but there was no constant relationship between 
survival-time and amount of fluid loss. In no case 
was the volume of fluid lost adequate to account 
for the death. Peritoneal fluid from non-viable 
loops had been shown to be toxic by transplantation. 
The toxin by itself produced collapse and death in 
a normal animal and the blood pressure was always 
depressed. In viable loops there was no evidence 
of a toxic fluid at 24 hours. In severe strangulation 
it might be present after one hour. The depressor 
substance was readily dialysable through a semi: 
permeable membrane. The toxin seemed to be 
formed in the wall of the gut and rapidly passed into 
the venous blood and into the lumen of the bowel. 
The rapidity of its formation in high concentration 
was against a bacterial origin. The depressor action 
-could be demonstrated in thoracic duct fluid also 
if the lymphatics were not occluded. Relief of 
venous obstruction allowing return of blood to the 
circulation did not improve the animal’s condition 
but set free more depressor substance. The substance 
might be identical with the depressor principle found 
in normal urine. The urine of cats with strangulated 
intestine had proved to be depressor. 


Mr. G. C. KNIGHT emphasised the significance of 
the experiments described by Dr. Slome. The 
toxemia in strangulation was characterised by early 
onset and its cause was probably a mixture of 
depressor substances. Bacterial action only con- 
tributed in later stages if at all. Death occurred in 
the presence of almost normal blood chlorides. 
Fluid loss was only an accessory. The severity of the 
strangulation was directly related to the survival 
period. The length of loop played a part, but not 
to an extent justifying classification of cases according 
to length. The parts played by renal function, saline 
therapy, and the release of the depressor substance 
into the circulation all required consideration. 
Attention should perhaps be focused more on the 
viability of the patient than of the gut. Experiments 
suggested that death occurred within 96 hours if 
simple release were practised, while the animals 
remained alive and well after excision of quite viable 
loops. Clinical cases had shown similar results, ` ` 


602 THE LANCET] 


ROYAL SOCIETY OF MEDICINE: ORTHOPZDICS 


[mance 14, 1936 


DISCUSSION 


Mr. R. Sr. L. BRocKMAN pointed out that there was 
a toxemia of intestinal obstruction whether the 
strangulation were severe or not. If the circulation 
were completely obstructed so that the loop died 
instantly, no toxic substance was formed in that 
loop. In the upper part of the intestine isolated 
loops were toxic; in the ileum they could safely be 
left. The upper part was more sterile, so bacteria 
could have little to do with it. Cells in the bowel 
above a strangulation were living in their own exudates 
which could not be passed on. As this process 
mounted the bowel it stopped the action of the glands 
in the upper part—the liver and pancreas. Patients 
often died a few days after an operation for relief. 
In dogs the fatal change had taken place at the 
moment of stoppage of biliary flow. When the 
stoppage reached the duodenum life stopped too. 
There might be in the duodenum some production 
of vital ferments necessary for the life of the whole 
organism. 

Mr. R. L. Tort said that the results reported 
confirmed his own work. He agreed that there were 
two distinct toxic factors. One appeared within the 
first hour and was very similar to histamine. It 
could also be obtained by strangulating omentum 
and might be the result of tissue breakdown folowing 
anoxemia. After about 20 hours a second protein- 
toxic factor appeared at the same time as the gut 
content changed to a black fetid toxic fluid. The 
length ordinarily strangulated in a hernia would not 
produce enough toxin to have a wide general effect ; 
the clinical effect of obstruction was very important. 
There was also dehydration from vomiting and 
distension above the strangulation. The amount of 
fluid witheld from circulation was a most important 
factor. Long-loop strangulation showed a special 
clinical picture associated with acute shock and 
pallor; the combination of toxic absorption and 
fluid loss were enough to kill the patient. Every loop 
about which there was the slightest doubt should be 
resected, and if the patient was in a bad state 
exteriorisation was a good measure. 

Mr. TURNER WARWICK said that complete ligation, 
in cats had not produced symptoms of obstruction apart 
from perforation. High obstruction might depend on 
chemical changes below it as well as above it. The 
constricted part of the bowel had not received the 
attention it deserved. A Canadian worker had 
shown that animals died of toxemia even if the 
loop were washed quite free from bacteria. Animals 
did not die if the distended coil were denervated— 
which suggested shock as the cause of death. 


SECTION OF ORTHOPEDICS 


AT a meeting of this section held on March 3rd, 
under the presidency of Mr. C. Max PAGE, a 
discussion on 


Fractures in the Region of the Shoulder-joint 


was opened by Mr. GEORGE PERKINS, with the remark 
that it was well occasionally to examine accepted 
principles of treatment to see how far practice was 
in accord with theory. The conception that a fracture 
was a dual injury was not a new one. In past years 
there had been some who concentrated on treat- 
ment of soft parts in fracture cases and appeared 
almost to forget about the bone. Many had treated 
the bone and forgotten the soft parts. If there now 
existed, as he thought there did, a modern school of 
thought concerning the treatment of fractures, that 


school emphasised one fact: that a fracture was a 
dual injury, and that both bone and soft parts required 
treatment; that treatment of those parts was of 
equal importance and should be undertaken simul- 
taneously. Taking the three stages of treatment, 
(1) reduction, (2) splintage until the bones moved 
as one piece, (3) protection until consolidation, it 
was agreed that nothing could be done for the soft 
parts in stage (1), but in stage (2) the masseuse 
standing at some distance from the patient made 
him (a) move all the free joints through their full 
range; (b) contact all his muscles over the 
immobilised joint ; (c) use his limb, this last being the 
most important. Thus when stage (3) was reached 
there was little for the masseuse to do—i.e., she simply 
had to make the patient move all the joints to their 
full range, with perhaps a little massage if it was 
mentally satisfying to the patient. When the bone 
repair was completed, repair of soft parts also was 
almost complete. There remained, in the aftermath 
stage, an occasional manipulation under gas anes- 
thesia to assist the complete range of movement. 

As to the relative importance of treating bone 
and soft parts, it was granted that bony union was 
essential, and in cases in which it was difficult to bring 
about that union the bone treatment was paramount. 
In fracture of the scaphoid, for instance, it might 
be necessary to immobilise the wrist-joint for six 
months in order to bring about the necessary union. 
But where there was dilliculty in restoring mobility 
to a joint, treatment of soft parts might be the 
more important. Shoulder and knee had in common 
the quality that when immobilised, even for a short 
time, they stiffened; that happened even when 
there had been no injury or inflammation round the 
joint, but it was more pronounced in the presence of 
injury. Some might say this applied to the shoulder- 
joint only if the arm was held immobilised close to the 
side, but with that he did not agree. In any fracture 
about the shoulder-joint, the treatment of soft parts 
was of far greater importance than the treatment of 
bone, even allowing that the bone needed treatment. 
But did the bone need treatment? Injury of bone 
was divisible into three phases: (1) reduction, (2) 
splintage until union occurred, (3) protection until 
consolidation took place. Anatomical reposition of 
fragments was rarely possible and rarely necessary. 
The surgeon was content with “good reduction,” 
meaning that when union was completed the align- 
ment of the bone would give rise to no loss of function. 
In fractures round the shoulder-joint, reduction rarely 
had to be attempted, often indeed the fractured 
surfaces were already in good reduction. In the cases 
in which reduction should be attempted, he considered 
it could not be done without an open operation. The 
kind of case needing this was where the shaft of the 
bone was in front of the head, and the fractured surface 
was jagged. 

Splints were used for two distinct reasons, some- 
times for both: (1) to hold the fractured ends still 
and so prevent them from moving on one another; 
(2) to hold the fractured ends in good position. If 
there were muscles inserted into both fragments, 
they were sufficient to keep the fractured ends still. 
If no muscle was attached to one or both, splintage 
was necessary. And sometimes the muscles attached 
to both fragments could not prevent all movement. 
But in the shoulder-joint a plexus of muscles was 
inserted in the neighbourhood of the fracture, and 
they sufficed, he thought, to hold the fractured ends 
still. To hold the ends in good position the two 
essentials were a longitudinal pull to reduce overlap 
and an upward pull to prevent backward sag. Unless 


THE LANCET! 


plaster-of-Paris was used, a splint would not prevent 
the fractured ends from moving on one another. 
Where a fracture lay between two hinged joints, 
as at the knee or ankle, good alignment was essential ; 
but if it was between ball-and-socket joint and 
hinge joint, mal-alignment was of little moment, 
because the plane of the ball-and-socket joint would 
accommodate itself to the plane of the hinge joint. 
The shoulder was a _ ball-and-socket joint. Most 
fractures would unite, whether treated with a splint 
or without. His contention was that fracture about 
the shoulder-joint should never be splinted, because 
(1) reduction was often unnecessary, and if necessary 
it was usually impossible; (2) the muscles sufficed 
for holding the fragments immobile; (3) mal-union 
was of minor importance; (4) treatment of the soft 
parts was of more importance than treatment of the 
bone. The bugbear was a stiff and painful shoulder. 
A patient with a fracture round about the shoulder 
should be given a sling, and treatment by a masseuse 
should be commenced at once, preferably in the 
recumbent position. The patient should move the 
muscles round the joint, and, as soon as he could 
be induced to do so, move the joint itself. If unwill- 
ingness was shown, he should be taken into hospital 
or nursing-home and the massage intensified. 

Mr. R. Watson Jones (Liverpool) said that during 
childhood and adolescence the shoulder was seldom 
injured. For the purpose of this discussion he had 
investigated every case of shoulder injury treated 
in his fracture clinic at Liverpool Royal Infirmary 
during five years—over 700 cases; he would speak 
mainly, however, of the 571 cases of dislocation of the 
upper end of the humerus. Of the 216 shoulder 
dislocations, only 6 were under 20 years of age. 
Radiograms clearly differentiated two types of 
isolated fracture of the great tuberosity. One was a 
result of direct contusion of the bone; the fragment 
split off from the end was frequently comminuted 
and never widely displaced. In the other type the 
displaced fragment was small, involving only the 
part of the tuberosity into which the supraspinatus 
tendon was inserted. It represented the first stage 
of avulsion of that tendon. If the fragment was not 
displaced, the functional result was excellent. But 
if the supraspinatus was completely torn away, the 
resulting disability might be serious. Dislocations 
of the shoulder-joint and dislocations with fracture 
of the great tuberosity should be grouped together, 
as they were clinically similar. A very different 
injury was dislocation of the shoulder with fracture 
of the neck of the humerus. Early forced passive 
movement was just as disastrous in shoulder disloca- 
tions as it was in elbow dislocations. Myositis 
ossificans was often seen in badly treated dislocations 
of the shoulder. When the great tuberosity had 
been torn off, the fragment of bone was usually large ; 
it was found to have been completely reduced when 
the dislocation was reduced. Avulsion of the supra- 
spinatus was of great importance and it could not 
be diagnosed until after mobilisation was begun. 
It was then found that active abduction was recover- 
ing more slowly than passive abduction ; if the deltoid 
was scen to be contracting normally the diagnosis 
was then clear. It was essential to support the 
arm in a frame with 90° of abduction until active 
movement was restored. Dislocations and fracture- 
dislocations of the shoulder were often complicated 
by nerve lesions; in this series 1 in 7. They were 

usually traction injuries. An analysis showed that 
the circumflex nerve was most commonly involved, 
next in frequency the posterior cord of the plexus 
and the musculo-spiral. Usually the lesion was a 


ROYAL SOCIETY OF MEDICINE: ORTHOPAEDICS 


[maron 14,1936 603 


physiological block, not a complete nerve severance ; 
it was not surprising that nearly every such case 
recovered after expectant treatment. | 

It had been customary, said Mr. Watson Jones, 
to divide fractures of the neck of the humerus into 
fractures of the anatomical neck and fractures of 
the surgical neck, but this he regarded as of no 
value. One natural group was that of fractures 
produced by a direct blow on the point of the shoulder 
—i.e., a crack fracture of the neck of the humerus, 
as a rule, subperiosteal and without displacement, 
and usually associated with a comminuted fracture 
of the tuberosity. Treatment and prognosis here 
were the same as in fractures of the great tuberosity 
without displacement. Another group was the 
adduction fracture, the arm being carried inwards. 
In the elderly patient the adduction fracture should 
be left impacted, active movement being begun at 
once; in younger patients the fracture should be 
manipulated and treated in an abduction frame. 
A third group was the abduction fracture, with inward 
angulation, the great tuberosity as a rule being 
fractured and pinched off. In some cases the 
tuberosity might not be completely detached, the 
head being rotated far out. In such a case, after 
reduction of the fracture, the surgeon might be forced 
to immobilise the limb in the abducted externally 
rotated position. If that was done, traction was 
essential in order to prevent the shaft from sliding 
back again under the head. Turning to fracture- 
dislocation, the impacted type could not possibly, 
he said, be reduced by manipulation. If it was to be 
reduced at all it must be operated upon, the head 
disimpacted from the shaft, and the tuberosity 
replaced. After the Nicola operation, if the proximal 
fragment bearing the articular cartilage was completely 
deprived of blood-supply, aseptic necrosis might cause 
arthritis and ankylosis of the joint. In the unimpacted 
fracture-dislocation it was well to attempt manipula- 
tive reduction. In a dock labourer, aged 42, this 
treatment had restored him to his heavy work with 
normal range of movement in all directions. Where 
aseptic necrosis had caused degenerative arthritis 
without ankylosis it was advisable to perform 
arthrodesis. In a doctor, after freshening of the 
surfaces, he drove a bone-graft through the head 
of the bone into the glenoid, and the patient still 
remained an expert boxer. In conclusion, Mr. Watson 
Jones said that the neck of the humerus was a common 
site for secondary neoplasms, and pathological 
fractures were sometimes mistaken for simple ones. 


DISCUSSION 


Mr. C. H. FRAnKav did not agree with Mr. Perkins 
that fractures of the neck of the humerus with dis- 
placement required operation. His practice had 
been to keep such cases. immobilised for six days, 
simply bandaging the arms to the sides, and afterwards 
starting active movements and gentle massage. 


Mr. II. A. T. FAIRBANK was glad that both openers 
had emphasised the drawbacks of abducting most 
of these fractures. He had often seen cases in which 
abduction had worsened the condition of the fracture. 
His own practice was to abduct the arm a little 
by a pad in the axilla. ` He had been impressed by 
the fact that displacement of the great tuberosity 
was unimportant. 


Mr. A. S. BLUNDELL BANKART said that for many 
years he had been treating fractures of the neck 
of the humerus in old people by immediate active 
movements; this had given practically complete 
mobility of the joint. 


604 THE LANCET] 


Mr. N. L. CAPENER said that sometimes fracture 
of the greater tuberosity led to supraspinatus strain ; 
this muscle was apt to contract, and, lying so deeply 
as it did, the effect was difficult to counteract. The 
result was some limitation of horizontal flexion, 
with inability to get the arm across the shoulder. 
The patient should be required to practise touching 
the opposite shoulder. 


Mr. ALAN Topp said the abduction treatment 
was useful in some cases. The cardinal principle 
to apply to most fractures in the region of the shoulder 
was to place the greater fragment which was controll- 
able in line with the lesser fragment which was 
uncontrollable. If to abduct the greater fragment 
would cause obvious mal-alignment, then abduction 
was out of place. 


REPLY 


Mr. WaTSON JONES thought it was possible to be 
too enthusiastic in mobilisation of shouider fractures 
on the first day. Where there was displacement 
mobilisation should wait for two or three weeks. 
Torn tissues which were moved too much would 
repair with a greater amount of scar tissue. Mobilisa- 
tion of fingers, wrist, and elbow should start at once. 
The stiffest shoulder was found in the patient with 
stiff fingers. 

Mr. PERKINS remarked that movement should be 
begun as soon as possible. In fractures around the 
shoulder-joint it was better to forget the bone and 
treat the injury as if it was a bruise. 


SECTION OF THERAPEUTICS AND 
PHARMACOLOGY 


AT a meeting of this section held on March 10th, 
with Dr. DorotHy HARE, the president, in the chair, 
a discussion on the 


Treatment of Addison’s Disease with Salt 


was opened by Dr. GEORGE GRAHAM. In outlining 
the development of this treatment, he said that 
Loeb in 1932 had made a complete analysis of the 
base and acid radicles of the blood in Addison’s 
disease, and shown that there was an escape of 
sodium, and with it of chlorine, from the blood 
when the adrenals were removed. Since that time 
Addison’s disease had been treated with salt. It 
was as if there were a leak through which sodium 
escaped from the body. It could be controlled by 
giving cortical extract or by adding more sodium 
to the reservoir. Patients immediately showed 
improvement when salt was given to them, and some- 
times they could give up their extract altogether or 
reduce the dose. Dr. Graham then described five 
cases treated at St. Bartholomew’s Hospital in the 
last two years. One had died in a few days without 
investigation. Two others had gone out of hospital 
much improved after salt treatment and had then 
died within a few days of contracting a febrile illness. 
It was important to keep in touch with these patients 
and to make those in charge of them realise that 
when they contracted feverish illnesses their dose of 
salt or cortex must be increased, just as the diabetic 
needed special care in such circumstances. One 
patient, a man of 34, had had typical Addison’s 
disease with much pigmentation, a blood pressure 
of 80/50, and a blood sodium of just under 300 mg. 
per 100 c.cm., and had been vomiting excessively, 
very weak, and quite unable to sit up. After a single 
dose of salt he had felt very much better and had 
sat up and read the paper. 


ROYAL SOCIETY OF MEDICINE : THERAPEUTICS AND PHARMACOLOGY 


[MARCH 14, 1936 


Dr. S. LEvy Srypson pointed out that the high 
cost, the weak concentration, and the necessity for 
injections constituted serious disadvantages to cor- 
tical treatment. Salt treatment was based on sound 
experimental and biochemical work and had been 
received with enthusiasm. Experience had, how- 
ever, revealed its limitations. He described six 
cases of Addison’s disease which illustrated the value 
and limitations of salt therapy, and drew the follow- 
ing conclusions: (1) salt by mouth might be of real 
value in the acute, subacute, and chronic phases of 
Addison’s disease ; (2) salt might be of no apparent 
value or the benefit might be so slight as not to 
be appreciated by the patient; (3) the emetic action 
of the chloride might prevent the oral administration, 
but sometimes salts of sodium other than the chloride 
might be satisfactorily substituted to overcome this 
difliculty ;; (4) 10 g. of salt daily was as much as 
most patients could possibly take, but sometimes 
20 g. or more were necessary; (5) cortical extract 
in adequate dosage by itself or in addition to salt 
therapy gave a much better clinical response than 
salt alone; (6) when the dose of cortical extract 
was adequate the addition of salt was of no benefit— 
this was in keeping with work on adrenalectomised 
animals; when, however, the dose of cortical extract 
was inadequate, the addition of salt might help 
appreciably ; (7) when patients had gone into a 
crisis in spite of having large doses of salt, the adminis- 
tration of cortical extract had produced recovery ; 
(8) it was possible to get signs and symptoms of 
adrenal insufficiency although the serum level of 
sodium, chloride, and potassium appeared to be 
within normal limits. These conclusions were in 
keeping with experimental evidence. The cortical 
hormone was now known to regulate the balance of 
sodium chloride and other minerals. Cortical extract 
aided the sodium leakage by repairing and stopping 
the leak, but administration of salt was nothing but 
a frantic effort to keep pace with the abnormal loss. 
The control of leakage by cortical extract could only 
be a question of dosage, but the large doses necessary 
for more severe cases rendered the use of extract 
difficult and sometimes impracticable. No one could 
be satisfied with the concentration of the extract at 
present available, but with the crystallisation of the 
essential element there would, Dr. Simpson believed, 
be no other treatment for Addison’s disease. 


Dr. E. N. ALLOTT described eight cases which he 
had seen from the beginning of their treatment. 
Some cases had normal blood-urea readings; a 
normal blood-urea was not incompatible with Addi- 
son’s disease. He submitted charts showing the etlect 
of treatment on the urea, the potassium, the sodium, 
and the chlorine in the blood. One patient who was 
having a huge dose of cortical extract, up to 60 c.cm. 
a day, had shown a reduction of the blood potassium 
only when salt was added to the cortical treatment. 
Ilis sodium and chlorine figures had never reached 
normal, During a crisis there was a fall in the sodium 
and chloride and a marked rise in the potassium. 
Curiously, the urea had fallen in the crises he had 
investigated. Dr. Allott concluded from his study 
of the chemical changes in the blood that the syndrome 
of low sodium and chlorine and high potassium was 
found in all cases, and that treatment with salt 
alone did not in all cases restore the blood picture 
to normal and keep it so. Cortical extract seemed to 
affect the potassium and urea much more than the 
sodium and the chlorine. Sometimes there was 
evidence of blood dilution as revealed by a fall in 
the serum protein and hawmoglobin. Two interesting 


THE LANOET] 


cases had been admitted to hospital for quite dif- 
ferent conditions. In both of them adrenal insuff- 

ciency had been diagnosed by blood chemistry and 
confirmed by post-mortem examination. One was a 
woman who had suffered from very severe vomiting 
which had been regarded as hysterical and not taken 
seriously until her systolic blood pressure had been 
found to be 70. She was almost moribund on admis- 
sion to hospital, although she showed no pigmenta- 
tion, and had died before any treatment could be 
instituted. At autopsy her suprarenals had been 

= found to be quite atrophic. The second patient 
had been diagnosed as cancer of the stomach and had 
shown the typical blood picture. The only pigmenta- 
tion he had shown had been a patch over the spine 
of each scapula. An important point for diagnosis 
was that in Addison’s disease the fall was much more 
.a fall in sodium than in chlorine, whereas in uremia 
the fall was more marked on the chloride side than 
on the sodium side. The typical blood picture was 
not found in other conditions such as lung abscess, 
cancer, and hzemochromatosis. 


Dr. GRAHAM observed that the really important 
thing was to obtain a cheap cortical extract. If it 
‘were not so expensive at present, no one would think 
of using salt. l 


The Vitamin B, Content of Human Diet 


Dr. AUDREY BAKER read a paper by herself and 
Dr. Margaret Wright on an estimate of the amount 
of vitamin B, provided in certain standard diets. 
‘Cowgill, she said, had made the first estimate of this 
vitamin by determining the minimum amounts 
necessary for dogs, pigeons, rats, and mice. He 
had devised a formula relating the amount to the 
body-weight and the calorie intake : 

Vit, =_3217_ e Wi 
Cal, 115,000 
It was nowadays possible to make an assay of food- 
stuffs against the international standard unit, and 
to get an idea, not only of the beri-beri threshold, 
‘but also of.the intake necessary for the maintenance 
of good health. Dr. Baker first of all considered a 
number of diets which were known to have been 
associated with outbreaks of beri-beri. When the 
amount of vitamin B, in these diets was worked out, 
it was found to vary from 71 international units 
to 382. Over 4000 cases of beri-beri had occurred 
in a few months in Bilibid prison, Manila, and the 
‘diet contained only 71 international units per person 
per day. The diet in the prison had been improved 
to 163 units but beri-beri, although reduced, had not 
‘been entirely stamped out. On a diet containing 
122 units in Java prisons there had been some cases 
sof beri-beri. In an Irish asylum 106 per 1000 of the 
patients had contracted the disease although their diet 
contained 438 units; it was, however, thought that 
the patients had not eaten all that was provided for 
them. There had been a thousand cases of beri-beri 
in the Dutch East Indian navy on a diet containing 
‘90 to 180 units; when this was improved so that it 
‘contained 253 units it had protected natives but not 
“Europeans. It was clear that no one specific intake 
protected all individuals; the vitamin allowance 
must be related to the weight and calorie intake. 
A diet which would protect from beri-beri might 
contain anything from 145 to 500 international units 
-per person per day according to the weight and 
diet. 

It was interesting to see what allowance of 
vitamin B, was obtained on various diets which had 


/ 


ROYAL SOCIETY OF MEDICINE: THERAPEUTICS AND PHARMACOLOGY [marca 14,1936 605 


been published. Barborka’s skeleton diet had 343 
units per person per day. The B.M.A. specimen bare 
ration gave 212 units on a basis of 3460 calories, 
but the committee stated that they thought that 
this diet was deficient in vitamins. The B.M.A. 
individual diet No. 2, described as typical for the 
working-man with adequate income and sufficient in 
vitamins and minerals, yielded 440 units for 3060 
calories. Barborka’s typical diet included ‘“‘ cooked 
cereal” and, according to the cereal selected, gave 
from 463 to 743 units. 

The question of children’s needs was a more difficult 
one. Judging from published diets, a higher level of 
B, was desirable. The B.M.A. diet for a child from 
3 to 6 gave 298 units for 2089 calories. Sample diets 
by Simmonds gave from 376 to 393 for children of this 
age and from 606 to 657 units for a child of 11. The 
Ministry of Health’s advisory committee on nutrition, 
in its report on Poor Law children’s homes, gave a 
2749-calorie diet which yielded 450 units of B, per 
child. 


Diets which were definitely stated to be high in 


vitamin contents gave larger figures. Barborka’s 
high vitamin diet represented 872 to 1012 units and 
Simmonds’s from 693 units upwards, while the highest 
of all was that recommended by Theobald for preg- 
nancy toxæmia: 1520 units. Experimental animals 
showed clearly that more B, was needed in pregnancy : 
three to five times as much as the normal. There 
was therefore a wide difference between the pro- 
tective level and a really high vitamin diet. In the 
intermediate zone the B, content of a mixed diet 
depended on an informed selection of foodstuffs. 
Such factors in the rejection of food as dislike, 
indigestibility, economy, or difficulty of preparation 
might reduce the content below the level of the 
physiological requirements for health. 


ROYAL MEDICAL BENEVOLENT FuND.—The hun- 
dredth annual general meeting of the Fund will be 
held on Tuesday, March 24th, at 5 P.M., at ll, 
Chandos-street, London, W., when Sir Thomas Barlow, 


F.R.S., the president, will take the chair. 

At a recent meeting of the committee 13 new applicants 
were helped and 29 grants were renewed. In all £1029 
was voted. The following are particulars of a few cases 
helped. ` 

A. B., aged 77. Retired from practice in 1925. Is now 
suffering from arthritis and severe sciatica and finds walking 
dificult. His savings are exhausted and he is living with his 
married son whose means are only £2 a week. The Fund 
voted an emergency grant of £5 and a maintenance grant of 
£40, payable in four instalments. 

Widow, aged 36, of M.B. who died last year leaving her 
and their two children penniless. The widow. is to take up 
training in chiropody and the tund voted a maintenance grant 
of £36, payable in four instalments. The Ladies’ Guild will 
help in the educational expenses of the children. 

C. D., aged 79, has outlived his savings and finds it extremely 
ditlicult to get posts as locum tenens. Fund voted £40, payable 
in four instalments. 

Daughter of doctor, aged 63. Suffering from tuberculous 
mesenteric glands. Lives in Switzerland for the sake of her 
health. A grant of £26 was voted by the Fund towards her 
medical expenses. 


The son of a deceased medical practitioner aged 88, 
who was in receipt of a Fund’s annuity till his death this 
year, writes: . 

“May I take this opportunity, once more, of thanking the 
committee for the manner in which my father’s annuity from 
the Fund was administered. It was very largely instrumental 
in making his closing years comfortable and peaceful.” 

As this is the centenary year of the Fund a special 
appeal is being made for new subscribers to carry on the 
work begun a-hundred years ago. Since then over 
£398,000 has been distributed in charitable allowances. 
Cheques should be sent to the hon. treasurer of the Fund, 
11, Chandos-street, London, W.1. 


606 THE LANCET] 


MEDICAL SOCIETY OF LONDON 


[mance 14, 1936 


MEDICAL SOCIETY OF LONDON 


AT a meeting of this society on March 9th the 
chair was taken by Sir Tuomas DUNHILL and a 
paper on 

Phlebitis and its Treatment 


was read by Mr. A. Dickson Wricut. The terms 
thrombosis and phlebitis were virtually synonymous, 
he said, since the former was almost an inevitable 
result of the latter, while some amount of reactionary 
phlebitis always accompanied thrombosis. ‘There 
seemed to be no one special organism or cause 
associated with phlebitis, and organisms had never 
been convincingly cultivated from the vein. On 
the continent there had been an endeavour to class 
phlebitis as a metabolic disease, caused by cholesterin 
and treated with light-hearted endocrine cocktail 
mixtures, often combined with the rather fantastic 
ritual of Bagnolles spa. Since 99 per cent. of phlebitis 
was in the legs the one common etiological factor 
seemed to be stasis. 

Certain forms of phlebitis could be regarded as 
parts of definite primary disease syndromes. Essential 
thrombophilia was a rare disease of great gravity with 
a tendency to affect the arteries as well as the veins. 
Farombophlebitis migrans was a febrile disease of 
long duration occurring in the extremities of persons 
with low blood pressure. It was not dangerous or 
disabling and rarely extensive, for only small vessels 
were involved. When focal sepsis had been removed 
the patient should go away to a healthy bracing 
place and not be kept in bed. Ephedrine should 
be given to raise the blood pressure and enough 
thyroid to produce a mild toxicosis. Nevertheless 
every disease had its malignant forms, and in 
this condition the kidneys might become infarcted 
and pleuropneumonia might develop. Traumatic 
phlebitis was the result of injury to superficial veins. 
It might occur in the axillary and subclavian veins 
as the result of carrying weights or of injuries through 
downward snatching. Prognosis in these cases was 
poor if the cephalic vein could not empty into a 
patent subclavian vein. If there was associated 
brachial paralysis the inflamed vein should be dis- 
sected out from the nerve bundle. Philebitis was a 
usual protective process in the neighbourhood of 
suppuration but if the clots themselves suppurated 
the condition became serious. This might be seen 
in the jugular vein in mastoid disease, the superior 
mesenteric vein in appendicitis, and the facial veins 
in carbuncle of the lip. A few cases had followed 
the injection of contaminated solutions into varicose 
veins. Proximal ligation was satisfactory and was 
sometimes combined with evacuation of the suppurat- 
ing clot. Buerger’s disease was an affection of the 
superficial veins of the leg and eventually of the deep 
veins also. In time the arteries might show an 
affection. Mesenteric thrombosis was often due to 
venous rather than arterial thrombosis and tended 
to occur in portal obstruction and after removal of the 
spleen. Familial phlebitis might take any form and 
post-operative thrombosis and embolism also ran in 
families. 7 

SECONDARY PHLEBITIS 


The vast majority of cases belonged to the secondary 
group and might follow a medical, obstetrical, or 
surgical illness. All prolonged prostrating illness 
was apt to be complicated by phlebitis—e.g., typhoid, 
pneumonia, influenza, and malaria, in that order of 
frequency. Rheumatic and typhoid fevers were the 
only cause of juvenile femoral thrombosis. Coronary 


thrombosis .was often followed and occasionally 
preceded by a femoral thrombosis and this condition 
might also be seen in pregnancy when thrombosis 
of normal and varicose veins was quite common. 
The largest number of all forms of secondary phlebitis, 
however, came under the heading of puerperal. The 
term phlegmasia alba dolens should be reserved for 
femoral thrombosis. A solution of this complaint 
was still awaited. Of the surgical causes, post- 
operative cases provided the bulk and appendicitis 
headed the list. Other operations of evil effect were 
cholecystectomy, hysterectomy, prostatectomy, and . 
gastric procedures. Certain countries had a bad 
reputation for this disease and operations on the leg 
veins had a high incidence ; no doubt the tourniquet 
was a fruitful cause. Fractures of the legs and pelvis 
also produced thrombosis. 

Phlebitis in the legs could be classified as superficial 
and deep vein thrombosis. The latter was the more 
serious and its appearance was a catastrophe in any 
case. It was contributed to by changes in the blood 
—e.g., increased coagulability, increase in blood- 
platelets, increased viscidity from dehydration, and 
increased sedimentation-rate; and by retardation 
of the blood flow due to the position of the patient, 
increase of abdominal tension or restriction of the 
respiratory movements. Nothing could be done to 
return the blood to normal and the injection of anti- 
coagulants was rather disappointing. Much, however, 
could be done to remove retardation of flow. The 
Fowler position was bad; it should be maintained 
with a foot-rest and not a knee pillow and dispensed 
with as soon as possible. It caused stasis in the veins 
and the lower limbs. Tight bandaging and meteorism 
restricted the venous return and peritoneal pain or 
rigidity of the chest wall restricted respiratory 
movements. Deep breathing exercises were very 
valuable. The leg should be examined regularly 
from the fifth day until getting up, and early sitting 
out after operation and childbirth had much to 
recommend it. All precautions should be doubled 
if there was a personal or family history of phlebitis. 


TREATMENT 


Posterior tibial phlebitis should be treated by 
binding the leg with Elastoplast from toes to groin ; 
this sometimes avoided a femoral extension. Femoral 
thrombosis caused swelling often heralded by low 
pyrexia and steadily increasing pulse. The pain 
was sometimes agonising. The patient should be 
kept horizontal with the leg in a Thomas’s splint on 
a Souttar’s beam, and fluid should be given 
abundantly. Citrate was valueless as, contrary to 
current belief, a large dose was a powerful coagulating 
agent. A thyroid high-protein diet was valuable- 
if a definite degree of thyrotoxicosis was produced. 
Local applications were valueless, but a cooling 
friction of menthol in methylated spint was 
an excellent placebo. Adhesive strapping some- 
times enabled the patient to get up as early as the. 
third week and generally before the sixth. 

Superficial phlebitis might be simple or ascending. 
The latter was more vicious and characterised by a. 
good deal of pain, pyrexia, inflammation, and peri- 
phlebitis. This type of case had provided the few 
embolic fatalities after injection treatment of varicose 
veins. Superficial phlebitis was much more often 
a spontaneous complaint than the deep variety and 
the main predisposing cause was previous phlebitis, 
Especially common was inflammation of the collateral 
varicose veins which developed many years after 
femoral thrombosis. Tocal sepsis should be sought 
in every case. <A large amount of superficial phlebitis 


THE LANCET] 


could be prevented by the early and adequate treat- 
ment of varicose veins. Superficial phlebitis was 
an innocuous complaint in an ambulatory subject 
but had a definite risk when the patient was in bed. 
Any fluctuant swelling in the veins should be aspirated 
and then 2 in. strips of adhesive plaster, }in. wide 
with chamfered edges, were stuck over the affected 
veins at the upper end of the clot and the whole 
leg bandaged tightly, from the toes to an upper 
Sorbo safety pad applied above the clot to prevent 
its wandering upwards. In ascending phlebitis the 
pressure applied should be greater and the rubber pad 
of double thickness. Most cases cleared up in a 
fortnight. In both simple and ascending types the 


patient must be kept about, even if he had fever. 


The bandaging prevented embolus. In 500 cases this 
treatment had always given excellent results. Embolo- 
phobia was a real trouble to many patients, and 
those who found their phlebitis treated thus lightly 
were most grateful. 

DISCUSSION 

Dr. A. P. CAWADIAS complained that Mr. Dickson 
Wright had dwelt too much on the metabolic element 
of phlebitis. No one on the continent thought that the 
condition was due to abnormal cholesterol metabolism. 
The pituitary gland had a certain regulating rôle on 
the metabolism of the vessels, and patients with phle- 
bitis often had pituitary syndromes. The incidence of 
phlebitis in families showed, however, that the 
metabolic element existed and was important. 
Physicians should search for this element because 
much of the future therapy of phlebitis depended 
upon knowledge of it. Physicians and not surgeons 
saw such conditions as gouty phlebitis. The medical 
treatment was the same as the treatment of the 
sequele. Preparations of pancreas, pituitary, and 
parathyroid were not very helpful and endocrine 
therapy must be designed on the endocrine formula 
of the individual patient. Physical treatment was 
most important, especially with infra-red radiation. 
Balneotherapy had proved useful, and the best drugs 
‘were such preparations as hamamelis, hydrastis, and 
pulsatilla. 

Mr. W. McKim McCotiraGuH said that death-rates 
from this cause varied greatly in different hospitals. 
Where deaths were frequent they might be due to 
improper aseptic technique or improper preparation 
-of the skin. The maternal death-rate from embolism 
was 6-8 per cent. of the total in England and Wales. 

Mr. C. P. G. WAKELEY said that in listening to 
Sir Bernard Spilsbury’s Harveian oration on pul- 
monary embolism a few years ago, he had been 
astonished to hear that sepsis played no part. He 
recalled vividly a patient of his who had been 
operated.on for hernia and had had a femoral throm- 
bosis which had passed up the inferior vena cava. 
He had suffered from glycosuria which had been 
taken to be due to thrombosis. This had suddenly 
-ceased and he had recovered. Thrombi could pass 
up the inferior vena cava and into the heart without 
killing the patient immediately. l 

The CuarrmMan said that one of his problems was 
the devastating sequel to a simple appendicitis when, 
just as the patient was about to go home, the surgeon 
found that phlebitis had set in, there was a pulmonary 
-embolism and the patient sat up and died. One 
woman, with a successfully operated diaphragmatic 
hernia, had done this as she was taking her first good 
meal. Ligation of the large veins above the clot 
seemed useless. The patients who caused him 
-anxiety were those who came to the out-patient 
-department with a swollen shoulder and a cyanotic 
-arm. They all cleared up in the end but were terrify- 


MEDICAL SOCIETY OF LONDON 


[mARcH 14, 1936 607 


ing in the beginning. He could not believe that all 
these conditions were due to strain. 

Mr. A. C. PALMER remarked that of the 18 cases in 
his department in 18 months, not all were due to 
grave conditions ; some had followed curettage and 
one an examination under an anesthetic. He had 
come to the conclusion that sepsis played a very 
minor part and that perhaps the most important 
factor was slight trauma associated with personal 
peculiarity. 

Dr. MONTAGUE SMITH related a case in which an 
elderly man had died after an operation for a growth 
of the sigmoid. There had been no question of 
sepsis there. He wondered whether patients with 
a protuberant abdomen and great long veins were 
more liable. Some work would be necessary in future, 
on the lines of Mr. Wakeley’s remarks, to determine 
the real cause of the terrible occasional cases of 
pulmonary embolism. 

Dr. A. H. DoUTHWAITE observed that the main 
point of the rare condition of thrombophlebitis 
migrans was the pulmonary complication : the 
clotting or phlebitis in the small pulmonary veins 
which caused agonising crushing pain in one side 
of the chest and complete immobility, but no spitting 
of sputum or blood. Some femoral thromboses 
associated with cancer of the stomach were primarily 
thromboses in the inferior vena. cava. He also had 
been astonished to hear that sepsis played no part. 
The temperature in these patients never quite settled 
after the operation, and this was suggestive of sepsis.. 
Physical treatment was important after the operation 
and every patient, especially after abdominal surgery, 
should be given massage of the legs or movements 
and static traction of the thigh muscles 24 hours after 
the operation, 

Mr. C. Hore CARLTON drew attention to the 
associated problem of septicemia, and quoted the 
case of a Chinese with an enormous carbuncle who 
had developed basal pleurisy. The acute phlebitis 
of the penis occasionally seen in prostatic cases was 
nearly always fatal; he asked for advice on treat- 
ment. In some severer cases of femoral thrombosis, 


_ especially where bladder drainage was being carried 


on, 1t was impossible to get the patient up. 

Mr. D. H. PATEY remarked on the difficulty of 
estimating whether the forms of treatment suggested 
by Mr. Dickson Wright were of any value since the 
incidence of pulmonary embolism was so relatively 
small. He doubted whether deep breathing exercises 
would make the diaphragm move; some radioscopic 
observations he had made indicated that they would 
not. 


Mr. DicKson WRIGHT, in reply, said he thought 
the good results claimed at Bagnolles probably had 
a large psychic element. There was no evidence that 
phlebitis had a pituitary origin and he doubted whether 
it would ever be shown to be due to endocrine 
disorder. A patient with an acute suppurative 
appendix was more likely to get thrombosis after 
an operation than one with a clean appendix. The 
immediate cause was probably increased sedimenta- 
tion-rate. Obesity was an important predisposing 
cause. Penile thrombosis after prostatectomy was 
part of an extensive thrombosis which was well 
known as a sequel of this operation. Draining the 
bladder need not interfere with getting the patient 
out of bed for several hours a day. Ligation was only 
indicated in suppurative phlebitis; varicose veins 
were ligated to produce thrombosis. Still more 
foolish was the practice of excising a mass of inflamed 
varicose veins, 


608 THE LANCET] 


[marncH 14, 1936 


REVIEWS AND NOTICES OF BOOKS 


1935 Year Book of Urology 


By Joun H. Cunnineuam, M.D., Associate in 
Genito-Urinary Surgery, Ilarvard University Post- 
graduate School of Medicine. Chicago: Year Book 
Publishers; London: H. K. Lewis and Co., Ltd. 
1936. Pp. 462. 9s. 6d. 


THERE must be few tasks more difficult to discharge 
with success than the editing of a volume reviewing 
advances in a branch of medicine that is growing 
rapidly. Dr. J. H. Cunningham has shown skill in 
eliminating papers that, while interesting enough, 
throw no new light on the problems of urology, and in 
including in his volume all those which are of real 
importance. The chief trend of the 1936 volume is 
thus to concentrate on significant papers and to 
quote fully from them rather than to attempt to 
include isolated scraps from a large number. For 
example, Mr. Swift Joly’s Ramon Guiteras lecture 
on urinary calculus has been reviewed at considerable 
length as an excellent survey of the extiology of 
calculus. The impression left on the reader by this 
Year Book is that urology, having gained its inde- 
pendence as a specialty in medicine, is now beginning 
to develop and maintain a close connexion with other 
branches of medicine during the study of urinary 
problems. As an example may be given our growing 
appreciation of the influence of denervation of the 
adrenals on conditions such as _ neuro-circulatory 
asthenia, hyperthyroidism, peptic ulcer, epilepsy, and 
polyglandular diseases. This new attack upon the 
adrenal nerve-supply comes within the surgical 
province of the genito-urinary surgeon, and it is a 
field of research full of promise. At the same time 
it is noteworthy how great is the help now being 
given to urologists by biochemistry, physiology, and 
endocrinology. 

It would not be remarkable if in a Year Book of 
the literature on any subject edited in America 
contributions of American workers should receive 
special prominence ; the national bias occurs in every 
country. So far as it is possible to do so, Dr. 
Cunningham has avoided undue partiality, and whilst 
including important papers from every country, has 
been particularly generous to British writers. 


Incompatibility in Prescriptions 


Fourth edition. By THOMAS STEPHENSON, D.Sc., 
Ph.C., F.R.S.E., F.C.S., Editor of the Prescriber ; 
sometime Examiner to the Pharmaceutical Society 
of Great Britain. Edinburgh: The Prescriber 
Offices. 1935. Pp. 62. 6s. 


THE medical student has little time to devote to 
chemistry and pharmacy and it is only when he is 
qualified that the subject of incompatibility in 
prescriptions begins to worry him. This book is 
conveniently planned to enable him to get the 
necessary information. It deals largely with the 
chemical and physical aspects of the subject. That 
the present edition has been thoroughly revised and 
brought up to date is evidenced by the notes on 
acetylcholine, acriflavine, benzocaine, calcium gluco- 
nate, and hexyl-resorcinol. The classification of the 
different types of chemical reactions is good and 
serves to emphasise the principles underlying the 
subject rather than to provide a mere list of unrelated 
incompatibles. Much care has been taken in the 
compilation of the examples. Exception might be 


=» 


taken to the inclusion of a statement that magnesium 
sulphate gives a clear solution with sodium 


bicarbonate without a warning that such a mixture 
is liable to explode if kept in a well-corked container, 
A slow evolution of carbon dioxide inevitably occurs 
and the rate of the reaction is considerably increased 
with slight rise of temperature. The prescribing 
together of these two ingredients, particularly in the 
presence of bismuth carbonate, should thus be 
avoided. The need for chemically equivalent 
quantities of potassium iodide and mercuric iodide 
to produce a precipitate should have been emphasised ; 
in mixtures the iodide is practically always present 
in excess. A number of interesting examples of 
therapeutic incompatibility is given and should 
suffice to warn the prescriber of some pitfalls. The 
second part of the book consists of a comprehensive 
dictionary of incompatibles, including many unofficial 
substances. It is to be regretted that luminal sodium 
does not appear under its proprietary name in either. 
the list or the index. | 

The book fulfils its object and can be recommended 
as a useful addition to the practitioner’s books of 
reference, 


Emotions and Bodily Changes 


A Survey of Literature on Psychosomatic Inter- 
relationships, 1910-1933. By H. FLANDERS 
DunzBaR, M.D., Ph.D., Departments of Medicine 
and Psychiatry, Columbia University. New York: 
Columbia University Press; London: Humphrey 
Milford, Oxford University Press. 1935. Pp. 596. 
258. 


Witn medical knowledge, as with the world’s 
food-supply, the problem of distribution is more 
bafflmg than that of production. Distribution is 
greatly facilitated by the volumes of short abstracts, 
which are becoming increasingly numerous and 
popular. This one deals with the old question of the 
relation of body and mind, and attempts to survey 
and present what has been written on it in the last 
twenty years. Part I. deals with the problem in 
general, and with the various physiological methods— 
precise in form but disappointing in result— which 
have been suggested for the investigation of its 
details. Part II., occupying half the book, works 
through the physiological “ systems ”? of the body 
and gives examples of their diseases. Part III. 
is a short section on therapy, and there follows a 
bibliography of 2251 titles. The abstracts are fairly 
full, and quotations and excerpts are freely used. 

The book is offered in the first place to the would-be 
research student as a means of orientation and a guide 
to what has been written. Papers are chosen for 
abstraction because they are interesting, not because 
they are necessarily judged to be sound. In merely 
arranging them the compiler has done a useful service, 


and in his few paragraphs of introduction and 
conclusion he has made the dry bones begin to live. 
His interest is that of the physician more than that 


of the philosopher. He finds that medical men, 
folowing the biologists, are just beginning to study 
the organism as a whole, its internal relationships 
and balances, and its interaction with its environ- 


ment. The antithesis of mind and body in the human 
organism is giving place to an attempted synthesis ; 
diseases and symptoms are no longer to be labelled 


organic or functional (meaning, of psychological 


origin), but in every case the question is to be, “ To 


THE LANCET] 


what extent organic and to what extent functional ? ” 
This point of view is gaining ground in medicine, and 
promises to throw light on obscure diseases as well 
as to broaden the service that medicme can give to 
humanity ; for that reason this book, or parts of it, 
should appeal to workers in many branches of 
medicine. 


I and Me 


A Study of the Self. By E. Granam Howe, M.B., 
B.S. Lond., D.P.M., Associate Physician, Institute 
of Medical Psychology; late Chief Assistant, 
Psychology Department, St. Thomas’s Hospital. 
London: Faber and Faber Ltd. 1935. Pp. 256. 
78. 6d. 


Dr. Howe must be congratulated on a brave 
attempt to solve by a somewhat new dialectical 
method the ultimate problems of thought and 
behaviour. He deals with the problem familiar to 
philosophers of the unity of the self by the proposition 
that all experience tends to be a relation of twoness. 
This concept of relation of two terms as the basis of 
fundamental logical propositions is not, of course, a 
new one, and the resolution of antitheses has baffled 
thinkers since the time of Zeno. Dr. Howe applies 
his theory of unity to such fundamental psychological 
problems as the family and society and continues 
-his exposition by a critical analysis of science and 
modern medicine. He accuses unscientific thinkers 
of idolatry and the competitive faculty which fights 
for half truths, always forgetting the other pole 
of an antithesis. Science, he says, is the study of 
reality as the external, and omits internal conditions 
in their relationship to externals or appearances. The 
truth in science and behaviour can only be reached 
by the resolution of opposites and the path to this 
realisation ends with the life of the Saints; he gives 
St. Francis as the shining example. St. Francis, 
however, was never able to resolve the antinomy 
of love and hate, though it is true that he had the 
capacity to accept both. This does not appear to 
be Dr. Howe’s solution, which implies the resolution 
rather than the acceptance of opposites. Funda- 
mentally his thesis would logically impose upon him 
an Oriental rather than a Western philosophy, and 
his ideal should be not so much a St. Francis as 
Bodhissatva. It is difficult to see what practical 
application this book could have, but no doubt 
Dr. Howe in his next volume will apply his philosophy 
to the actual problems of living. - 


Objective and Experimental Psychiatry 


By D. Ewen Cameron, M.B., Ch.B. Glasg., D.P.M. 
Lond., Physician in Charge, Reception Service, 
Provincial Mental Hospital, Brandon, Man. ; 
formerly Assistant Physician to the Glasgow 
Royal Mental Hospital. New York : The Macmillan 
Company; London: Macmillan and Co., Ltd. 
1935. Pp. 271. 12s. 6d. 


Dr. Cameron opens his work with an apparent 
paradox by stating that the study of psychiatry needs 
dehumanising—freeing from anthropomorphism—and 
that although we are still engaged in the forging of 
experimental instruments, the ideals for all future 
lines of inquiry shall be quantitative, verifiable, and 
repeatable experiments and observations. Medical 
science like the other sciences must free itself from 
animism. And furthermore it must pursue the 
scientific method however much its findings may meet 
the obstacle of prejudice which is raised when the 


REVIEWS AND NOTICES OF BOOKS 


ree 14, 1936 609 


higher functions of the mind are subjected to detached 
scrutiny and analysis. Dr. Cameron holds that we 
must once and for all abandon the dualism born of 
the belief in the inviolate soul and in accepting 
causality and abandoning free will, accept as a fact 
that human behaviour is predictable and con-- 
trollable. Admitting the legitimate claims of gestalt 
and holism, the author believes that the investigation 
of partial processes by quantitative experiment will 
tell us what the organism does, if not what it is, and 
that this should not be summarily dismissed as a 
sterile study. Dr. Cameron then proceeds to discuss 
at length the various partial approaches to the study 
of psychiatry. Particularly interesting is the chapter 
on tests fot intelligence, the subject being approached 
with commendable reserve. The importance of 
environment in determining the quality of the highest 
level reactions is fully recognised. The chapter on 
conditioned reflexes takes the literature well up to 
date, but the one on heredity is all too brief. The 
rest of the book is devoted to recent researches in 
combined psychiatric and pathological studies. 

The volume is well documented chapter by chapter, 
and should be in the hands of those students of 
psychiatry who are interested in the experimental 
approach. ° 


Vitamins in Theory and Practice 


By Lestuir J. Harris, Sc.D., D.Sc., Nutritional 
Laboratory, University of Cambridge and Medical 
Research Council. Cambridge: University Press. 
1935. Pp. 240. 8s. 6d. 


In welding his Royal Institution lectures into a 
book Dr. Harris has given us a popular account of the 
vitamins which, in a fairly small compass, sets out 
most of what a layman ought to know about them. 
The facts are accurately given, though possibly 
over-simplified in certain places. The abandon- 
ment of a dignified style appropriate to scientific 
literature in favour of a more lively and colloquial one 
is a doubtful advantage, and not altogether successful 
here since it seems to involve a definite loss of lucidity. 
A great many well-chosen illustrations are supplied 
and the last chapter entitled ‘‘ Dietetics—What to 
Eat ” is full of interest. It contains some astonishing 
data on the improvement in nutritional condition 
of school-children which has taken place in this 
country since a genuine science of nutrition has 
grown up. Acquaintance with such facts as these 
should hearten all who desire to see progress in 
this direction go still further. 


The Obstetric Pelvis 


By HERBERT THoms, M.D., F.A.C.S., Associate 
Professor of Obstetrics and Gynecology, School 
of Medicine, Yale University. Baltimore: Williams 
and Wilkins Company; London: Bailliére, Tindall 
and Cox. 1935. Pp. 115. Ills. 6d. 


Dr. Herbert Thoms has discovered many points 
of interest about the pelvis in the course of his pro- 
longed and considerable experience. Starting with 
a comparison of the male and female pelvis, he 
describes in detail the three normal types of female 
pelvis that he recognises. IIe notes that the value 
of external measurements of the pelvis has long been 
doubted, and gives much space here to a detailed 
description of X ray technique, with the use of a 
grid, as a more close means of estimating the 
real size and shape of the bony birth canal. It 


610 THE LANCET] 


is of interest that so ardent an advocate of exact 
pelvimetry as Dr. Thoms is constrained to admit that 
the deciding factor is generally in the end the efficacy 
of the uterine contractions. He demonstrates that 
occipito-posterior positions are more likely to be 
found in women, who have what he calls the 
anthropoid pelvis. Final chapters deal with injuries 
and displacements to the sacrococcygeal joint and the 
symphysis pubis. The book is well illustrated and 
makes interesting reading, though most of the subject 
matter is not new. 


Agents of Disease and Host Resistance 


By FREDERICK P. GAY and associates, past or 
present members (with four exceptions) of the 
Department of Bacteriology, College of Physicians 
and Surgeons, Columbia University, New York. 
London:  Baillière, Tindall and Cox. 1935. 
Pp. 1581. 45s. 


Tris is a large and ambitious work devoted to the 
etiology of parasitic diseases in the most general 
sense. It deals comprehensively and systematically 
with immunology, bacteriology, epidemiology, proto- 


NEW INVENTIONS 


[marnoH 14, 1936 


zoology, and helminthology. There are good reasons 
why these subjects should be treated together in 
manuals for the elementary student, but there appears 
no advantage in such an arrangement on a large scale. 
It is clear that the editor has meant to produce a 
“ treatise ” rather than a book of reference. The 
connecting thread which runs somewhat faintly 
through the work is the general pathology of etiology. 
Dr. Gay has been assisted by many specialists, 
chosen mostly from the same medical school in 
order to achieve a homogeneity difficult to secure 
when wisdom is drawn from a wider field. Each 
individual article is well written and no labour has 
been spared in the editorial share. It seems to us 
unlikely, however, that students will attempt to 
read such a long and by no means lightly written 
work with any approach to continuity. Its form, 
moreover, offers little encouragement to the reader. 
The book is heavy to hold and has much small print, 
and rather niggardly margins. As a work of reference 
it is no doubt of value, though since we have already 
many good reference books on bacteriology and 
cognate subjects, it cannot be said to fill a need. 
It is nevertheless a sound and learned production 
which may be consulted with advantage by advanced 
students, teachers, and research workers. 


| NEW INVENTIONS 


SPECIAL CIRCUMCISION FORCEPS 


In the course of running a minor operation clinic 
at Guy’s Hospital where the work is done by dressers 
of little or no experience, it was evident that the 
operation for circumcision entailed under these 
circumstances considerable needless hmemorrhage, 
and the results were to say the least of it inartistic. 

The blind method, where the forceps are applied 
to the intact foreskin, gives a neat result, but in 
theory seems to contravene an essential surgical 
principle that it is as well to see exactly what you 
are cutting before you cut, and in practice, under the 
conditions mentioned above, has occasionally been 
attended with disastrous injury to the glans. 

The method of slitting the dorsum of the foreskin, 
wiping the glans off the adherent foreskin around the 
whole of its circumference and removing it with 
scissors under direct vision after ligaturing the 
frenular artery has been found to be the safest 


FIG. 1.—The circumcision 
forceps. 


method, {but has resulted in a jagged edge, due 
to the uncontrolled cut, and hemorrhage from the 
remaining arteries until these have been secured. 

In order to combine the advantages of the first 
method with the safety of the second the special 
circumcision forceps were designed and proved so 
successful that it was thought their use might profit- 
ably be extended to those with more experience. 


The foreskin is slit along the dorsum exactly in the 
midline as far as the corona, this mancuvre being 
attended by a minimal amount of bleeding. The 
glans is wiped off and the frenular artery secured. 
The special forceps are then applied to the foreskin 
around one-half of its circumference about 34 cm. 


yo 


w ADD J ees 
A Min a re E == == 
i 


— 


al 


Í 
Í 


i `, S| | yo 
~/ ae 


away from the penis as shown in the illustration. 
The foreskin is pared flush with the instrument and 


\ two fine catgut mattress sutures are inserted passing 


through both mucous membrane and skin between 
the forceps and the penis. On removal of the forceps 
there is accurate apposition of skin and mucous 
membrane and generally no bleeding whatever from 
the crushed vessels. The instrument is then reversed, 
the remaining foreskin removed, and two more 
mattress sutures inserted. A sterile finger bandage 
soaked in tinct. benzoin co. and applied to the penis 
completes the operation. 

Dressers performing the operation for the first 
time produce with these forceps a comely effect, 
take half the time, and succeed in letting blood only 
to the extent of just staining their fingers, whilst 
those with a little more experience find it a useful 
and practical method. 

The instrument is manufactured by Down Bros., 
St. Thomas’s-street, London, S.E., and can be supplied 
in any size. 

H. J. B. Artis, F.R.C.S. Eng. 


THE LANCET] 


INDUSTRIAL PULMONARY DISEASE 


[marca 14,1936 611 


THE LANCET 


LONDON: SATURDAY, MARCH 14, 1936 


INDUSTRIAL PULMONARY DISEASE | 


THar the incidence and fatality of silicosis in 
-Great Britain during the last few years is probably 
‘much greater than is suggested by the number 
of notified cases and death certificates is a 
-conclusion that may fairly be drawn from Dr. 
E. L. MippietTon’s Milroy lectures, delivered before 
-the Royal College of Physicians on Feb. 27th and 
‘March 3rd. Silicosis is now recognised as the 
most important of that group of diseases which 
have been termed collectively the pneumono- 
-conioses. In this country it is always the result 
of prolonged exposure to certain kinds of dust in 
the course of occupation. .The chief symptom is 
progressive dyspnea; the chief sign, detectable 
in life by X rays, is the presence of fibrous nodules 
in the lungs, which appear post mortem as palpable 
macroscopic nodules. According to Dr. MIDDLETON 
recourse to histological examination is usually 
necessary for diagnosis only in the presence of 
‘such complications as tuberculosis—by far the 
most common one—and malignant disease. He 
‘pointed out that the presence of tuberculosis may 
render the diagnosis very difficult and quotes 
E. H. KETTLE’S statement’ that since the dif- 
ferential diagnosis depends on the amount and 
distribution of the collagen in the tissue reaction, 
it is a matter of degree. 

Silicosis is not reportable, as are certain other 
occupational diseases, and until a few years ago 
the term had hardly been used for the purpose of 
certifying the cause of death in this country. Since 
the beginning of 1930, by arrangement with the 
Registrar-General, the Home Office has obtained 
copies of the certificates of all deaths due to fibrosis 
of the lungs, silicosis, asbestosis, or pulmonary 
disease due to dust. Dr. MIDDLETON, from his official 
appointment, was thus in a position to collect data 


‘not previously available. During the five-year period 


1930 to 1934 inclusive the number of deaths 


included in the group was 4038. In 1521 of these 


silicosis was mentioned on the certificate as a 
cause of death. The deaths were divided among 
29 industries; the figures remain fairly constant 
for each over the five-year period except for coal- 
miners, who show a steady increase from 41 in 
1930 to 85 in 1934. They head the list with a 
total of 326 deaths for the five years, the next im- 
portant groups numerically being those engaged in 
the manufacture of pottery (270), sandstone 
mmasons (255), metal grinders (142), sandstone 
«quarriers and dressers (117), and gold-miners who 
had returned home from South Africa suffering 
from the disease (104). Analysis of the 270 pottery 
<leaths showed that the occurrence of silicosis 


2 Proc. Roy. Soc. Med., 1933, xxvi., Sect. Path. p. 28. 


among potters is always preceded by exposure to 
flint dust either alone or mixed with clay. The 
actual number of deaths in each industry has of 
course less significance than their proportion to 
the number of workers at risk, but this figure is- 
rarely obtainable. For example, in the census 
of England and Wales for 1931 the total number 
of sandblasters amount only to 1395; 17 of them 
died of silicosis in that year and 45 in the five- 
year period, giving a mortality-rate of 6-4 per 1000 
living, which would be still higher if the census 
figure did not include shot blasters working on 
clean metal who are not exposed to siliceous dust. 
The dust hazard is from the abrasive, usually a 
quartzose sand or crushed flint, which has now 
been largely replaced by metal grit or shot. A 
striking fact which emerges from the investiga- 
tions on sandblasters is the shortness of the period 
of employment which led to death from silicosis, 
compared with other occupations. Another 
industry, the manufacture of abrasive soaps, was 
altogether abandoned at one factory in 1928 owing 
to the death of workers, attributed to inhalation of 
the dust. Out of a total of 81 persons employed in 
the process at this factory, 22 left within two months 
of beginning work, 1 of these dying eight years 
later of tuberculosis. Of the remaining 59 employed 
13 died of tuberculosis or silicosis. In tin-miners 
the 91 men who died of silicosis in the period 
under review represent an annual fatality-rate of 
11 per 1000 wage-earners employed in the industry 
in 1934. Hematite mining, formerly considered 
free from risk, is now known to produce silicosis, 
and during recent years evidence has been accu- 
mulating that certain workers employed in coal- 
mines contract a disabling and even fatal fibrosis 
of the lung. Dr. MmppLETon detailed the processes 
underground in a coal-mine which involve exposure 
to siliceous dust, and noted that between June, 
1931, and December, 1935, the Silicosis Medical 
Board of the Home Office issued 987 certificates 
on account of silicosis in coal-mines ; these included 
237 suspensions, 581 certificates for total disable- 
ment, and 169 for death. In these and other 
occupations in which silicosis, that is, the nodular 
form of pulmonary fibrosis, occurs, the workers 
have been exposed to the dust of free (uncombined) 
silica. There are, however, other industries which 
involve exposure of workers only to combined 
silica in the form of silicates. The type of fibrosis 
produced in the lung by the action of silicates, such 
as fireclay, sillimanite, china clay, tale, and mica 
differs from that produced by free silica, and can 
be distinguished from it by radiological and histo- 
logical means. - The pulmonary symptoms and 
signs arising from exposure to silicates are gener- 
ally slight, asbestos dust being unique amongst 
them for the prevalence and severity of the 
disease which it causes. During the five-year 
period 50 deaths were certified as due to asbestosis. 

In view of the gravity of these scourges it is 
satisfactory to learn from the annual report of 
the Medical Research Council, noticed elsewhere 
in this issue, that their committee on industrial 
pulmonary disease, appointed at the request of 
the Home Office in 1930, have now in progress a 


612 THE LANCET] 


PEPTIC ULCER 


"MARCH 14, 1936 


asked the Home Secretary if he would con- 


carefully planned and codrdinated programme of < 


research. The problem is being attacked from all 
possible aspects—physical and chemical, experi- 
mental and pathological, clinical and statistical— 
since at present preventive measures are severely 
hampered by lack of exact knowledge. Silicosis 
is insidious in its onset, and it is not known how 
much of the dangerous dust must be inhaled, 
and over what period, to produce disabling effects. 
Much also remains to be discovered as to the 
influence—as regards degree of danger—of the 
size-distribution and concentration of the dust 
particles at the time of inhalation. Research into 
the physical nature of the dust clouds capable of 
producing disease was accordingly one of the first 
undertakings of the committee, and this is now 
being pursued by means of a new form of thermal 
precipitator devised by H. L. GREEN and H. H. 
Watson.? More recently the committee have been 
considering the need for further study of the 
chemical properties of dusts arising from industrial 
processes, such as the composition of the particles 
and their solubility under different conditions, 
and this work will be done under the direction of 
Prof. H. V. A. Briscor. Meanwhile, biological 
investigations on the subject are being continued, 
notably pathological investigations of material 
from human cases of industrial pulmonary disease 
and experiments on the different effects which 
dusty atmospheres of various kinds have on the 
lungs of animals. Direct studies of disease in 
the living subject are also being made as oppor- 
tunity offers, but the possibilities of making 
progress in this direction are slight. Most of the 
symptoms produced are not peculiar to disease 
owing its origin to dust, and the question thus 
becomes a statistical one, involving a comparison 
between the incidence of pulmonary disease 
among persons exposed to dust inhalation in their 
occupations and the incidence in the general 
population; but the task of obtaining records for 
strictly comparable groups of people, differing 
only in the one respect of exposure to dust, is 
beset with serious practical difficulties. 

The other side of the problem, which concerns 
the Home Office rather than the Medical Research 
Council, involves the arrangements under which 
victims of industrial pulmonary disease or their 
dependants can obtain compensation from 
employers. A memorandum on the Industrial 
Diseases of Silicosisand Asbestosis issueda year ago * 
gives a succinct account of the various schemes pro- 
viding for compensation and of the medical arrange- 
ments for examination and certification of cases. 
The memorandum states that compensation in 
cases where death or disablement is caused by 
silicosis, or silicosis accompanied by tuberculosis, 
is now payable in all the industries where a serious 
risk of the disease exists. That the mechanism 
is not as smooth as might be desired is plain, 
however, from the periodical complaints in 
Parliament of which the most recent is repoited 
on p. 632 of this issue. Last month 4 Mr. Leacan 


s Medical Teoreareh Council, Special Report Serics No. a 1935. 
3 H.M. Stationery Otce. February, 1935. 4a 
: ae THE LANCET, March 7th, 1936, p. 576. 


sider introducing further legislation to ensure 
prompter and easier certification of cases of 
silicosis in the mining and quarrying industry, 
and to ensure that compensation and measures 
for the recovery of the victims might be 
made more certain; and, as a supplementary 
question, whether he did not agree that ‘‘ both the 
law and the regulations operate very harshly 
towards these poor fellows.” Sir JonHN Smoy, 
in his replies, said that he would be happy to 
consider any suggestion for the improvement of 
the medical arrangements and the procedure under 
the Silicosis Schemes, and that he had the fullest 
sympathy with those who wanted to have the 
whole situation cleared up and simplified. It is 
clearly desirable that medical men should familiarise 
themselves not only with the criteria for the 
differential diagnosis of the various industrial 
pulmonary diseases during life but with the 
present mechanism for obtaining compensation, in 
order that any remediable defects in it may be 
exposed and adjusted. 


PEPTIC ULCER 


Dr. DaniteL Davies has done a service in 
projecting peptic ulcer once more on the screen 
of public attention and interest, for the real 
problem of its cause and mechanism is apt to be 
neglected by those whose first concern is of necessity 
to treat its symptoms and its complications. 
His Bradshaw lecture, which appears in our last 
issue and in this, is a clinical study of 377 cases 
of chronic peptic ulcer, on the features and fortunes 
of which he makes some useful observations. 
He prefaces these by a reference to the experi- 
mentalist’s success, achieved at last, in producing 
chronic peptic ulcer in animals. F. C. Mann 
and „his colleagues diverted the bile and the pan- 
creatic juice in dogs into the lower ileum, and 
half of them developed duodenal ulcers. When the 
duodenal secretion also was diverted, and the 
stomach anastomosed directly to the jejunum, 
jejunal ulcer developed in nearly every animal. 
The ulcers were histologically just like chronic 
peptic ulcers in man, and their occurrence at 
precisely those spots in the intestine on which the 
acid gastric content impinged points very strongly 
to the acidity as a prime factor in their causation. 
Rapidly advancing ulcers could reach the stage of 
perforation in 48 hours, and three weeks was long 
enough for tbe typical appearances of chronic 
ulcer to develop. 

Dr. Davies looks for clinical parallels to these 
phenomena. His figures for gastric acidity 
illustrate the common finding that in patients 
with duodenal ulcer the gastric juice is either 
normal or above normal both in amount and in 
acid concentration. This is usually regarded as a 
constitutional trait of the patient. Dr. DAvIEs, 
however, found a number of cases where the acidity 
appeared to be lower after treatment, and he 
wonders whether it may not often fluctuate more 
than is realised. This question is extraordinarily 
dificult to answer. Even the acid concentration 


o TUTTE o a a a ——_— er 


THE LANCET] 


THE IMPORTANCE OF GONORRHCEA 


i 


[mMarnoH 14, 1936 613 


measured in the ordinary test-meal, depending 
as it does on half a dozen or more variables, is 
not easy to interpret, and no kind of test-meal 
can be expected to give a very accurate picture 
of the acidity to which the duodenal mucosa is 
exposed throughout every 24 hours. HENNING’S 
work?! on the persistent nocturnal secretion of acid 
in patients with duodenal ulcer needs emphasis 
again in this connexion. BLOOMFIELD and 
POLLAND,? advocating the simple examination of 
the pure juice secreted in response to histamine 
are recognising the uncertainties of the test-meal 
methods, and transferring their attention from 
what the stomach perhaps does, to what the 
stomach, maximally stimulated, can do. Their 
method should help to define some of the deter- 
minants of gastric acidity, though it will not 
give a full answer to Dr. Davræs’s question. 
Among the gastric ulcer cases his figures show 
less departure from the normal range than do the 
duodenal ulcer figures, and in both there is so 
much overlapping between normal and abnormal 
groups that the acidity level in any single patient 
is of very little diagnostic value indeed. There 
remains, however, the obvious general relation 
between acid and ulcer, both in man and in the 
experimental animal, and therein lies at present 
the justification for alkalis and other antacid 
measures as a part of ulcer treatment. 

Dr. Davies's radiological findings bring further 
evidence that gastric ulcers often heal—or at 
at least go so far on the way to healing that their 
niches disappear—within a few weeks, and he 
has some Significant examples of the reappearance 
of craters within similarly short spaces of time. 
It is quite likely that the ulcer itself, like the ulcer 
dyspepsia, comes and goes with a mysterious 
alternation. The problem broadens at once. It 
is not a single ulcer that is to be dealt with, but a 
stomach that has developed a habit of ulcerating. 
Is any gastric mucous membrane capable of 
behaving like this? No, only subjects with a 
constitutional proclivity will have ulcers; that 
is the answer of Hurst and those who believe 
with him in ulcer diatheses. More evidence on 
this topic is needed, and it would clarify matters 
greatly if the evidence were presented under 
two headings such as these. First, there are 
observations like the occurrence of ulcers in 
families, from which a constitutional factor may 
be inferred, but not defined. Secondly, there 
are observations such as the commonly accepted 
relationship of high acidity to duodenal ulcer, 
or DRAPER’S anthropometric measurements, which 
go some way towards defining in anatomical or 
physiological terms the constitution in question. 
No diathesis is satisfactorily described until 
-such definition is achieved, and the means by 
which the constitution invites the disease made 
clear. But if we grant the existence of an ulcer 
-diathesis as a working hypothesis, we next inquire 
what sets the stomach ulcerating. Is it a direct 
infection ? No organism has been convicted, but 
-æ virus has not been excluded. Is it toxins from 


Henning, N., Norpoth, L. : Arch. f£. Verdauungskr., 1933, liii., 64. 
3 Jour. Amer. Med. Assoc., 1929, xcii., 1508. 


a distant focus or from without ? Is it an excess 
of mechanical or chemical stimulation? More 
factors than one are likely to be involved and 
among them Dr. Davis stresses the psycho- 
logical one. In general he thinks the increasing 
incidence of peptic ulcer may be related to the 
increasing psychological strain of modern town 
life ; in particular he quotes many examples of the 
development or recurrence of ulcers following 
emotional upsets and strain. He pleads, therefore, 
for “a treatment which is wide enough to envisage 
the whole man and his environment.” It may be 
more important to lessen anxiety or limit responsi- 
bility than to diminish acidity. The weeks in 
bed insisted on by most régimes for the medical 
treatment of ulcer usually achieve this, if only 
incidentally and temporarily. Dr. Davis, obliged 
to treat his patients ambulant, has no doubt 
dealt with their psychological problems more 
directly and less short-sightedly, for his results 
so far as they can be assessed at this stage are 
not unsatisfactory. He ends with another protest 
against the hard demarcation of “functional ” 
from organic disease ; he is right, and the doctrine 
needs more preaching, for it is so easy to acquiesce 
in and so difficult to practise. 


THE IMPORTANCE OF GONORRHEA 


THE high incidence of gonococcal infections in 
all civilised communities and the relative failure 
of measures by public health authorities to check 
or control their spread are facts which the lay 
public and most of the medical profession seem 
to view with indifference. Gonorrhcea is not a 
spectacular disease. Its emergencies are few and 
its mortality negligible. Its victims do not make 
themselves conspicuous. Yet there can be few 
diseases which bring in their train such misery and 
wretchedness, so much ill-health and incapacity, 
so many permanent ill-effects on mind and body. 
Far more often than not, it affects the young, 
the strong, the producing section of the community ; 
and its total cost to any nation is beyond computa- 
tion in terms of public health estimates. 

Many factors have combined to negative the 
efforts which have been made and are being made 
to cope with this disease. The absence of a 
specific remedy, the necessity for concealment, 
the lengthy and dispiriting treatment, family 
reinfections and inadequate standards of cure, 
are real bars to progress. But perhaps the lack 
of inspiration and encouragement to the aspiring 
investigator—a lack which reflects the popular 
appraisal of the problem—has done more than 
anything else to produce what PELOUZE describes 
as almost twenty years of stagnation of scientific 
and clinical interest. Recognition of this need for 
coordination and stimulation of research led to the 
appointment in the United States in 1932 of a 
Committee for the Survey of Research on the 
Gonococcus and Gonococcal Infections. The report 
of this committee, which is issued as a supplement 
to the January number of the American Journal 
of Syphilis, Gonorrhea and Venereal Diseases, 
reflects great credit upon the assiduity and 


614 THE LANCET] 


discrimination of those concerned in its preparation, 
and will be found directly valuable by all who 
have to treat gonococcal infections. The nature 
and the magnitude of the problem is indicated by 
the estimate that in the United States alone there 
are a million cases a year. The committee’s 
contribution towards a solution consists in the 
first place of a statement of the biology of the 
gonococcus, presenting the known and accepted 
facts with a critical summary of what has been 
written on the subject in the past five or six years. 
Some 50 further pages are devoted to the results 
of research into gonococcal infection in man, and 
here the compilers are able to maintain the same 
keenly critical attitude—except occasionally, and 
naturally, in relation to the investigations of 
workers with whom they are in close contact. 
Finally the report contains a summary, a discussion, 
conclusions, and suggestions for future develop- 
ments. A study of the document as a whole 
must convince the reader that its authors are 
right when they deplore the confusion of thought 
over tbese problems, the lack of unanimity on 
fundamentals, and the fact that conclusions are 
often drawn and defended on wholly inadequate 


THE RADIOLOGIST’S PROPERTY IN HIS NEGATIVES 


[MARCH 14, 1936 


grounds. They also note that there is muck 
wasteful overlapping of effort by research workers,. 
and where, as often, this is due to their being out 
of touch with current publications, the present 
report will do much to remedy the deficiency. 
Financial and other facilities are held to be 
insufficient, and it is remarked that many who 
receive an adequate preliminary training in this 
type of work pass on, through force of circumstances 
and often through no wish of their own, to other 
spheres of labour. The committee thinks it probable 
that less than ten centres in the whole of the United 
States are engaged in serious study of gonorrhea, 
Few will deny that these criticisms and 
conclusions are equally applicable to the state 
of affairs in this country, and it is to be hoped 
that signs of awakening interest abroad may lead 
to a more general realisation of the importance 
of the problem here. The encouragement, coördina- 
tion, and financing of inquiries into cancer have 
become a national concern, backed by the interest 
and support of the medical profession and all classes 
of the community. Is it too mucn to expect that 
some comparable attention may be given to the 
urgent demands of the gonococcal infections ? 


ANNOTATIONS 


THE RADIOLOGIST’S PROPERTY IN HIS 
NEGATIVES 


Tue British Institute of Radiology has found it 
necessary to make a pronouncement as to the 
property in radiographic negatives of private patients. 
It states with authority and confidence that the 
property is in the radiologist by whom, or under 
whose instructions, or in whose department, the 
negative is made. The statement is applicable also 
to hospitals where arrangements permit the visiting 
radiologist to receive and examine private and paying 
patients ; the hospital receives a proportionate part 
of the radiologist’s fee towards the cost of materials 
used. In the case of hospitals this problem of 
property can be highly important because insurance 
companies and solicitors are sometimes inclined to 
demand as of right the visible results of the radio- 
logist’s work. Sometimes also patients raise the 
same question. If disposed to dispute liability for 
fees, they have been known to argue that there is 
nothing to pay for if the negatives have not been 
handed over. When that argument was used last 
year in an American case, the Supreme Court of 
Michigan disposed of it very sensibly. Radiographic 
negatives, said the judges, were practically meaning- 
less to the layman; they were an important part of 
the doctor's clinical records, valuable to his professional 
experience; they were analogous to the micro- 
scopical slides which doctors prepare as an aid to 
diagnosis and treatment and which would hardly be 
said to belong to anybody but to the doctor who 
prepares them. 

Patients unfortunately are apt to think of them- 
selves as visiting the radiologist to have an X ray 
photograph taken just as they go to a professional 
photographer’s studio for their portraits. In the 
latter case, where the sitter pays for the portrait, 
the copyright is in the sitter though the legal property 
in the negative remains in the photographer, 
though part of the bargain may be that the photo- 
grapher is not at liberty to sell copies or to use the 


negative without the sitter’s authority. That was 
the decision in Boucas v. Cooke in 1903, where Cooke, 
the “boy preacher,” had his photograph taken (for 
payment) in order that a block might be made for 
reproducing his portrait for distribution at mis- 
sionary meetings. The analogy of portraiture is 
shown by the British Institute of Radiology to be 
misleading. Patients do not visit a radiologist in 
order to purchase a picture of their bones, nor should 
they be encouraged in any such idea. The radio- 
logist makes his examination in order to reach an 
opinion about the patient’s condition ; the radiogram 
is merely incidental to the formation of that opinion ; 
indeed it may happen that an opinion can be formed 
from screen examination alone and, if so, the radio- 
logist’s fee is none the less payable. 


HISTORICAL ASPECTS OF PSYCHOLOGY 


In the paper he read at the Royal Society of 
Medicine last week Prof. Millais Culpin pointed out. 
that the history of psychological medicine had not 
been one of steady progress since the eighteenth 
century. Stahl, for example, had propounded his 
valuable conceptions, in many ways akin to those 
which now hold the field, but his views had not 
influenced the course of medical opinion about 
neurosis during the succeeding two centuries. Within 
the last fifty years great changes had taken place. 
The artefacts of Charcot’s clinic in France could 
be paralleled in their own time by the outbreak 
of “railway spine” in this country; the medical 
attitude to both was influenced by the notion of 
purely physical causes and by an aversion from 
teleological interpretation. In spite of the refutation 
of Charcot’s teaching about hysteria by Bernheim, 
and the researches of Janet, Morton Prince, and 
the psycho-analysts, it was not until the outburst. 
of psychogenic disorders in the late war that a psycho- 
logical approach to hysteria and other neuroses. 
began to prevail over the neuronic and molecular 
explanation of their pathology. Freud’s views were 
those of a pioneer and a genius, but, looked at 


í 


' -THE LANCET] 


historically, they seemed to have been put forward 
on to a scene that was set for them; a dynamic 
psychology, working in part with the conception 
of unconscious mental activity, had been adumbrated 
by various physicians and philosophers, and the 
situation was not unlike what had occurred earlier 
at moments of vicissitude in the history of psycho- 
logical medicine. Unduly simple interpretations, 
whether in terms of conditioned reflexes or endo- 
crine glands, were to be met with succeeding each 
other now, just as Haller’s “irritability of nerves ”’ 
had followed van Helmont’s Archaeus, at the time 
when Stahl was proffering vainly a more adequate 
explanation of the part played by states of mind 
and total dispositions in causing mental and physical 
disease. 

The discussion which followed Dr. Culpin’s address 
ranged from the therapy at Epidauros to the claims 
of modern psychopathology. The members of the 
section of history of medicine were evidently agreed 
that in psychiatry, as in every other branch of 
medicine, a true and wide picture of the present 
state of our knowledge could not be obtained unless 
one paid heed to the historical background. It is, 
however, a common observation, as in the case of 
Freud to which Prof. Culpin drew attention, that 
innovators and men of genius are often without a 
full knowledge of earlier and contemporary work in 
their field. Such ignorance may be a source of 
strength ; it enables them to follow new lights, 
undeflected. This argument is not entirely at variance, 
‘however, with the orthodox one so strongly urged 
in the discussion. Few are called to be innovators 
of ideas, and even men of genius are much influenced 
by the work and ideas that prevail in their time or 
have preceded them.? Other recent writers? on 
Dr. Culpin’s theme have pointed out how regularly 
‘psychological medicine has followed the fashions and 
philosophies of the period; unwitting assumptions 
are made, current belief is mistaken for assured 
fact, and familiar general modes of thought are 
woven into the new structure. The influence of 
Nietzsche, to which Dr. Cawadias referred, has 
doubtless played a part in moulding the psychological 
theories of to-day; a more detached historical 
view than that possible to the psychopathologist 
might discern in his accepted tenets of the moment 
much that derives from biological and philosophical 
habits of thought which are now being superseded 
-or reshaped. 


A STUDY OF HYPERNEPHROMA 


In introducing his monograph Prof. P. Bull makes 
a modest disclaimer. It contains, he says, ‘“‘no 
original ideas on the pathogenesis of hypernephromata, 
no unknown pathological-anatomical discoveries, nor 
any new clinical observations. . . . The work is 
primarily written for my Norwegian colleagues. . . 
As it has been my lot to treat a comparatively large 
number of hypernephromata, I have felt it as a kind 
of duty to give an account of my own clinical experi- 
ences during more than twenty years.’ The mono- 
graph was subsidised by the Malthe Fund and is 
published as a supplement to the Norsk Magazin for 
Laegevidenskapen for January. That 37 cases of 
hypernephroma of the kidney may be seen in a 
score of years by a general surgeon, not limiting his 


2 Pagel, W.: Religious Motives in the Medical Biology of the 
Seventeenth Century. Bull. Inst. Hist. of Med., 1935, iii., 97, 
213, and 265. 

2 Greenwood, M., and Smith, May: Pioneers of Medical 
Psychology. Brit. Jour. Med. Psychol., 1934, xiv., 1 and 158 ; 
Lewis, A. J.: Historical Survey of Melancholia. Jour. Ment. 
Sci., 1934, lxxx., 1 and 277. 


SURVIVAL IN PULMONARY TUBERCULOSIS 


[marcu 14,1936 615 


activities to the urinary tract, is an indication that 
the condition must not be considered altogether 
rare. Of the 37 patients 21 were males, and three- 
quarters of the total were between the ages of 40 
and 59. Hematuria was the first symptom in about 
a third, while in another third hematuria plus pain 
were the first manifestations. Only about half the 
patients showed macroscopic hematuria when they 
came to hospital, and 8 did not even show micro- 
scopic hematuria on admission. Pyuria was demon- 
strable in only every sixth case. It will thus be seen 
that the routine laboratory examination of the urine 
is apt to be defective as an aid to diagnosis. Pig- 
mentation of the skin was observed only in 1 case, 
but among the 21 males no less than 5 suffered from 
varicocele. Pyelography provided convincing evidence 
of a new growth in 18 out of the 21 cases thus 
examined, and Bull thinks that hematuria traceable 
to the kidneys, but otherwise of doubtful origin, 
should be an absolute indication for pyelography. 
In all, 26 of the 37 patients underwent nephrectomy, 
which in 20 cases was extraperitoneal and in 6 trans- 
peritoneal. The ultimate results justify operation, 
although it was not always successful in preventing 
recurrence. All the 5 cases with thrombosis of the 
renal vein or vena cava ended in this way; but, 
on the other hand, the prognosis when the lymphatic 
glands about the renal vessels showed metastases 
proved not absolutely hopeless. 


SURVIVAL IN PULMONARY TUBERCULOSIS 


By careful inquiry into the after-histories of 
patients treated at sanatoria, various attempts have 
been made to assess the success attending the treat- 
ment of patients with pulmonary tuberculosis. 
One of the more extensive surveys was made by 
Sir Percival Horton-Smith Hartley, R. C. Wingfield, 
and J. H. R. Thompson? and related to the patients 
treated at the Brompton Hospital Sanatorium at 
Frimley during the years 1905-14. Since 1924, 
when the report of this survey was published, the 
After-History Records Department at the hospital 
has functioned continuously, and functioned so 
successfully that rather less than 8 per cent. of the 
patients have been lost sight of. The material 
available for analysis has consequently become very 
considerable, amounting to 8766 patients admitted 
to the sanatorium between 1905 and 1931. The 
records of these patients—largely representative of 
the classes of insured persons of the London area— 
have been made the subject of a valuable report 
by Horton-Smith Hartley, Wingfield, and V. A. 
Burrows.? The numbers involved have made it 
possible to study the after-histories of patients of 
each sex separately, of different age-groups, and of 
different grades of severity. Tor the last the classifica- 
tion suggested by the Ministry of Health in Memo. 37/T 
has been adopted—namely, Grade A, patients 
T.B. minus, and Grade B, patients T.B. plus, divided 
into three groups of increasing severity. For each 
of these groups the mortality experience has been 
computed, the figure adopted for comparison being 
the probability of surviving five years after the date 
of admission to the sanatorium and at the expiration 
of each succeeding year. Against these probabilities 
are placed the corresponding figures from English 
Life Table No. 9, which was based upon the deaths 
of 1921-23. 

Examination of the figures shows that the mortality 


1 Med. Res. Coun., Spec. Rep. Ser. No. 85, 1924. 
*The Expectation of Survival in Pulmonary Tuberculosis, 
Brompton Hospital Reports, vol. iv., 1935. 


616 THE LANCET] 


of these patients depends almost entirely on the stage 
of the disease at entry and is relatively unaffected 
by sex or age. The prognosis varies directly with 
the extent of lung involved, though the authors 
point out that striking individual exceptions are 
often encountered. The prognosis of the average 
case unfortunately does not appear to have changed 
materially during the past thirty years, for the patients 
of more recent years show after-histories very similar 
to those of cases treated in the earlier years of the 
period studied. On the other hand it seems that 
for a selected class—namely, patients treated by 
artificial pneumothorax—modern treatment has 
considerably improved the prognosis. The majority 
of patients chosen for this treatment belonged to the 
class B3—i.e., with little or no prospect of recovery— 
because in the majority of cases this treatment 
was not used until the usual routine treatment had 
proved ineffectual. Comparison of this group with 
the experience of all the remaining patients of the 
same sex, medical grade, and age at admission shows 
a probability of survival materially increased in 
those so treated, the benefit enduring for at least 
12 years. This method of comparison appears to 
be the best available but it inevitably leaves the 
reader wondering why if two patients are really 
equal in all relevant characteristics one is chosen for 
A.P.T. and another not; does some unrecognised or 
immeasurable factor lead to the discrimination 
and is this factor correlated with survival? A funda- 
mental factor in the prognosis of the pneumothorax 
cases is shown to be the freedom from disease of the 
contralateral lung. Presumably the control group 
did not differ in the frequency with which this 
characteristic was present. An important feature 
of the authors’ tables is the high mortality in the 
second and third years after admission to the 
sanaterium. This, as they point out, may be due 
in part to the fact that it may be several months 
before the disease terminates in death, but it also 
emphasises the well-known fact that the most perilous 
year for a patient suffering from tuberculosis is the 
year following his discharge. He has then to face 
conditions of living and occupation and may relax 
that “careful watchfulness over his general routine 
of life ” which no sufferer from pulmonary tuberculosis 
can ever afford to neglect however secure his health 
may appear. \ 

A special analysis has been made of the distribution 
of deaths over the calendar year, and it is found that 
the monthly variability is greater for deaths of the 
Frimley patients than it is for the deaths from 
pulmonary tuberculosis recorded in the general 
population but less than the variability of other 
causes of death in the general population. This 
intermediate position of the Frimley patients points, 
the authors argue, to the conclusion that the mortality 
experience of patients who have had sanatorium 
treatment is more favourable than that of members 
of the general population suffering from pulmonary 
tuberculosis. The argument is not very clear. 
If a relatively high monthly variability of deaths 
can be taken as evidence of increased vitality then 
it would seem that the comparison needed is between 
ex-sanatorium patients and other patients with 
pulmonary tuberculosis, both groups dying of any 
cause. The comparison of ex-sanatorium patients 
dying of any cause with other patients dying only 
of pulmonary tuberculosis must give a greater 
variability to the former, since tuberculosis has less 
seasonal variability than many other causes of 
death. The authors’ belief that this statistical 
evidence is the first to show the value of sanatorium 


NERVOUS COMPLICATIONS AFTER SPINAL ANALGESIA 


[mance 14, 1936 


treatment needs, we think, careful consideration. 
From their final conclusion no observer of tuberculosis 
patients is likely to differ. They conclude that in the 
majority of cases ‘“‘ two stages may be observed—the 
first symptomless, the second symptom-producing ; 
that for this reason all too frequently patients with 
early disease fail to seek advice; that modem 
methods of treatment can only improve the prognosis. 
where the disease is not too extensive, so that the 
patient can fall into a selected category; that he 
is unlikely to fall into this class, unless the disease 
can be detected during its symptomless stage. This 
must be the goal of clinical research if further progress. 
is to be made.” The perfection and more general 
use of radiology during the last ten years, encouraging 
earlier diagnosis and more accurate control of treat- 
ment, may well show a beneficial effect when, as 
is to be hoped, this admirable investigation is extended. 
in another ten years’ time. 


NERVOUS COMPLICATIONS AFTER SPINAL 
ANALGESIA 


THE possibility of damage to the central nervous: 
system from endothecal injection has been a subject. 
of controversy since the early days of spinal analgesia. 
There have always been some who maintained that. 
nervous sequelæ were numerous and serious ;. 
others who asserted the opposite. The former, 
it must be admitted, could rarely bring definite: 
evidence in support of their belief and were apt to 
fall back on the statement that ‘neurologists saw 
many cases of trouble after spinal injections.” 
Gradually knowledge is becoming more definite and 
it appears that the risk of damage from endothecal 
injection must be accepted as a real one, although 
it is at present quite impossible to estimate how 
its frequency compares with the frequency of undesir- 
able symptoms after inhalation anæsthesia. Nor 
is it possible to compare the comparative frequency 
of really serious sequelæ after the two methods. For 
such comparisons we need parallel series of cases 
embracing very large numbers, and even then unless 
the operations and the conditions of the patients 
in the two series were substantially similar the 
comparison would be of little value. The kind of 
damage which may follow spinal analgesia is well 
shown in a recent article} from New York which is. 
of value because of the full description of the cases, 
seven in number, and of the microscopic post-mortem 
evidence in one of them. The authors give no 
indication of the number of cases among which these 
seven occurred, so that our knowledge of the frequency 
of damage is not furthered by the article in question. 
It would appear that a meningitis, of non-septic 
nature, is not an uncommon sequel of spinal injection. 
This is recovered from rapidly, but when the nerve- 
roots, and still more the cord itself, are affected the 
trouble is more serious and may be permanent. 
Paralysis arising in this way is exemplified in one of 
the seven cases quoted by the American authors. 
and H. K. Ashworth cited? a similar instance. 
Dr. Ashworth stated that minor symptoms or lesions 
after spinal injection were not infrequent and often 
persisted, although he believed serious or dangerous 
sequele to be rare. His investigation of patients 
with post-operative nervous symptoms showed the 
importance of a thorough examination, several 
instances being found where symptoms demonstrably 
due to some other cause had been attributed to the 


1 Brock, S., Bell, A., and Davison, C.: Jour. Amer, Med. 
Assoc., Feb. Sth, 1936, p. 441. 
? Proc. Roy. Soc. Med., 1933, cxxvi., 501. 


THE LANCET] 


ALCOHOL IN HOSPITAL PRACTICE 


[Maron 14,1936 617 


spinal injection. Endothecal analgesia is so valuable 
a method, and in some circumstances so superior 
to all others, that it is very important for its risks 
to be understood and every possible means taken to 
obviate them. Besides the patent necessity for 
strict surgical cleanliness there is need for care both 
in the method of making the injection and in the 
choice of dosage. With regard to the last point it 
is to be noted that the doses of percaine used in the 
New York cases were in several instances much above 
those commonly injected in this country. 


ALCOHOL IN HOSPITAL PRACTICE 


Dr. Courtenay Weeks has collected some interesting 
Statistics showing the decline in the use of alcohol in 
hospital practice from 1900 to 1934.1 In 1934 the 
hospitals of the British Empire spent, on an average, 
only 3-8d. per patient on wines and spirits. Most of 
the hospitals in the London area spent more than the 
average. St. George’s, for example, spent 20-4d. per 
head and this far from convivial figure shows a 
‘decline of 4d. compared with the figure for 1923. 
In the provincial general hospitals the decline was 
equally marked. Exceptions, murky or glittering as 
you will, were the Margate Royal Sea-Bathing 
(28-5d.) and the West Kent (22-8d.). In Ireland, 
the Tyrone County Hospital spent 22-4d. per head 
and the Dublin Meath 18-2d. Nor does Scotland 
stand where she did. Only the Oban (W. Highland 
‘Cott.) and the Johnstone and District Hospitals spent 
more than a shilling a head. Except for the Merthyr 
General Hospital (25-3d.), the Welsh hospitals were 
all below the average. Of public assistance institu- 
tions, the Bristol-Southmead Municipal Hospital 
‘spent 22-6d. and the Dartford (Kent) 19-7d. The 
L.C.C. General, the Women’s and Children’s Hospitals, 
and the sanatoria all returned low figures. Bootle 
(Linacre) was the only hospital for infectious diseases 
to return a figure as high as 19-3d. English mental 
hospitals (4:8d.) were markedly more abstemious 
than either Scottish (lld.) or Irish (16-5d.). All 
hospitals of the Empire overseas returned low figures 
and the same is true of the European countries 
though many French hospitals freely prescribe 
‘“ Potion de Todd,” a strongly alcoholic carminative. 
Dr. Weeks’s object in collecting these statistics is to 
preach the cause of temperance. IIe claims that they 
prove that the profession no longer believes in the 
therapeutic value of alcohol. No doubt his claim is 
partly true, but other factors, for example, the 
increased cost of alcoholic liquors, must also be 
responsible for their diminished use. The propaganda 
which accompanies the statistical data may prove 
tedious to some readers. Had Dr. Weeks contented 
himself with a plain statement of facts he might 
perhaps have carried greater conviction. 


ACUTE POISONING FROM CORROSIVE 
SUBLIMATE 


Mercury bichloride is, after arsenic, the commonest 
metallic poison responsible for acute poisoning. 
‘The intention is most commonly suicidal, but many 
accidental cases are on record. As little as grs. 3 
has been fatal, but much larger doses have been taken 
with survival. The poison always causes intense 
vomiting, so that most of it is generally eliminated 
within a few minutes. The vomiting is usually 
persistent and is soon accompanied by profound 
purgation. Occasionally death occurs within a 


2 Alcohol in Hospital Practice. By Courtenay C. Weeks, 
M.R.C.S., L.R.C.P., Director and Medical Lecturer, the National 
Temperance League. London: National Temperance League. 
1935. Pp. 35. Yd. 


few hours from collapse following the intense dehydra- 
tion and dechloridation. More commonly death 
takes place in 5 to 10 days from uremia, and in these 
there is anuria, generalised cdema, and very high 
blood-urea. There is, however, a paucity or absence 
of published data on the quantitative elimination of 
the metal during life and on its distribution in the 
organs after death. These data must necessarily be 
of fundamental importance in guiding treatment, 
and recent chemical studies by Sollmann and 
Schreiber! are accordingly of considerable interest 
and value. Their material was derived from four 
patients seen during life and three autopsies, and a 
very large number of careful analyses were made. 
These showed that immediate gastric lavage is 
important, but that subsequent lavage of stomach or 
colon is of little effect. The first gastric lavage 
should be very thoroughly carried out and many 
pints of water used for the washing. The feces 
are the principal vehicle for the excretion of the metal, 
and enemas were thus of value only if the patient had 
not had the usual diarrhoea, for copious colon irriga- 
tions yielded negligible quantities of mercury in 
the non-fecal washings. In their autopsy studies 
Solmann and Schreiber found that the concentration 
of mercury is uniformly highest in the kidneys ; 


the liver follows with about half to two-thirds of the 


concentration in the kidneys; then the spleen with 
one-seventh, the intestines with one-ninth, the heart, 
skeletal muscle, and lungs, with about one-fifteenth ; 
and finally the brain with one-twenty-seventh. 
The concentration of mercury in the blood was 
0:015-0-:12 mg. per 100 c.cm., about one-fortieth 
of that in the kidneys. It seems rational to combat 
the early loss of water and chlorides through vomiting 
by giving continuous intravenous saline by the drip 
method. At the same time great caution should 
be exercised to avoid waterlogging in view of the 
probability of renal damage. The control of the 
quantity of saline administered by the usual criterion 
of the volume of urine passed is obviously unsafe 
as there may be suppression of urinary excretion. 


PRURITUS AND LEUCOPLAKIA 


PRURITUS vulve, with or without pruritus ani, 
is one of the most distressing and intractable of all 
the commoner affections of the skin and adjacent 
mucous membrane. There are grounds, moreover, 
for thinking that its incidence is increasing, and the 
paper by Dr. Elizabeth Hunt which we publish on 
p. 592 will be useful both for its careful analysis of 
causation and for its suggestions about treatment. 
In a longer treatise which has just appeared else- 
where ? she has analysed in detail no less than 73 
cases of lichen planus of the vulva, which she believes 
to be often confused with leucoplakia vulve—a 
much more serious affection in that it not infrequently 
terminates in epithelioma, which the former never 
does. This contention, which she supports on 
clinical and microscopical grounds, may safely be 
left to the examination of her dermatological readers ; 
but she is undoubtedly right in saying that the 
diagnosis of leucoplakia vulve—like the diagnosis. 
of leukoplakia in the mouth—is used too loosely 
by the profession generally. Nevertheless we might 
err in caution if we went the whole way with Dr. Hunt. 
We very much doubt if she will obtain credence for 
her findings that out of 300 cases of pruritus vulvæ 
no less than 105 (i.e., over a third) were due to, or 
associated with, lichen planus. This is certainly not 


1Sollmann, T., and Schreiber, N. E.: Arch. Internal Med, 
1936, lvii., 16. 
* Brit. Jour. Derm. and Syph., February, 1936, p. 53. 


618 THE LANCET] 


the ordinary experience of dermatologists either in this 
country or abroad, and we take leave further to doubt 
her claim, or that of any other physician, to be able 
to establish the cause with certainty in 297 out of 
300 cases of a disorder which is one of the most 
puzzling of cutaneous syndromes. Many clinicians 
may also find it difficult to believe that only one 
case of ringworm was present in so large a series, 
and they may be further perplexed by the omission 
of a menopausal or endocrine variety of pruritus 
which is widely recognised as common. In other 
respects, however, Dr. Hunt will find sympathetic 
support for her views. There is certainly an undesir- 
able tendency to resort to surgical remedies, which 
are rarely successful and mostly mutilating. With 
the exception of nerve section, they should be 
reserved for cases of a frankly malignant type, or 
those regarded as pre-malignant on microscopical 
examination. On the medical side, too, there is 
probably far too much prescribing of local and general 
sedatives. Not a few of these unfortunate women 
have become chronic morphine addicts, and it should 
not be forgotten that cocaine and its substitutes 
soon lose their anzsthetic properties and sometimes 
become an important factor in the protraction of the 
disease. 


INVESTIGATION OF URTICARIA 


FASHIONS pass; booms turn into depressions And 
less is nowadays heard of wild hopes that “ allergy ” 
will prove to be the solution of most of the remaining 
problems of medicine. To force an allergic explana- 
tion upon an obscure disorder will often make it 
retreat further into obscurity. At the same time 
there are few more fascinating diseases than those 
which are generally interpreted in terms of sensitisa- 
tion—for example, urticaria—and there must be revela- 
tions about them waiting for us round a corner. 
At present we are mainly at the stage of observation 
and experiment, the one often leading to the other. 
Thus the discovery of sensitisation to chloramine 
causing spasmodic rhinorrhea, urticaria, and eczema 
has led Salén 1 to test the chloramine sensitiveness 
not only of this particular patient, but also of a 
number of other veterinary students. To explain 
the positive skin reactions he found in many showing 
no clinical manifestation of sensitiveness he concludes 
that this may be a process normally evoked in most 
people by adequate exposure to an antigen. The 
clinical manifestations of such sensitisation may only 
occur, however, in those with an inherited pre- 
disposition to such reactions. In other words, a positive 
skin test and presumed sensitisation merely indicate 
adequate contact and do not imply liability to 
allergic reactions. It does indeed look as though 
some such explanation must be invoked to explain 
the unreliability of cutaneous tests, but it is possible 
that some unrecognised factor in the local mechanism 
of the test reactions, quite independent of general 
considerations, is responsible for these inconsistencies. 
In practice we can no longer suppose that every case 
of urticaria will be elucidated by conscientious 
skin-testing against all possible inhaled, ingested, or 
contact allergens, and the patient’s problem has 
still to be viewed upon a broad medical basis. 
Particularly in cases of simple factitious urticaria, 
in urticaria following exertion, and in that provoked 
by exposure to cold is it difficult to determine the 
etiology and institute rational therapy. Thus Levine,? 
who has lately given a full report of a case of urticaria 
due to cold, has been unable to draw any positive 


1 Salón, E. B.: Acta Med. Scand., 1935, Ixxxvi., 486. 
2? Levine, H. D.: Arch. Internal Med., 1935, lvi., 498. 


INVESTIGATION OF URTICARIA 


[mancH 14, 1936 


conclusions about etiology; and it seems doubtful 
whether the state is any more than an exaggeration 
of the normal physiological response. 


LEPROSY IN THE EMPIRE 


Last Tuesday’s meeting at the India Office 
produced many striking statements from the principal 
speakers. As chairman of executive of the British 
Empire Leprosy Relief Association ? Sir Edward Gait 
said that the number of lepers in the Empire was 
now put at at least two million. Sir Leonard Rogers, 
F.R.S., spoke of his belief that if infection in child- 
hood could be prevented the disease would almost 
die out within a couple of generations, and the same 
argument was brought out by Dr. E. Muir, formerly 
of the Calcutta School of Medicine, who has succeeded. 
Dr. Thomas Cochrane as the Association’s medical 
secretary. Leprosy, he said, like tuberculosis belongs 
to a certain stage in the life-history of a nation. 
Here in England we rose above that level in the 
fourteenth and fifteenth centuries, just as we are 
now gradually rising above the rather higher level 
of tuberculosis. The campaign against leprosy 
among backward races must have in its forefront. 
the amelioration of their social and economic con-. 
ditions. The problem was largely a child problem 
because children are more prone than adults to 
infection and develop an active form which spreads. 
infection. So far there was no specific remedy, 
though “we have a form of treatment which under 
favourable circumstances will heal the less virulent 
cases.” Compulsory isolation of infectious cases. 
would never succeed among vast uneducated popula- 
tions, for it drove the disease underground. But, . 
as in many other departments of medicine and social. 
science, much could at once be accomplished if we 
would only put into effective use the knowledge 
already acquired. The chief difficulty, in Dr. Muir’s. 
opinion, is the ignorance and indifference of people 
at home. In this country we are at present secure 
against many of the diseases which ravage our 
colonies and dependencies, and ‘‘ with this feeling of 
security people have very little idea of the difficulties. 
and problems with which governments, missionaries, 
and others are struggling in those distant lands for 
which we have taken upon us the responsibility.” 
Funds would pour in, as Sir Leonard Rogers said, if 
leprosy were as prevalent in Europe now as it was. 
five hundred years ago. 


On March 17th and 19th at 5 p.m. Dr. John 
Parkinson will deliver the Lumleian lectures to the- 
Royal College of Physicians of London, his subject 
being enlargement of the heart. Medical practitioners 
will be admitted on presentation of their card. 


OUR news columns this week contain an advance. 
notice of the Second International Congress of the 
Scientific and Social Campaign’ against Cancer, 
which is to be held in Brussels next September, 
under the auspices of the International Union 
against Cancer. 


Sir Gowland Hopkins, O.M., professor of bio- 
chemistry at Cambridge, has been appointed to the 
faculty of Harvard University for the academic year 
beginning next September and will deliver three 
lectures in the Harvard medical school as Edward K. 
Dunham annual lecturer. The Dunham foundation 
is designed to promote understanding between 
students and investigators in the United States and 
other countries. 


2 The annual report for 1935, just issued, may be had from. 
the association at 131, Baker-street, London, W.1. 


THE LANCET] 


[marncH 14,1936 619 


PROGNOSIS 


A Series of Signed Articles contributed by invitation 


XCII.—_ PROGNOSIS IN CARCINOMA OF 
THE COLON 


THE precision of diagnosis by a competent observer 
using adequate radiological equipment is now such 
that no carcinoma of the colon submitted to examina- 
tion by X rays can escape detection. Its site and 
outline can be demonstrated, and the mobility of 
the affected segment of colon can be determined. 
The demonstration is simple when suspicion of the 
presence of a carcinoma has been aroused, but unfor- 
tunately the absence of symptoms in the early stages 
of most cases of malignant disease of the large bowel 
makes diagnosis dependent on obstruction. The 
cases in which a diagnosis is reached before obstruc- 
tion has occurred are limited to those in which a 
growth is found in the course of an operation or an 
X ray examination initiated for the correction or 
detection of some other disease. 

Study of the natural history of carcinoma of the 
colon shows that from one to two years elapse between 
the first appearance of the growth and the first 
attack of obstruction. During that period of pro- 
gressive diminution in the calibre of the bowel, the 
mechanism of compensatory hypertrophy of its 
muscular coat is so efficient that the patient may 
and frequently does feel no impairment of his normal 
health sufficient to take him to his doctor. But 
during this clinically silent period of growth, metas- 
tasis to lymph glands often curtails the prospects of 
survival. Prognosis after removal of a carcinoma 
from any part of the body is conditioned chiefly by 
the presence or absence of metastasis at the time of 
operation, and this principle is as rigidly determined 
for the colon as for the breast. 


TYPE OF GROWTH 


The common pathological type of carcinoma in 
the large bowel is a localised growth of scirrhous 
habit, which spreads slowly round the circumference 
of the gut to form a ring stricture. It affects chiefly 
the left half of the colon and produces an obstruction 
which often antedates metastasis by a sufficient 
margin to make radical removal successful, as success 
is estimated in the surgery of malignant disease. In 
the right half of the colon, carcinoma tends to be 
more bulky than in the left half and to be less rapid 
in the destruction of its host. The bulky tumour 
which fungates into the lumen of the bowel is often 
characterised by so much ulceration and sloughing 
of its mucous surface that an adequate though irre- 
gular passage for the intestinal contents is main- 
tained. On account of this tendency to ulceration 
and of the fluid nature of the content of the proximal 
colon, the onset of obstruction may be delayed and 
the first symptoms to attract the patient’s attention 
may be weakness caused by loss of blood and toxic 
absorption from the ulcerating surface, or pain 
associated with infiltration of surrounding tissues by 
the tumour. Examination of the abdomen at this 
stage of the disease may reveal a palpable tumour, 
but if the carcinoma is situated in the hepatic flexure 
it may be so concealed by the lower ribs and the 
liver as to escape detection. 
trated by the frequency with which carcinoma of 
the hepatic flexure remains unsuspected until per- 
foration compels investigation. The splenic flexure, 
being higher than the hepatic, is even less accessible 
to palpation, but its characteristic pathological type 


~ better. 


This point is illus- 


of carcinoma is the ring stricture and, as a clinically 
recognisable obstruction usually antedates glandular 
metastasis, the outlook for the patient is considerably 
The most favourable type of carcinoma of the 
colon is the one which produces obstruction at an 
early stage of its development, whether because it 
grows at the ileo-colic junction where the lumen is 


narrow or because its polypoid shape provides an 


adequate stimulus to the formation of an intus- 
susception. 
SITE 


The influence of the anatomical site of an 
operable carcinoma of the colon on prognosis is 
forcibly demonstrated by the ease with which resec- 
tion can be performed in those parts of the bowel 
which are provided with a mesentery. Removal of 
a growth of a transverse or of the pelvic colon is 
much simpler than is resection of the fixed parts of 
the colon, whether the patient’s condition allows of 
primary reconstitution of the continuity of the bowel 
or necessitates a two-stage operation of the Paul 
type. Provided that the removal be adequate, the 
easier the operation the lower the mortality. 


SYMPTOMS AND SIGNS 


The value to the patient of an attack of acute 
obstruction, lasting perhaps for 48 hours, at a rela- 
tively early stage in the evolution of his disease can 
scarcely be over-estimated; nor can the value of 
recognition by his doctor of the potential signi- 
ficance of such an incident in a middle-aged man or 
woman. The second attack may not come for several 
months, during which the growth will progress and 
may spread to lymph glands, and during which the 
general health will deteriorate as the result of toxic 
absorption from the chronically obstructed bowel. 
Wasting is seldom a feature of the disease. Obesity 
is probably as common among the subjects of carci- 
noma of the colon as among healthy people of the 
same age. It increases the risk of operation, not only — 
because the stout often tolerate severe abdominal 
operations badly, but also because of the technical 
difficulties imposed by a short, fat-loaded mesocolon. 

In the absence of demonstrable metastases, a 
rational prognosis can only be founded on the data 
provided by exploration of the abdomen. When the 
operation is performed in the absence of acute obstruc- 
tion there will have been ample opportunity for a 
complete investigation beforehand. The exact site, 
approximate local extent and mobility of the growth 
will be known, so that those precious commodities, 
time and manipulation, can be devoted to the con- 
structive phases of the operation where absence or 
limitation of metastasis encourages removal of the 
growth. 

IMMEDIATE RISK OF A RESECTION 


In assessing the immediate risk of a resection 
the preoperative preparation of the patient must be 
allotted a value comparable with our estimate of the 
adequacy of his cardiovascular and respiratory 
mechanism, and of his renal sufficiency. Preparation 
for operation should include not only attention to 
the alimentary canal but also the raising of the 
hemoglobin content of the blood by the necessary 
number of transfusions to at least 80 per cent. Only 
in the most favourable circumstances can the patient 
expect to escape with a single operation, and in the 
practice of many surgeons the possibility is limited 


620 


THE LANCET] 


PROGNOSIS IN CARCINOMA OF THE COLON 


[marcu 14, 1936 


to growths of the right half of the colon from the 
cecum to the middle of the transverse colon. Even 
then a temporary opening to prevent a rise of gaseous 
pressure within the bowel is often advisable. In 
other cases, more than one operation will usually 
be required in the interests of safety, a short circuit 
or colostomy preceding the removal of the tumour. 
A third operation may be necessary to close the 
colostomy. 


IMMEDIATE OUTLOOK IN ACUTE/OBSTRUCTION 


The immediate outlook for a patient who is first 
seen in a state of absolute intestinal obstruction 
depends on such general factors as age and preceding 
physical condition, and on the number of days during 
which obstruction has been absolute. When the 
growth is in the ascending colon the clinical picture 
is often dominated by the participation of the small 
intestine and vomiting may be severe, but with 
obstruction of the more distal parts of the colon 
distension is the chief feature and vomiting is late 
and capricious in its incidence. The pulse-rate may 
rise scarcely at all for the first four days. Within 
these limits an attack of obstruction does little to 
jeopardise the success of the ultimate resection 
provided that the bowel on the proximal side is 
drained for an adequate time before removal of the 
growth is attempted. In this connexion it is neces- 
sary to recognise that a czecostomy cannot be relied 
upon to drain the colon distal to the hepatic flexure, 
and that Paul’s operation, where suitable, is by far 
the safest way out of an attack of obstruction. 


REMOTE PROGNOSIS 


A prognosis founded on the relative completeness 
of a resection must take into account the information 
afforded by naked-eye and microscopic examination 
of the tissues removed. The length of colon on 
either side of the growth is always ample provided 
that its mucous membrane is healthy, but mere 
length can only guarantee a margin beyond the 
zone of submucous infiltration, and if polypi are 
found on the mucous membrane it is likely that 
others will have been left in the patient and these 
will carry a slight but definite risk of malignant 
change. Of far greater importance is the presence 
or absence of growth in the lymph glands which will 
have been removed in continuity with the resected 
bowel. These glands may be enlarged either by 
growth or by inflammatory changes resulting from 
absorption of infection from a malignant ulcer. If, 
on microscopic examination, they are found to 
contain deposits of carcinoma, the expectation of 
life will be greatly diminished. 

An operation which achieves adequate gomeval 
of the carcinoma as judged by the standards of the 
pathologist may be expected to yield from four to 
eight years of freedom from recurrence, growths of 
the right half of the colon giving a more favourable 
outlook than those of the left half. On account of 
the damage produced by an attack of obstruction 
and the greater liability to post-operative complica- 
tions which it involves, and by reason of the number 
and often the severity of the necessary operations, 
restoration to health is usually slow. [Full vigour 
may be regained or the patient may be hampered 
by minor degrees of obstruction caused by adhesions. 


. RECURRENCE 


Recurrence is limited to the abdominal cavity 
and produces intestinal obstruction or enlargement 
of the liver. These two clinical features may coincide 
and either may be accompanied by ascites. When 


recurrence takes the form of intestinal obstruction 
accompanied by gradually increasing distension of 
the abdomen and by the presence of palpable masses, 
it is unlikely that further operation will be justified 
either by prolongation of life or by relief of suffering. 
The problem presented by recurrence of intestinal 
obstruction without a palpable abdominal tumour 
or with a single lump, especially if this is localised 


to the pelvis, demands a fresh investigation by the 


same methods as in the case of the primary tumour. 
Prognosis is again dependent on the pathological 
conditions found at operation. A single recurrent 
growth in either small or large bowel or in one or 
both ovaries with an adherent coil of intestine may 
be amenable to excision with a prospect of two or 
three years of useful life. In less favourable cases 
a short circuit or a colostomy may prolong life and 
reduce suffering for several months, though thé 
patient is unlikely to regain more than a relative 
degree of health and activity. 


E. K. Martin, M.S., F.R.C.S., 
Surgeon, University College Hospital. 


i 


OUR issue of August 10th contained the last of 
the articles collected in book form and issued as 
**Prognosis,”’ Vol, I. (10s. 6d.). The subjects dealt 
with week by week in this series since that date are 
as follows :— 


Congenital Stenosis of the Pylorus, by Miss Gertrude 
Herzfeld and Dr. H. L. Wallace. Fractures of the Bodies 
of the Vertebre, by Mr. H. Ernest Griffiths. Malocclusion 
of the Teeth, by Mr. A. T. Pitts. Fibroids, by Mr. Victor 
Bonney. Jojunal Ulcer, by Dr. R. P. Picton Davies. 
Foreign Bodies in the Air and Upper Food Passages, by 
Mr. V. E. Negus. Papilloma of the Bladder, by Mr. 
Cyril A. R. Nitch. Cerebro-spinal Fever, by Dr. C. Worster- 
Drought. Non-malignant Diseases of the Breast, by 
Mr. Eric Pearce Gould. Tetanus, by Dr. Leslie Cole. 
Gastric and Duodenal Ulcer, by Dr. J. J. Conybeare. 
Middle-ear Suppuration, by Mr. Walter Howarth. Csesarean 
Section, by Mr. Eardley Holland. Ulcerative Colitis, by 
Dr. A. F. Hurst. Internal Derangement of the Knee-joint, 
by Mr. R. C. Elmslie. Pituitary Tumours, by Mr. Hugh 
Cairns. Malignant Growths of the Testicle, by Mr. 
Kenneth M. Walker. Tuberculous Infections of the 
Skin, by Dr. Henry C. Semon. Trigeminal Tic, by Dr. 
Wilfred Harris. Chronic Bronchitis and Emphysema, by 
Dr. R. A. Young. Deafness, by Mr. Harold Barwell. 
Asthma, by Prof. L. J. Witts. Hemiplegia in Middle 
Lite, by Dr. Neill Hobhouse. Fractures of the Upper 
End of the Femur, by Mr. George F. Stebbing. Enlarge- 
ment of the Spleen, by Dr. J. W. McNee. Congenital 
Syphilis, by Dr. David Nabarro. Spinal Caries, by Sir 
Henry Gauvain. 


KING EDWARD’s HOSPITAL FUND FOR LONDON.— 
Hospitals situated within 11 miles of St. Paul’s which 
want to participate in the grants made by this Fund for 
the year 1936 should apply before March 31st to the hon. 
secretaries of the Fund at 10, Old Jewry, E.C.2. Applica- 
tions will also be considered from convalescent homes 
which are situated within the above area or which, 
being situated outside, take a large proportion of patients 
from London. 


GLASGOW ROYAL MATERNITY AND WOMEN’s Hos- 
PITAL.—At the annual meeting of contributors and sub- 
scribers to this hospital it was pointed out that increasing 
use was being made of the antenatal department. During 
the past year, 1600 cases, or 35 per cent. of all those 
admitted to the hospital, attended the antenatal dis- 
pensary, the total attendances being 16,572. Na fewer 
than 68 per cent. of the total admissions were abnormal, 
and the need for extending a part of the hospital was 
being felt. 


THE LANCET] 


[maron 14,1936 621 


SPECIAL ARTICLES 


MEDICAL RESEARCH COUNCIL 
ANNUAL REPORT FOR 1934-35 


THE Introduction to the report of the Medical 
Research Council provides year by year in 30 brief 
pages an index, a record, and a forecast: an index 
to the trend of medical research during the period 
under review; a record of results achieved to the 
date of its close; and a forecast, often already 
confirmed in the intervening six months, of the 
conclusions reached as the outcome of work essentially 
complete but not yet published. It is a peculiar 
merit of this annual report to steer between the 
policy, unfair to other workers in the same field, 
of staking out claims for discoveries of which full 
details are not available and that of supplying a 
mere summary of communications already familiar 
to the readers of scientific periodicals. ae 

This year a dozen subjects from among those on 
which work has been actively pursued are selected 
for review. Pride of place is given to 


Nutrition : Application of Modern Knowledge 


There have been many recent indications of greater 
public interest in nutrition. Though this interest 
may have been aroused not solely nor even primarily 
because of the intrinsic practical importance of 
proper feeding in its relation to health, but largely 
because of the probable economic effects on agriculture 
and industry, the Council express satisfaction that 
the discoveries of their own and other investigators 
of nutritional problems are likely in the near future 
to play their due part in advancing human welfare. 


HISTORICAL SURVEY 


In view of this change in attitude they enumerate 
some of the more practical discoveries which they 
have assisted during the 20 years of their existence. 


In the first year of their work they initiated research 


on rickets which led to the elucidation of its nutritional 
satiology, and in particular to the discovery of a calcifying 
vitamin (vitamin D), a substance which was ultimately 
prepared in its pure form by workers at the National 
Institute for Medical Research. They also promoted, in 
association with the Lister Institute, clinical investigations 
on rachitic children at Vienna, which confirmed the 
laboratory investigations and placed the methods for the 
prevention and cure of the disease on a firm basis. Later 
they supported work, arising from the rickets investiga- 
tions, as a result of which it is now practicable to improve 
greatly the structure of the teeth of the rising generation 
by proper feeding in infancy and childhood. They are 
also responsible for the clinical investigations which 
demonstrated that, apart from dental structure, decay of 
the teeth can be slowed down by diet. This work has led 
to a new outlook on what is probably the commonest 
disability of civilised man—namely, dental decay—-and 
has supplied facts ready and feasible for widespread 
translation into practice. 

One of the most important practical investigations 
initiated by the Council demonstrated the effects of 
supplementing the diet of growing children with milk and 
other substances. Through their Accessory Food Factors 
Committee the Council have initiated and financially 
supported investigations made with the object of stan- 
dardising the different vitamins. Vitamin D was first 
standardised in this country, and the whole series of 
investigations later made it possible for international 
conferences, convened by the Health Organisation of the 
League of Nations in 1931 and 1934, to establish inter- 
national standards and units for vitamins A, B,, C, and D. 
Thus people throughout the world can now discuss these 


vitamins in terms of units, in the same way as they can 
discuss time and distance in units of hours and metres. 
Other inquiries supported by the Council called 
attention to the high incidence and significance of anzmia 
both in pregnant and lactating women and in their infants 
in this country, and showed how the condition could be 
avoided or mitigated. Certain nutritional investigations 
have been directed to the study of goitre, and others 
have had as their object the determination and close 
analysis of the usual dietaries of different sections of the 
community. l 
These are only a few of the more important 
contributions to knowledge in nutrition for which 
the Council have been responsible. Throughout 
their existence they have realised the fundamental 
importance of this rapidly developing subject, and 
have placed it in the foreground of their programme. 


THE NEW TEACHINGS 


It is fortunate that the essential teachings can be 
reduced to a few simple statements. The first is 
that the younger the child the more essential is 
correct feeding for proper growth and health. It 
is thus necessary to apply the new teachings of 
nutrition to the case of the pregnant and lactating 
mother; and, despite the great importance of 
improvement in the dietary of school-children, proper 
feeding of the infant and child of pre-school age is 
an even greater need. Breast feeding is of even higher 
value than has been previously believed, and ought 
to be more extensively adopted and continued for 
longer periods. 

On the dietary side, the broad requirements can 
be simply stated to the public—without mention 
of calories, vitamins, or other technicalities necessary 
to the investigator—by saying that much more milk 
(“ safe” milk), cheese, butter, eggs (especially egg- 
yolk), and vegetables (especially green vegetables) 
ought to be consumed. In particular, milk ought 
to be the chief drink for children, and especially 
in the first years, while bread and other cereals should 
in these early years be greatly reduced. 


CURRENT WORK 


Prof. E. P. Cathcart and Mrs. A. M. T. Murray 
have completed the analysis of data on family diets 
collected from various towns in Great Britain over 
a period of years, particular attention being given to 
the iron, calcium, and phosphorus contents of the 
diets. A quantitative survey of the diets of crofters 
and others in remote Highland areas is contemplated 
for purposes of comparison. 


A quantitative study of the ordinary diets of 
120 men and women has been completed by Miss E. M. 
Widdowson, working under Dr. R. A. McCance, who 
with Dr. L. R. B. Shackleton has also continued 
his observations on the chemical composition of 
fruits and vegetables and their losses in cooking. 
It appears that most of the iron of vegetables and 
bread, and little of the iron of meat are utilised in 
human nutrition, and that about half the phosphorus 
of cereals, nuts, and pulses is in a form which cannot 
be absorbed. 

Prof. S. J. Cowell has done further experiments on the 
factors controlling the excretion of calcium in the intestine. 
It appears that the rate of excretion depends on the 
degree of saturation of the tissues generally with calcium, 
but that it is not much affected by sudden variations in 
the calcium content of the blood. Miss E. M. Hume, 
assisted by Mrs. I. Smedley MacLean, D.Sc., have made 
further observations on the effects of fat deficiency which 
were noted by Burr and Burr in rats. Experiments are 


622 THE LANCET] 


MEDICAL RESEARCH COUNCIL REPORT 


[maRcH 14, 1936 


in progress to determine what substances in lard and 
linseed oil are responsible for curing the lesions produced 
and for restoring the rate of growth to normal. An 
inquiry is also being made into the influence of the fats 
in the diet on reproduction. Under the general direction 
of Prof. W. W. C. Topley and Prof. Cathcart, Dr. Marion 
Watson has obtained preliminary results which indicate 
that diet and various environmental factors have specific 
effects on the fertility, growth, and survival-rates of young 
mice. Attempts are now being made to determine whether 
it is possible by dietetic means to increase the resistance 
to Bact. aertrycke. 

Dr. Helen Mackay is examining the value of a soya 
bean preparation as a supplement to milk in the diet of 
infants. The iron content of the bean is comparatively 
high, and it is thought that it may possibly replace 
inorganic iron salts for the prevention and treatment of 
nutritional anemia. An inquiry at the North Eastern 
Hospital, Tottenham, showed that the addition of extra 
rations of vitamins A and D to the diets of children with 
measles was without effect on the course of this disease or 
on the incidence of the minor skin infections. 


The method devised by Mr. C. O. Harvey to measure 
minute quantities of iodine in biological substances 
has been used by Miss M. G. Crabtree to study the 
iodine content of samples of milk, pasture, and 
drinking water from different parts of England 
with the idea of obtaining definite proof whether the 
incidence of goitre in certain districts is actually 
related to the iodine-content of the local milk and 
water supplies. The findings so far indicate that the 
iodine-content of milk from the non-goitrous districts 
of Suffolk is higher than of that from the goitrous 
districts of Somerset. 


VITAMIN STUDIES 


The seven pages devoted to vitamin studies in 
this year’s report record much work on various 
components of the vitamin-B complex, and on 
vitamin C (ascorbic acid) with short sections on the 
chemistry of vitamin E and notes on the storage and 
on the standardisation of vitamin A. 


As part of an inquiry into the vitamin B, content of 
human diets Mr. P. C. Leong has measured the amounts 


of this vitamin present in genuine wholemeal wheat and | 


in ordinary brown bread and has found the difference 
between them to be surprisingly small. By arrangement 
with physicians at several hospitals trials are being made 
of the therapeutic effects of vitamin-B concentrates in 
‘“ pink disease”’ in children; encouraging results have 
been obtained in a few cases, although caution is required 
in their interpretation. 

Application of the work of Mr. L. J. Harris, Sc.D., and Mr. 
S. N. Ray, Ph.D., on the diagnosis of vitamin-C deficiency to 
children under the care of Prof. L. G. Parsons and of Dr. 
E. Pritchard suggests that a suboptimal intake of vita- 
min C is common in artificially fed infants but not in 
breast-fed ones, human milk being three or four times 
richer in this vitamin than cow’s milk. Observations on 
adults by Dr. M. A. Abbasy and Dr. Harris indicate that 
one or two oranges a day suffice rapidly to bring reserves 
of vitamin C up to normal in persons whose diet has been 
deficient in this respect, but there is evidence that mothers 
often disobey instructions to give orange juice regularly 
to their infants. 


The only mention of work on vitamin D in this 
section of the report is on that of Miss Fischmann, 
who is studying its influence on ossification in tissue 
cultures. Elsewhere (p. 137) reference is made to the 
observations of Prof. J. B. Duguid, assisted by 
Dr. M. R. P. Williams, on the experimental production 
of a form of nephritis by giving large quantities 
of orthophosphates by mouth, in the presence of 
hypervitaminosis D; and (p. 110) to the study by 
Dr. Dorothy Russell- of the vascular, renal, and 
pituitary changes found in this condition. 


Examples of Combined Clinical and 
Laboratory Research 

Ergot in childbirth: isolation of ergometrine— 
The end of the fascinating story, extending over 
30 years, of the struggle to reconcile clinical and 
pharmacological experience in respect to the activity 
of various preparations and derivatives of ergot is 
here recalled. 

Again and again, during this period, new constituents 
have been isolated from ergot which, although of great 
physiological interest, failed to replace in the confidence 
of the practising doctor the watery extracts of the whole 
drug. He continued to rely, for the purpose of stimulating 
contractions of the uterus, on these extracts given by the 
mouth, though he was assured that they contained none 
of the alkaloids found to be pharmacologically active 
when injected. This discrepancy between clinical practice 
and pharmacological evidence lasted till 1932 when Dr. 
Chassar Moir was able to demonstrate by objective 
records the powerful contractions of the human uterus 
induced by the popular watery extract of ergot. Close 
coöperation between the late Mr. W. H. Dudley, D.Sc., 
working on the chemical side, and Dr. Moir enabled them 
jointly to announce in March, 1935, the discovery of 
ergometrine as the substance in ergot responsible for the 
most familiar of the actions of ergot. 


The Council point out that these researches, 
while illustrating how results of equal or even greater 
importance may be attained by the laboratory as 
by-products of the chase, also illustrate how vital to 
the solution of a problem, originating in and concern- 
ing clinical practice, may be the guidance provided 
by continued investigation upon the clinical material 
itself, 


The curative agent of pernicious anemia.—Another 
example of the need for continuous clinical guidance 
is in the testing of the therapeutic activity of prepara- 
tions derived from liver. It is as yet impossible to 
foretell whether any particular preparation will 
be active until it has been tested on patients suffering 
from pernicious anemia. No effective laboratory 
test of activity has yet been established, in spite of 
world-wide endeavours, while the chemical complexity 
of the liver principle has prevented the discovery of 
any chemical or physical property which can be 
regarded as a measure of its therapeutic influence. 
The Council were able to organise last year clinical 
trials by Prof. Stanley Davidson, Prof. E. J. Wayne, 
and Dr. C. C. Ungley of a preparation of liver extract 
made by a British firm according to the method 
of Dakin and West, published in America; the result 
of these trials (published in THE LANCET, Feb. 15th, 
1936, p. 349) demonstrated the extremely high degree 
of potency of this preparation. Injections of from 
0-1 to 0-2 gramme of it once weekly, brought about a 
large increase in the red blood corpuscles of the 
patients tested and in the course of a few weeks 
restored them to health. 

Prevention of child-bed fever—Here also the 
combination of clinical and laboratory research bas 
been effective. 

The fact that the morbid agent known to be responsible 
for puerperal sepsis is a stroptococcus characterised by 
ability to hemolvse red blood corpuscles has of recent 
years been supplemented by the knowledge that the 
cocci having this property comprise several groups and 
sub-groups, of which only certain members are harmful 
to human beings. It emerges moreover that the hæmo- 
lytic streptococci occasionally found in the genital tract 
of healthy parturient women are not, as was formerly 
supposed, identical with those causing puerperal fever, 
which latter come from some outside source. Dr. Dova Cole- 
brooke has recently tracked down the probable sources 
of infection. She has confirmed the view that the strep- 


THE LANCET] 


tococci of the respiratory tract bear an intimate relation 
to puerperal fever; and her results suggest that the 
respiratory tract of the mother must be taken into account 
as well as that of her attendants, and that familial sources 
of infection may also be looked for. 


Arising from her work is the lesson that it is 
dangerous for any person suffering from an acute 
infection of this tract to engage in maternity work, 
and that maternity and surgical cases should not be 
treated under the same roof unless the nursing stafis 
can be kept separate. 

Standards for sex hormones.— Under this heading the 
Council urge medical men using sex hormones in their 
work to insist on knowing the exact nature and 
strength of the preparations supplied. The market 
is flooded with different preparations, and each 
manufacturing firm has given a proprietary name 
to its own particular product. While some of these 
proprietary preparations are good, both their composi- 
tion and activity being controlled, others are of a 
semi-bogus nature. The situation lent itself both to 
quackery and to ignorant treatment of disease 
until last year a conference, convened by the 
Permanent Standards Committee of the Health 
Section of the League of Nations, met in London 
under the chairmanship of Sir Henry Dale, and made 
important decisions in respect of nomenclature and 
standardisation. l 

A uniform scientific nomenclature and standard units 
have been adopted for three important natural substances 
of which therapeutic preparations are now available. 
These are: (1) “ estrone,” ‘ œstriol,” and ‘ cestradiol,”’ 
the cestrus-producing hormones (the alternative names 
applying to hydroxy-ketonic, trihydroxy and dihydroxy 
preparations, respectively); (2) ‘‘ progesterone,” the 
hormone of the corpus luteum which produces in the female 
the changes associated with pregnancy and pseudo- 
pregnancy; and (3) “ androsterone.” a chemical sub- 
stance closely related to that responsible for the develop- 
ment of the secondary sex characteristics in the male. 


The effectiveness of the proposals must ultimately 
depend on the attitude of those who use the substances. 
The Council point out that clinical knowledge of 
the actions of these sex hormones is still very 
elementary, and it is certain that they are physio- 
logically potent, often in unexpected directions. 


Miscellaneous Inquiries.—Travelling 
Fellowships 


Other studies reviewed editorially by the Council 
are the researches into the value, eftects, and possible 
dangers of different methods of producing anesthesia ; 
the artificial cultivation of living tissues ; iodine and 
thyroid disease; industrial pulmonary disease ; 
bed-bug infestation and the toxicity of industrial 
solvents. We shall have occasion from time to time 
to comment on some of these and on work in progress 
at the National Institute for Medical Research, at the 
-clinical research units, and under the external research 
schemes subsidised by the Council. 

Regret is expressed that in consequence of a change 
in policy of the Rockefeller Foundation, the system 
of international fellowships is being abandoned in 
favour of concentration upon a more restricted 
programme for the promotion of research. The 
Council had been privileged to award five or six 
whole-time fellowships every year, of the value 
of between £350 and £450 each; analyses showed 
that of the. 70 men and women who had completed 
their tenure of these fellowships 12 are professors, 
.36. others are engaged full-time, and a further 16 
half-time in. higher teaching and research. . The 
organisation of.a new scheme of the same kind is thus 


e 


MEDICINE AND THE LAW 


[{marca 14,1936 623 


considered highly desirable. A start has been made 
in the establishment of one such fellowship by the 
trustees of the late Lord Leverhulme, and the Council 
suggest that other potential benefactors have here 
a great opportunity of performing an important 
national service. | 


Mr. Ramsay MacDonald, who as Lord President 
introduces this year the report of the Committee for 
Medical Research of the Privy Council, announces 
that the grant-in-aid provided by Parliament for the 
expenditure of the Medical Research Council last year 
amounted to £165,000, compared with £139,000 in 
each of the three previous years. The increase has 
made it possible to proceed with plans for new 
research work which had been temporarily in 
abeyance and to undertake additional investigations 
required for the purposes of administrative depart- 
ments. Prof. J. A. Ryle and Prof. Matthew Stewart 
have replaced respectively Lord Dawson of Penn and 
Prof. A. E. Boycott as members of the Council, 
and the impending retirement of the chairman, Lord 
Linlithgow on his appointment as Viceroy of India 
is announced with warm appreciation of his services. 


MEDICINE AND THE LAW 


A Fatal Dose of Paraldehyde 


In Strangways-Lesmere «~. Clayton and others 
Mr. Justice Horridge has refused to hold a district 
hospital at Weymouth liable for the negligence of 
its nurses. The negligence consisted of administering 
6 ounces of paraldehyde to the plaintiff’s wife before 
an operation in mistake for 6 drachms. The honorary 
surgeon to the hospital gave instructions to the house 
surgeon for the patient to have per rectum 6 drachms 
in 9 ounces of water. The night nurse made a 
pencilled note of the instructions on the bed-board 
and handed it to Nurse A when the latter came on 
duty. The judge accepted the evidence of the day 
sister and the night sister that this pencilled note, 
thrown away after the operation, specified 6 drachms 
and not 6 ounces. It was the duty of Nurse A to 
administer the drug and of Nurse B to check the 
quantity. The bottle of paraldehyde was taken from 
a locked cupboard; the label stated that the dose 
was } to 2 fluid drachms. Nurse .A poured out 
6 ounces (half the bottle) and mixed it with 9 ounces 
of water; Nurse B watched her do so. The patient 
died of heart failure due to an overdose of paral- 
dehyde. Mr. Strangways-Lesmere sued the general 
committee and trustees of the Weymouth District 
Hospital and also Nurses A and B. He contended 
that a hospital was, like any other employer, liable 
for the negligence of its servants. The test was the 
power of the governors of the hospital to control the 
nurses’ work. A hospital authority was, he con- 
tended, protected in respect of the negligence of its 
nurses only where the negligence occurred in the 
course of work demanding professional nursing skill 
over the performance of which the governing body 
could have no control whatever. Here, said the 
plaintiff, the hospital authority had clearly assumed 
control over the measuring and checking of dangerous 
drugs by nurses because a hospital regulation had been 
made which required the sister on duty to check the 
dose. This regulation appeared not to have been 
properly published to the staff; it was not known to 
Nurse A or Nurse B ; no precautions had been taken 
to see that the rule was carried out. On the other 
hand the hospital authorities argued that their 


624 THE LANCET] 


MEDICINE AND THE LAW 


[mance 14, 1936 


relationship to the nurses was not that of master and 
servant when the nurses were preparing patients for 
operations ; the nurses were really carrying out the 
orders of the surgeon in mixing, checking, and 
administering the drug—which was work demanding 
professional training and skill. This argument, based 
on the well-known decision in Hillyer v. St. Bartholo- 
mew’s Hospital, succeeded. Mr. Justice Horridge 
agreed that the administration of paraldehyde was 
a skilled operation: it was true that there was a 
practice at the hospital that all the administration 
of dangerous drugs should be checked, but he did not 
think the hospital authorities undertook to administer 
the doses themselves: the nurses, in giving the 
doses, were doing their own work as skilled nurses 
and not as servants of the hospital authority. The 
administration of paraldehyde, as in this case, was 
not a matter of a nurse’s routine but one in which a 
nurse had to use professional skill. It was not work 
which Nurse A was put in the place of the hospital 
authorities to do, or work which the authorities 
intended to do for themselves. The only legal duty 
on the hospital authorities was to see that the nurses 
whom they engaged were duly qualified persons. 
The judge was asked to say that, as there was a 
practice of the hospital to have the doses of dangerous 
drugs checked, therefore the hospital was at fault in 
not putting up a printed notice to that effect. He 
found, however, no evidence that other hospitals 
exhibited such notices; the evidence was that 
checking was a well-known practice in hospitals and 
that the practice was in operation in the Weymouth 
Hospital. It followed that no negligence had been 
established against the hospital, and judgment with 
costs was given in the hospital’s favour. 


THE NURSES’ LIABILITY 


The higher the work of nurses is reckoned as an 
expert professional performance, the more vulnerable 
they become in the law courts as a separate target. 
In the Weymouth case the judge found that there 
was negligence on the part of Nurse A and Nurse B ; 
the damages had been agreed at £100 (if liability 
should be established), and judgment was given for 
this amount with costs against the two nurses. The 
judge said they would have been negligent even if 
the night sister had herself made the mistake of 
writing “‘6 ounces’’ on the pencilled note. Nurse A 
had looked at the bed-card and, if she had been careful, 
she must have seen that the dose was there stated 
to be “6 drachms.” Both Nurse A and Nurse B 
ought to have looked at the bed-card in measuring 
out the dose: in that case they would have seen 
that it was 6 drachms and not 6 ounces. Nurse A 
was also negligent because the label on the bottle of 
paraldehyde gave the ordinary dose by the mouth 
as 4 to 2 fluid drachms and she admitted that 
she knew that, when administered per rectum, 
the quantity would be at the most three times the 
quantity administered by the mouth, whereas the 
dose she actually administered was considerably 
larger than that. It had been argued on behalf of 
Nurse A that the case was unusual. In 99 cases out 
of 100 the patient’s bed-card should be the nurse’s 
Bible, but here the bed-card was inaccurate in no 
less than three particulars, and the house surgeon had 
given instructions which were at variance with the 
directions on the bed-card. As she had received 
instructions from the night sister, it could not be 
said that Nurse A was negligent in not following the 
bed-card. This argument was largely based on the 
assumption that the night sister made the mistake 
of writing “6 ounces ” in her pencilled note. As 


already stated, the judge rejected this assumption 
and held the two nurses liable. 


SYMBOLS OR METRIC SYSTEM 


In the Weymouth Hospital case it was supposed 
that the nurses had confused the drachm-symbol for 
the ounce-symbol. A medical witness, invited to 
explain these signs to the court, said that one had 
“one twist at the top” and the other had “two 
twists.” Counsel dramatically observed that a 
human life may depend upon the extra twist. The 
possibility of error has naturally revived discussion 
of the advantage of the metric system over the 
traditional mysteries of the apothecary’s script. The 
New English Dictionary shows ‘oz.’’ to have been 
adopted from the Italian ‘“‘ öz ” or “öZ.” a fifteenth- 
century abbreviation: the line above the letters is 
the familiar sign of a contraction, the full word 
being onza or in the plural onze. In Italian manu- 
script forms of the abbreviation the letter z had a 
full tail below and the tail was usually carried in a 
circle under, round, and over the o so as to form the 
line of contraction above it. It must also be remem- 
bered that the symbol 3 signified the omission of a 
final syllable, so that 04 would mean ounce or ounces. 
It is said that, when printing was introduced, the 
4 became a z to suit the convenience of a limited 
fount of type, and that, before this change became 
general, the symbol o% had been slurred by hasty 
writing into 3 and the lower weight of the drachma 
was adapted therefrom as 3, with “one twist” 
instead of two (see THE LANCET, 1906, ii., 453). In 
discussing the British Pharmacopeia of 1914 (THE 
LANCET, 1914, ii., 907), reference was made to 
certain recommendations that the old apothecaries’ 
symbols should be abandoned. The symbol 3j, it 
was pointed out, may be used to represent 60 grains 
and also to represent the fluid drachm; the symbol 
Z j to represent 480 grains, sometimes 437-5 grains, 
and also to represent the fluid ounce. Tradition in 
the writing of prescriptions, however, dies hard. Nor 
is that surprising in view of the replies to the question : 
“ Is the metric system used in teaching?” put by 
the General Medical Council to the teaching bodies 
in 1929. Four of the London and seven other medical 
schools gave a frank “no”; the remaining replies 
were little more than a qualified ‘“‘ no.” Liverpool 
had tried the metric system but discontinued it as 
the students preferred the imperial. The Aberdeen 
reply is perhaps the most significant: ‘ Sufficient 
instruction given to enable students to prescribe 
in the metric system, but they are told that it offers 
no advantages as regards safety.” If the metric 
system were in use, human fallibility is such that 
the decimal point might be inserted in the wrong 
place with serious results. In the Weymouth case 
the judge elicited the fact that any competent nurse 
should be able to distinguish one symbol from another. 


Societies Charitable and Uncharitable 


In the current number of the Fight Against Disease 
the hon. treasurer of the Research Defence Society 
writes on the menace to hospitals of ‘‘ antivivisec- 
tion’? methods and finance. He cites a passage from 
the Abolitionist (the journal of the British Union for 
the Abolition of Vivisection) which comments on 4 
recent bequest of legacies to the Bristol General 
Hospital and the Bristol Royal Infirmary on condition 
that “no experiments on living animals have been 
carried out in the premises for a period of five years 
prior to the date of actual payment.” The Abolitionist 
observes that the Bristol Royal Infirmary is No. 39 


THE LANCET] 


on the list of places registered for vivisection under 
the 1876 Act, and presumes that the legacy will be 
withheld ; ‘‘ it would be well,” it adds, ‘‘ if it became 
customary to bequeath legacies with this condition.” 
This comment naturally moves the treasurer of the 
Research Defence Society to remark upon the per- 
sistent attempts of antivivisectionist bodies to divert 
subscriptions from hospitals merely because the 
hospital necessarily includes on its staff a pathologist 
licensed to conduct inoculation experiments for 
diagnostic purposes, on which the early and efficient 
treatment of patients depends. Such propaganda 
may reasonably be described as uncharitable—an 
epithet which invites re-examination of the technical 
legal classification of antivivisection societies as 
charities. | 

Lawyers are aware of a doctrine known as the 
rule against perpetuities. Ordinary gifts are void if 
they infringe that rule. The law, however, has more 
kindness for charities than dislike for perpetuities. 
Gifts to a charity do not fail even if they exceed the 
period of time within which ordinary gifts must 
take effect. Hence it is important to know whether 
the objects of the gift are, in the eye of the law, 
charitable or not. The courts have regarded all 
objects as charitable which are either expressly 
named in a now repealed statute of Elizabeth or 
which are deemed to be by analogy within its spirit 
and meaning. There are plenty of decisions which 
show that societies for the prevention of cruelty to 
animals are ‘“‘charitable.”” There is at least one 
decision, In re Foveaux, where antivivisectionist 
objects were held charitable. Mrs. Frances Foveaux 
left money to her daughter Catherine with a special 
power of appointing a fund in favour of charity. 
The daughter by her will appointed legacies of 
£300 each to three named antivivisection societies, 
and Mr. Justice Chitty had, in 1895, to say whether 
the legacies were valid. He began by refusing to 
enter into, or pronounce any opinion on, the merits 
of the controversy between the supporters and 
opponents of the practice of vivisection. The court, 
he said, stood neutral. Stated broadly, the one side 
held that the practice, under careful safeguards, 
although it might inflict some suffering on the lower 
order of animals, was justifiable and tended to pro- 
mote the welfare of the human race and also of the 
lower order of animals in general. This side had in 
its favour the Act of 1876 under which the Home 
Office issues licences. On the other hand, said the 
judge, the antivivisectionists held that the practice 
was wholly unjustifiable ; it was cruel and immoral. 
He followed the previous decisions which favoured 
societies for prevention of cruelty to animals. Accept- 
ing the principle that all cruelty is degrading, he 
held that, if a society for preventing cruelty to 
animals is charitable, then a society for preventing a 
particular form of cruelty to animals must also be 
charitable. He was careful to guard against saying 
that mere infliction of pain was necessarily cruelty ; 
infliction of justifiable pain might not be cruelty. 
He wound up his judgment by saying that the anti- 
vivisection societies with which the case was con- 
cerned might be near the borderline, but he thought 
they were charities. 

The Foveaux case has long been followed, but in 
1929 its value was a little shaken in the Grove- 
Grady will case. Here a bequest to found the “‘ Beau- 
mont Animal Benevolent Society,” with provisions 
for a sort of sanctuary where all wild creatures 
would live free from human interference, was upheld 
by Mr. Justice Romer as a valid charitable trust. 
On appeal a strong argument to the contrary was 


MEDICINE AND THE LAW 


[MARCH 14, 1936 625 


built up by Mr. Wilfrid Greene, now a Lord Justice. 
Mr. Greene contended, amongst other things, that, 
if the court were not satisfied that propaganda and 
expenditure for the suppression of vivisection were 
beneficial to the community, they could not be the 
subject of a charitable trust. The Court of Appeal 


(Lawrence, L.J., dissenting) held that a trust in 


perpetuity for animals might be good if in its execu- 
tion there was necessarily involved a benefit for the 
community ; if no such element were present, the 
trust would be bad. Lord Justice Russel, one of 
the majority judges, said he knew of no decision 
upholding such a trust in favour of animals on any 
other ground than that the execution of the trust 
(in the manner defined by the creator of the trust) 
must produce some benefit to mankind. ‘‘I cannot 
help feeling,” he went on, “that in some instances 
matters have been stretched in favour of charities 
almost to bursting point.” He thought the authorities 
had reached the farthest admissible point of benevo- 
lence to charities in favour of animals; for his 
part, he was not prepared to go any further. The 
cases had run to fine distinctions, and, speaking for 
himself, he doubted whether some of the former 
decisions would not nowadays go the other way. 
“ For instance, antivivisection societies, which were 
held to be charities by Chitty, J., in In re Foveaux 
and were described by him as near the borderline, 
might possibly, in the light of later knowledge in regard 
to the benefits accruing to mankind from vivisection, 
be held not to be charitable.” Lord Justice Russell 
referred later to the Wedgwood case where a trust 
in favour of animals was upheld in 1915. He observed 
that it was not a decision that every trust for 
the benefit of animals would necessarily involve the 
benefit of the community, or that a trust for the 
benefit of animals which involved no benefit to 
the community would be a charitable trust. 
Undoubtedly the law adjusts itself to changes in 
public feeling and general knowledge. The Chitty 
judgment in the Foveaux case pointed out that the 
medieval ‘‘dole’’ charities were no longer to be 
regarded as beneficial; they tended to pauperise a 
district and the court might nowadays find itself 
against them. Old beliefs change. The antivivi 
section ideas of past generations, still provocatively 
propagated by the societies, refuse to allow that any 
experiment on animals can be beneficial. Lord 
Justice Russell, in the passage already cited, assumes 
without hesitation the benefits accruing to mankind 
from vivisection. The recent failure of the Battersea 
General Hospital, while maintained on uncompromis- 
ingly antivivisectionist lines, is further evidence 
of the change. The hospital frankly admitted that 
the restrictions prevented it from giving medical 
treatment in accordance with the best modern 
standards. It was even confessed that the staff had 
been infringing the restrictions in the interests of 
the patients. The antivivisectionist societies still 
stand for a policy which attacks what is now recog- 
nised as beneficial to the community. To this 
extent their own objects are the reverse of beneficial 
to the community and will cease to be charitable, 
in the legal sense, as soon as the courts follow the 
direction suggested by Lord Justice Russell. It 
is not too late for the societies to abandon their 
propaganda against the officially licensed systems 
of experiments on animals and to concentrate upon 
other and more admirable forms of animal welfare. 
The price of remaining charitable for the purpose of 
exemption from the law against perpetuities is to 
be less uncharitable in the simpler meaning of the 


layman. 


626 THE LANCET] 


BUCHAREST 


(FROM OUR OWN CORRESPONDENT) 


THE HIGH INFANT MORTALITY 
INVESTIGATIONS by Prof. Mezinescu, of the Univer- 


sity of Bucharest, revealed a disconcerting rise in- 


the infant mortality in the last decade. In Rumania 
50 per cent., that is 12,000 infants, die during the 
first year, and of the remainder only half reach the 
fifth year. Not only are our figures higher than any 
in Europe, says Mezinescu, but what is more sad, 
the mortality is no lower now than it was fifty years 
ago. The situation is not much better in the towns 
than in the villages ; the rate is highest in Bessarabia 
and lowest in the province of llfov, containing 
Bucharest. He drew the attention of the govern- 
ment to the fact that large districts with twenty or 
twenty-five villages have only one doctor, who is 
quite unable to treat all the children in the epidemics. 
There should not be more than ten villages to a 
district, he said, and there should be a good salary 
to attract medical men, because the ordinary income 
from private practice is negligible on account of the 
great poverty of the rural population. 


RECOGNITION OF FOREIGN DIPLOMAS 


In the years 1924-34 no less than 1261 foreign 
diplomates have had official recognition in Rumania, 
As a rule, said Dr. Peter Stroescu at the annual 
general meeting of the National Medical Association, 
such recognition violated the principles of law and 
of national pride. Some of the diplomas may be 
acceptable, but most have been obtained with a 
much shorter period of study than that demanded 
in the Rumanian universities, and some do not 
qualify their owners for medical practice even in 
the country of issue. It is noteworthy, he said, that 
these diplomas are granted not by the important 
centres but by small universities which are almost 
unknown in the scientific world. Another abuse is 
the permission given to physicians who cannot 
produce their original documents and licences as 
evidence of qualification. Having failed in practice 
after many years in another country, they do not 
meet any difficulty when they decide to settle in 
Rumania. These faults, Dr. Stroescu said, need 
active and urgent remedy, and all the regulations 
for recognising foreign diplomas must be revised ; 
all who cannot produce original certificates within a 
certain period should be prohibited from practising. 
He proposed a rigorous investigation before granting 
recognition and that a comprehensive examination 
should be passed. These reforms should also be 
extended to the registration of dental practitioners. 
Dr. Tetul, of the University of Bucharest, has said 
that the foreign diplomas are obtained mainly by 
Bessarabian Jews and Magyars, and Dr. Danica 
asked that regulations should be introduced govern- 
ing the proportion of the different races in medical 
practice and that the Association should demand 
that all foreign diplomas should no longer be recog- 
nised. 

TAXATION OF COSMETICS 


A new Act imposes a 10 per cent, ad valorem duty 
on all cosmetics, even if they contain official drugs. 
The duty is to be paid in stamps attached to the 
wrapper in such a way that they are torn in opening 
the packet. As the list includes hair lotions - con- 
taining quinine, sulphur, or resorcin ; powders contain- 
ing salicylates and zine oxide; ointments with 
ichthyol] and mercury ; and bath salts with medicinal 


BUCHAREST.—IRELAND 


[MARCH 14, 1936 


properties, a protest meeting was called by the 
National Medical Association. This will probably 
result in the withdrawal of these preparations from 
the list, confining the tax to those that are purely 
cosmetic. 


BCG VACCINATION IN RUMANIA 


In spite of all objections, B C G vaccination is con- 
sidered indispensable by an ever-increasing majority 
of pediatricians. This attitude is supported by 
several articles recently published in this country, 
among them one by Bradiceanu, who favours intra- 
cutaneous injections of the vaccine. The criticisms 
made are that vaccination is ineffective and that 
it is harmful. In reply Bradiceanu blames the 
first on lack of absorption, because so many children 
vomit the material when it is given by mouth, and 
he thinks that the intracutaneous method intro- 
duced by Wallgren will solve the problem. The 
principal aim is to attain a relative immunity especi- 
ally against the primary infection, but the infant 
has to be guarded for at least two months against 
every kind of tuberculous contact, and vaccination 
will not protect him from massive or constant 
invasions. As to its being harmful, Bradiceanu says 
that no one has yet proved that the attenuated 
organism of BCG can regain its virulence ; in the 
absence of reliable statistics, the significance of the 
slow growth and gastro-intestinal disturbances of 
vaccinated children cannot be judged. 


IRELAND 


(FROM OUR OWN CORRESPONDENT) 


NATIONAL HEALTH INSURANCE IN 
FREE STATE 


THE committee stage of an amending Bill to the 
National Health Insurance Acts gave an opportunity 
in the Dáil last week to draw attention to a peculiar 
feature of the administration of national health 
insurance in the Irish Free State. Itis that in such 
administration neither in the central authority of 
the Controller’s office nor in the office of the Unified 
Society is there a single medical man employed, nor 
is there any machinery by which medical opinion or 
medical knowledge is brought to bear on the work of 
insurance. The Bill before the Dáil was one dealing 
with the management of the Unified Society which 
a few years ago replaced the numerous approved 
societies. An amendment was brought forward to 
provide that there should be one medical practitioner, 
to be appointed by the Minister, as a member of the 
committee of management of the Unified Society. 
At the end of the discussion the Minister promised 
to consider the matter and the amendment was 
withdrawn. When national health insurance was 
first established in Ireland in 1912 the central authority 
was a commission of which one of the four members 
was bound by statute to be a medical practitioner. 
On the staff of the commission were two medical 
inspectors. ,Nearly all the approved societies had 
medical advisers of their own. Some ten years ago 
the commission appointed three medical referees to 
assist them in deciding as to entitlement to sickness 
or disablement, but these gentlemen have no share 
in or influence on administration. The commission 
was abolished some years ago, and as vacancies 
occurred in the post of medical inspector no fresh 
appointments were made. The Unified Society, in 


(Continued at foot of opposite page) 


THE IRISH 


© which the several approved societies were merged ` 


THE LANCET] 


PANEL AND CON 


TRACT PRACTICE 


(Manon 14,1936 627 


Two Successful Appeals on Specialist Service 


AN insurance practitioner has appealed with success 
against two decisions of the Surrey insurance com- 
mittee. Both cases related to operations—removal 
of the appendix and removal of a twisted ovarian 
cyst—performed at a hospital outside the area of the 
doctor’s insurance practice upon insured patients. 


CASE ONE 


In the first case an attempt having failed to secure 
a bed in a local hospital arrangements were made 
for the patient’s admission to another hospital some 
distance away. The practitioner, before operating, 
made it clear to the patient that the operation was 
outside the scope of medical benefit and that there 
would be a fee of five guineas, and a further guinea 
for the anesthetist. The fees were paid and the 
patient then applied to the H.S.A. for assistance 
which was not available. The doctor advised the 
insured person to apply to his society, but the man 
wrote to the insurance committee and correspondence 
between the committee, the doctor, and the patient 
ensued. The doctor was told by the clerk of the 
committee that he should have submitted form G.P. 45 
to the committee within two days of the date on 
which treatment was given. The clerk’s letter was 
mislaid and the doctor had to ask for a copy, pro- 
mising his observations upon the receipt of the 
copy. He added that it had occurred to him that 
as the hospital was outside the area of his practice 
the patient would have no right to call on his services 
there, and the question whether appendicectomy 
was within the scope of medical benefit or not would 
be immaterial. 

The clerk’s reply indicated that the correspondence 
had been submitted to the medical benefit subcommittee, 
that he had been instructed to state that it would appear 
that the submission of the account to the patient con- 
stituted a breach of the terms of service, and went on 
to ask the doctor to send a cheque for six guineas so 
that a similar amount might be sent to the patient. The 
doctor objected that the subcommittee had found him 
guilty of a breach of the terms of service without receiving 
any statement from him. He reiterated that he had 
informed the patient that the operation was not within 
the scope of medical benefit, and that he had filled in 
form G.P. 45 on his return home from performing the 
operation, and to the best of his knowledge and belief 
posted it. In due course the medical service subcom- 
mittee heard the case and took the view that the form 
G.P. 45 had not been posted; they recorded the opinion 
that the fee paid by the patient was returnable to him. 
The insurance committee adopted the recommendation 
that the terms of service had not been complied with, and 
that the sum of six guineas should be deducted from the 
practitioner’s remuneration and be refunded to the 
insured person. 

The doctor appealed to the Minister, basing his 
case mainly on the form of the inquiry and, as the 
persons appointed to hear the appeal were not im- 
pressed that aspect need not be particularised. But 


' their report, commenting upon the fact that the 


— m e  .. M a i i  eeee- m O 0 o ee 


(Continued from previous page) 


two years ago, has had no medical adviser on its staff. 
At present the national health insurance system 
operating in the Irish Free State performs no functions 


© directly concerned with either the prevention or the 


cure of disease. 


It merely administers a number of 
cash benefits. | - 


doctor did not raise any question regarding the 
form of the resolution passed by the committee, 
expresses the view that the Minister could and 
should do so. Under Article 34 of the Regulations 
a committee can recover from a practitioner expenses 
reasonably and necessarily incurred by an insured 
person owing to the practitioner’s failure or neglect 
to comply with the terms of service, and can repay 
to the insured person the sum so recovered. But 
the liability. for the fees had been incurred, not by 
reason of any default on the doctor’s part but by 
reason of a contract voluntarily entered into by the 
parties, a contract which did not in any way conflict 
with the doctor’s duties under the terms of service. 
On legal grounds therefore they recommended that 
the appeal should be allowed. The view of the referees 
on the merits of the insurance committee’s decision 
may .be given in their own words: 

“ In the first place it will be noted that the decision 
was to withhold £6 6s., a sum which comprises the anes- 
thetist’s fee of £1 ls. Now it was not suggested that 
Dr. A. had previously been remiss in sending forms G.P. 45. 
In fact the evidence led us to suppose that this was the 
first occasion on which he had charged for an operation 
on an insured person. Yet, for overlooking the necessity 
for submitting form G.P. 45, or possibly for merely for- 
getting to post the form when filled up, the insurance 
committee propose not only to deprive the doctor of his 
fee, but also to make him pay out of his own pocket the 
an:esthetist’s fee. 

“To our mind such a penalty is out of proportion to 
the offence.”’ 


CASE TWO 


In the second case the patient entered the same 
hospital during the evening of Dec. 23rd, 1934. 
The operation began about 11.45 p.m. and lasted 
about three-quarters of an hour, the doctor returning 
home about 1 a.m. On the same day, Dec. 24th, the 
doctor wrote to the committee giving details of the 
operation and of his special experience, stating that 
he had informed the patient that the operation was 
outside the scope of medical benefit, enclosing an 
anesthetic claim form, and inquiring whether in the 
circumstances the claim in respect of the services 
of an anesthetist would be allowed. The doctor 
asked for a supply of anesthetic claim forms as 
well as of G.P. 45, and inquired whether he would 
have to submit form G.P. 45 containing the particulars 
set out in his letter. Correspondence ensued and the 
case was submitted to the medical benefit sub- 
committee, who, under the provisions of Article 32 (2) 
of the Regulations, referred it to the medical service 
subcommittee. No fee had been charged. The 
service subcommittee found that the doctor per- . 
formed the operation on Dec. 23rd—24th, and that 
form G.P. 45 was received by the committee on 
Dec. 31st. They reported that the terms of service 
are explicit that the notification should be on a form 
to be provided by the committee, and the sub- 
committee, taking the view that practitioners know 
that the time is extremely limited in which they are 
required to furnish the form to the committee cannot 
avoid the conclusion that the onus is upon the doctor 
to have the forms in his possession, ready for use, 
or to take the quickest possible means of obtaining 
such forms so as to be able to comply with the terms 
of service. 

The insurance committee resolved, on the recom- 
mendation of the subcommittee, that in their opinion 
the terms of service had not been complied with, 
and that the doctor was precluded from making a 
charge to the insured person for the treatment given. 


628 THE LANCET] 


PUBLIC HEALTH 


[marnon 14, 1936 


It is hardly to be wondered at that the doctor appealed, 
contending that the insurance committee had acted 
unreasonably. The report of the persons appointed 
to hear the appeal is again given in their own words: 


“ The doctor suggested that Christmas Day and Bank 
Holiday should be excluded in the computation of time, 
and that if the clerk had acted promptly in complying 
with his request for a supply of forms G.P. 45 the return 
would have been made in time. He also suggested that 
he had in fact complied with the terms of service by 
giving full particulars in his letter of Dec. 24th. He 
alleged that compliance with the terms of service was 
rendered difficult by the failure of the committee to 
afford adequate supplies of the forms, and said that only 
two forms were sent in response to his request of Dec. 24th. 
He alleged, further, that the clerk had adopted an unreason- 
able and unfair attitude towards him, and he illustrated 
his complaint by reference to a paragraph in a letter 
dated August 3rd, 1935, addressed by the clerk to the 
Minister of Health in reference to the doctor’s appeal. 
The paragraph reads as follows: 

‘ <$ The substance of the doctor’s contentions arises out 
of circumstances which require examination. 
until the doctor was informed that a form was necessary 
and that he was out of time that he replied using words 
which clearly meant that he proposed to contend that 
Dec. 24th and not Dec. 23rd was the date of the operation, 
and it is submitted that this alteration was made for no 
other purpose but to enable him: (1) to state that he 
asked for a form in plenty of time, and (2) to use the 
fact that there had been a day’s delay in answering his 
first letter for the purpose of throwing upon the office 
the responsibility for his non-compliance with the terms 
of service.’ 

“ The words used here by the clerk seem to contain the 
innuendo that Dr. A. did not carry out the operation on 
Dec. 24th, notwithstanding his assertion that he did so, 
and that in making the statement he was actuated by 
improper motives. The clerk used words to the same 
effect at our inquiry. We pointed out that the medical 
service subcommittee had found that the operation was 
performed on Dec. 23rd and 24th, and we asked the clerk 
whether, before deciding to question Dr. A.’s bona fides 
in this connexion, he had taken any steps to ascertain 
from the patient or from the hospital authorities whether 
the operation was completed before the 24th. He said 
that he had not done so. We need hardly say that the 
suggestion contained in the paragraph involves a serious 
reflection on Dr. A.’s character, and it should never have 
been made without first taking all possible steps to ascer- 
ain the true facts of the case; and we cannot help think- 
ing that the clerk’s action in this matter gives some support 
to Dr. A.’s allegation of unfairness on the clerk’s part. 

“ We are not aware of any authority for the view that 
Christmas Day and Boxing Day should be excluded in the 


It was not’ 


computation of time, and we are forced to the conclusion 
that, on a strict construction of Clause 10 of the terms 
-of service, Dr. A. failed to furnish the insurance com- 
mittee with form G.P. 45 within the prescribed time, and 
that, consequently, any demand for payment of his fees 
would amount to a breach of the terms of service which 
would render him liable to disciplinary action. Having 
regard, however, to the fact that the insurance com- 
mittee was immediately furnished with full particulars of 
the operation and that Dr. A. forwarded form G.P., 45 
to the committee as soon as he could obtain a form from 
the clerk, we do not think that it was a case in which the 
committee should have thought it necessary to intervene 
if a fee were claimed. 

“ It should be noted that the resolution stated that 
the terms of service were not complied with. This is 
tantamount to saying that there had been a breach of 
the terms of service. As, however, Dr. A. had made no 
demand for the payment of his fees, it is impossible to 
hold that there had been any breach, and we accordingly 
recommend that the appeal be allowed. 

“ We have not made any direct reference to the clerk’s 
arguments in this case. So far as we can understand 
them they were to the effect that the provisions of Clause 10 
were quite rigid and left no discretion to the committee. 
We entirely dissent from this view. While it is true 
that the committee have no power to sanction a breach 
of the terms of service, we see no foundation for the view 
that they are bound to examine microscopically every 
transaction with a view to ascertaining whether there 
has been some technical departure from the terms of 
service, however insignificant. We consider that the 
insurance committee in these above two cases passed 
resolutions which were ultra vires, adopted an attitude 
towards Dr. A. which the circumstances did not justify, 
and put him to unnecessary trouble and expense, and we 
recommend accordingly that Dr. A. should be awarded 
costs against the committee.” | 


In allowing the appeals in both cases the Minister 
directed that the doctor should be awarded five 
guineas costs against the committee, and practi- 
tioners will welcome this indication that the Minister 
approached the matter from a common-sense point 
of view. It is a pity that the committee were so 
insistent on the letter of the law that they appear 
to have blinded themselves to its spirit. In the 
second case, in particular, a reasonable person might 
well ask what details other than those given by the 
doctor in his letter of Dec. 24th would or could have 
been included in form G.P. 45—and anyhow who 
would seriously contend that either an appendicec- 
tomy or the removal of an ovarian cyst 1s other than 


' a specialist service ? 


PUBLIC HEALTH 


The Building Line in London 


THe Town and Country Planning Act of 1932 
gave the London County Council general control 
over the development of London, and therewith of 
the height of any buildings to be erected. The 
relevant committee in a report to the Council pre- 
sented on Tuesday does not wish to enforce a general 
standard height throughout the county; it prefers 
to be guided partly by the trafic problems of the 
area but more especially by the need for ensuring 
sufficient light and ventilation for the buildings 
erected, particularly on the lower floors. The needs 
vary according as the area is (1) of a central business 
nature or chiefly used for basic industry; (2) resi- 
dential but unsuitable for single family dwelling- 
houses ; (3) suitable rather for family dwelling-houses 
than for multiple dwellings. In its model clauses the 
Ministry of Health has already suggested a limita- 


tion in the height of buildings based on a maximum 
overall height restriction with an angular limit, and 
the L.C.C. town-planning committee has now arrived 
at a formula applicable to the three building zones 
indicated. In the third zone in which single family 
dwelling-house development is likely to predominate 
the height in feet is to be limited to 40 for dwelling- 
houses, whether single or multiple, and 60 for indus- 
trial buildings, the height not to exceed in any case 
the width of the street. In the multiple dwelling 
area the height of the single dwelling-house has the 
same limitation but the multiple dwelling may be 
60 feet high and the industrial 80 feet. In the central 
zone the limit in each category may be exceeded by 
another 20 feet ; and the height may be 1} or 14 times 
respectively the width of the street. Higher buildings 
may be permitted in special circumstances or special 
restrictions imposed in the neighbourhood of ancient 
monuments The plan specifying the zones is to be 
issued before Easter. a | 


THE LANCET} 


Mr. Coste’s Retirement 


On April 8th Mr. J. H. Coste, F.I.C., chemist to 
the L.C.C. public health department, will reach the 
retiring age. Mr. Coste entered the Council’s service 
in 1894, became chief assistant to the late Mr. Frank 
Clowes, D.Sc., in 1908, and when the chemical work 
was transferred to the public health department in 


1913 he was given the designation of chemist in that 
department, and appointed official agricultural 
analyst for the county. The establishment committee 


THE SERVICES 


[maron 14,1936 629 


in announcing his retirement remarks that Mr. Coste 
has for many years held a very high position in the 
chemical world ; his work with its extensive variety 
of analytical and experimental duties has been of 
great value to the Council, and by his retirement 
the Council is losing the services of a distinguished 
member of its staff. Mr. Coste is an authority on 
the treatment of sewage, technical gas calorimetry, 
and the investigation of fog and smoke; he has 
long been a member of the atmospheric pollution 
committee constituted by the Department of Scientific 
and Industrial Research. 


THE SERVICES 


ROYAL NAVAL MEDICAL SERVICE 

Surg. Capts. G. V. Hobbs to Ganges: T. Creaser to 
Pembroke for R.N.B.; and E. C. Holton, O.B.E., to 
Pembroke for R.N.B., and for duty with S.R.A., R.N. 
Hospl., Chatham, as Naval Health Officer, Nore Command. 

Surg. Comdrs. A. H. Harkins to Victory for R.N.B. ; 
W. E. Heath to Drake for R.N.B.; and G. E. D. Ellis, 
O.B.E., to Drake for Devonport Dockyard. 

Surg. Lt.-Comdr. (D.) R. J. M. Andrews to Victory 
for R.M. Infirmary, Portsmouth. 

Surg. Lt.-Comdr. R. R. Baker to rank of Surg. Comdr. 

Surg. Lt. W. F. Viret to Tern. 

Surg. Lt. (D.) S. R. Wallis to Neptune. 

A. F. Ferguson, J. B. Morris, H. P. L. Rhodes, and 
D. N. Williamson, as Surg. Lts. (D.) entered for short 
service, and apptd. to Victory for R.N. Hospl., Haslar. 


ROYAL NAVAL VOLUNTEER RESERVE 
Surg. Lt.-Comdr. R. B. H. Wyatt placed on Retd. List. 
Surg. Lt. W. G. Campbell, M.B., to Pembroke for R.N.B. 
Surg. Lt. (D.). L. B. Hilton to Drake for R.N.B. 


ROYAL ARMY MEDICAL CORPS 

Short Service Commissions: Lts. (on prob.) confirmed 
in their rank: J. J. Sullivan, M. Kosloff, A. Gleave, 
J. L. Gordon, A. M. Pugh, J. H. Taylor, D. N. Keys, 
G. C. Dansey-Browning, S. J. Meyersohn, M. H. P. Sayers, 
D. P. Stevenson, S. Brown, P. B. Hanbury, G. A. E. 
Harman, G. A. Weir, H. N. Perkins, J. D. Cruickshank, 
P. J. Geoghegan, W. N. J. Clarke, and T. D. M. Martin. 

Lt. (on prob.) A. R. O. Denton resigns his commn. 


REGULAR ARMY RESERVE OF OFFICERS 

The undermentioned having attained the age limit of 
liability to recall, cease to belong to the Res. of Off.: 
Lt.-Col. R. E. Humfrey, C.M.G., and Maj. J. L. Wood, 
O.B.E. 

Capt. A. Hemingway, from the Supp. Res. of Off. 
R.A.M.C., to be Capt. 

SUPPLEMENTARY RESERVE OF OFFICERS 
R. P. Leake to be Lt. 
ARMY DENTAL CORPS 

Lt. (on prob.) W. F. Finlayson is confirmed in his rank. 

Short Service Commissions: To be Lts. (on prob.): 
R. Edwards, A. F. Town, H. J. Burns-Jones, W. J. 
Constantine, P. J. Pigott, and R. G. Kent. The under- 
mentioned Lts. (temp. commissions) to be Lts. (on prob.) : 
J. H. Sherwen, C. W. Upton, B. E. ffrench, W. F. 
O’Carroll, and R. J. Godfrey. 

TERRITORIAL ARMY 

Capt. D. A. O. Wilson to be Divl. Adjt., 53rd (Welsh) 
Div., vice Maj. G. E. MacAlevey, M.C., vacated. 

Lts. to be Capts: W. D. F. Lytle, B. C. Jennings, 
J. Tidd, and H. W. E. Jones. 

G. O. Brooks (late Cadet C.S.M., Oakham Sch. Contgt., 
Jun. Div., O.T.C.) and Scott-Russell Trick to be Lts. 


‘TERRITORIAL ARMY RESERVE OF OFFICERS 
Maj. R. B. Green, M.B., F.R.C.S., from Active List, 
to be Maj., Jan. 27th, 1936. (Substituted for the notifica- 
tion in the Gazette of Feb. 18th, 1936.) 
ROYAL AIR FORCE 


Squadron Leaders L. Freeman to R.A.F., General 
Hospital, Hinaidi, Iraq, for duty as Medical Officer; 


T. R. S. Thompson to R.A.F. Station, Andover, for duty 
as Medical Officer. | 

Flight Lt. A. L. St. A. McClosky is promoted to the 
rank of Squadron Leader. 

Flight Lt. F. I. G. Tweedie to School of Army Coédpera- 
tion, Old Sarum. 

Flying Offr. W. J. L. Dean to R.A.F. Station, Biggin Hill. 

RESERVE OF AIR FORCE OFFICERS 


Special Reserve: Flight Lt. D. S. Buchanan relinquishes 
his commission on completion of service. 
INDIAN MEDICAL SERVICE 


Maj. W. E. R. Dimond to be Lt.-Col. 
The undermentioned officers retire: Col. Sir C. JI, 
Brierley, Kt., C.I.E., and Col. W. T. McCowen, V.H.S. 


Col. Brierley, whose name was in the recent New Year 
honours, was inspector-general of civil hospitals and jails, 
North-West Frontier Province. 


Indian Medical Department: Maj. (Sen. Asst. Surg.) 
L. V. O. Easdon retires. 
COLONIAL MEDICAL SERVICE 
Miss J. C. Drury, B.Ch., M.R.C.S., L.R.C.P., has been 
appointed Bacteriologist-Pathologist, King Edward VII. 
Hospital, Bermuda. 


DEATHS IN THE SERVICES 


Colonel SAMUEL Jonn Tomson, C.I.E., I.M.S. (retd.), 
who died at Mentone on Feb. 27th in his 83rd year, was 
the son of Mr. J. B. Thomson of Ramsgate, and was - 
educated at St. John’s College, Hurstpierpoint, and 
St. Mary’s Hospital. He qualified M.R.C.S. in 1874, 
was resident obstetric officer there, and later house surgeon 
at the Kent and Canterbury General Hospital. In 1877 
he entered the Indian Medical Service, was gold medallist 
and Herbert memorialist at Netley, and was with the field 
force at the relief of Kandahar in 1880, being awarded the 
medal. In 1890 he became a member of the Leprosy Com- 
mission, and in 1896 was Sanitary Commissioner of the 
N.W. Province and Oudh. In 1902 he served as director of 
Burgher camps in the Transvaal, receiving the medal with 
two clasps. In 1898 he was created C.I.E. for services con- 
nected with plague and famine, and C.B.E. (Mil.) in 1919. 
He retired from the service in 1908, but on the outbreak 
of war in 1914 was appointed commandant to the 2nd War 
Hospital at Birmingham with the rank of brevet-colonel. 

The death occurred on March 9th in London of Sir JAMES 
Macır, K.C.B., Colonel, late R.A.M.C. Son of the late 
Rev. William Magill of Cork, he was born in September, 
1850, educated at Queen’s College, Cork, and at University 
College, London, and took the degrees of M.D., M.S. 
Queen’s University, Ireland, and M.R.C.S. Eng. in 1871. 
Entering the Army as staff assistant surgeon in March, 
1872, he was appointed in 1876 to the Coldstream Guards 
becoming surgeon-major in 1885, surgeon It.-col. in 1896, . 
and ultimately colonel in the Army Medical Services. 
He served in the Sudan in 1884-85 (severely wounded 
at Abu Klea) and also in South Africa, 1899-1902. For 
these services he was mentioned in dispatches, received 
the medal with two clasps and the bronze star, and was 
again mentioned in dispatches, receiving two medals with 
eight clasps, and the C.B. (Mil.) in 1900. He was principal 
medical officer, Egypt, from 1905 to 1907, when he retired. 
He was appointed organising secretary of the British 
Red Cross Society in 1910 and the K.C.B. (Mil.) was 
awarded him in 1917. 


630 


THE LANCET] 


[marca 14, 1936 


CORRESPONDENCE 


TREATMENT OF VAGINAL DISCHARGE 
To the Editor of THE LANCET ' 


Sir,—It appears that opinions differ considerably 
upon the subject of Trichomonas vaginalis. If 
one were to believe the literature issued by certain 
manufacturing chemists trichomonas is common. 
Mr. Luker says it is very rare. My own feeling is that 
in gynecological practice the trichomonas though 
not common ought to be remembered, for once 
discovered it is fairly easy to eradicate. The type 
of case in which trichomonas infection should be 
suspected is where a discharge persists after routine 
treatment for urethral and cervical infection, gono- 
coccal or non-specific. In such a case Trichomonas 
vaginalis would appear to be in the nature of a 
secondary invader, producing its effect when the 
original infection has abated. The following case 
is an example :— 

A.B., aged 48 years, attended first complaining of 
vaginal discharge of ten weeks’ duration which she had 
treated herself by douching. Gonococci were found in a 
urethral smear, and there was slight endocervicitis clini- 
cally. She was treated with douches, contramine pes- 
saries, and later with a gonococcal vaccine. After six 
months’ treatment there was clinically neither urethritis 
nor cervicitis, no pus cells in a urethral smear and few in 
a cervical smear. There persisted, however, a fairly 
profuse thick white vaginal discharge in which Tricho- 
monas vaginalis was found. After one week’s treatment 
with Devegan the discharge was considerably less, and 
trichomonas was not found. Treatment was repeated 
for a further week when discharge had ceased and no 
pus cells were seen in cervical or vaginal smears. 


A vaginitis produced by trichomonas alone is 
manifested by a frothy yellow discharge and a vaginal 
wall marked with red spots. This clinical picture is 
not always seen in its entirety. In an article entitled 
Non-operative Gynecological Treatment (Post-Grad. 
Med. Jour., March, 1936) Dr. V. B.’ Green-Armytage 
states that trichomonas infection is responsible for 
at least 30 per cent. of cases of the infective type of 
leucorrhcea in virgins. In a series of 25 cases, 
examined by permission of Miss G. M. Sandes, 
F.R.C.S., at the out-patient department of the 
London Lock Hospital (which is attended by gynsxco- 
logical and urological as well as venereal disease 
cases), 5 (or 20° per cent.) were found to have 
trichomonas in the vaginal discharge. These cases 
conformed mainly.to the type described above, and 
were chosen for investigation for that reason. They 
are not strictly comparable to the type to which 
Dr. Green-Armytage refers, but if the two are taken 
together they illustrate that trichomonas is not a 
factor to be overlooked in the investigation of any 
case of leucorrheea. 

The treatment adopted here is as follows: The 
patient is instructed how to insert a Devegan or 
Stovarsol tablet into the vagina, and does this each 
night. In some cases morning douching is ordered. 
Patients are seen each week and a vaginal specimen 
examined. In no case has trichomonas been found 
after one week’s treatment, which is then continued 
until discharge ceases. A further week’s treatment 
is given after the first menstrual period to avoid 
recurrence during the alkaline tide. 

It would appear that Devegan, Stovarsol, Spirocid, 
and Orarsan are of equal service in this condition. 

I am, Sir, yours faithfully, 
JAMES MARSHALL, 


Resident Medical Officer, London 
Lock Hospital. 


March 6th. 


GASTRIC ACIDITY AND ITS SIGNIFICANCE 
To the Editor of THE LANCET 


Sir,—Dr. A. F. Hurst’s comments in your issue of 
Jan. 18th are of great interest to me because with 
a large mass of evidence and his great experience he 
has been able to confirm results which we hope to 
publish in the near future. Thus it has also been 
the experience of both Alvarez and ourselves (private 
communication) that the acidity remains high in 
gastric and duodenal ulcer in spite of severe hæmor- 
rhage, and in certain other cases with gastric 
symptoms. We have also found free acidity in severe 
anæmias of other types. In my paper of Jan. 4th, 
however, I was not concerned with these cases, but 
confined myself to the hemorrhagic anæmias without 
gastric symptoms. Further experience certainly 
seems to show that I have probably erred in placing 
my achlorhydria-hemoglobin level too high. What- 
ever this level may be it is, after all, only an aver age, 
with, as I stated, considerable individual scattering 
above and below. 

That the achlorhydria in our cases is secondary to 
the hemorrhagic anzmia is shown by the fact that 
free acid appears and later rises with improvement 
in the blood condition. (Some individuals of course 
have achlorhydria throughout.) Further, in animals 
we can produce lowering of the acid at will by bleeding, 
and this condition remains as long as the animal 
is anemic. The full details of these observations 
will be published in the near future. 

As regards the effect of asthma, I was quite 
well aware that gastric acidity is commonly low 
or absent between attacks. But I threw out a 
suggestion that it might be of interest to investigate 
the effect of asthma on gastric acidity during the 
attack. Does the rise of plasma CO, during an 
attack raise acidity? Or does the accompanying 
anoxemia have the opposite effect? I can find 
no information on the question. 

I am, Sir, yours faithfully, 
FRANK L. APPERLY. 

Medical College of Vite uenmond, Virginia, U.S.A., 


OPERATION FOR FEMORAL HERNIA BY A 
MIDLINE EXTRAPERITONEAL APPROACH 


To the Editor of THE LANCET 


Sir,—In reference to Prof. A. K. Henry’s. article 
in TuE LANCET last week (p. 531) may I refer him 
to the Proceedings of the Royal Society of Medicine 
(vol. xv., No. 4, 1922, p.13). He will see there that 
I described a midline extraperitoneal approach for 
inguinal and femoral hernia. The only modification 
I would make to that description is that I see no 
reason for not operating on’ younger patients. I 
would point also to the care that is necessary to avoid 
injury to the ureter in operating on femoral hernie. 

I am, Sir, yours faithfully, 


March 9th. G. LENTHAL CHEATLE. 


PROGNOSIS IN SPINAL CARIES 
To the Editor of THE LANCET 


Sir,—It is rather irritating to find an otherwise 
carefully compiled article seriously marred by figuring 
which will not stand careful scrutiny. In to-day’s 
issue of THE LANCET there is an unfortunate example 
of this in the article Prognosis in Spinal Caries on 
page 562. Apparently the total number of cases 


E O e E E meee, m ee 


THE LANCET] | 


under review was 1666; of these 1582 cases were 


discharged during the period and 61 died. No mention 
of the 23 cases required to make up the total. 
Percentages are usually shown in relation to the total 
number treated, and in this case in my opinion they 
should be represented in this way : 


Total number of case 1666 =100 % 
: 1582 = 


- Discharged ii 95:00 % 
Died nee 61= 364% 
Unaccounted. . 23= 1°36 % 

l 100-00 % 


In “Causes of Death” the figures 


given in the 
first instance are— 


Miliary T.B and meningitis 
Sepsis and amyloid disease 16 
Other causes mA 13 


but if the tabulated figures are added up we get 
32, 15, and 14 respectively. In an investigation of 
this kind it would probably be better to deal with 
only those cases in which a conclusion has been 
reached, and in this way the figures should be 
shown thus : 

Total cases the outcome of which is 

own , $ .- 1643 

Discharged 1582 = 96:3% 

Died .. | 61= 37% 

As figures given in THE LANCET are frequently 
quoted in support of various theories it is very 
desirable that they should be clear and not capable 
of misinterpretation. I can offer no criticism of 
clinical observations but I can check the deductions 
when figures are involved and shall continue to 
dispute any theory put forward in the popular press 
which is founded on a fallacy. In the present case 
the discrépancy is not great but the fact that the 
death-rate is over-stated reduces the credit due to 
Sir Henry Gauvain for the excellence of his treat- 
ment which gives a death-rate only a little over 
three times that of the whole population. 

I am, Sir, yours faithfully, 
S. D. Prersy FISHER. 


The Crescent, Alwoodley Park, Moortown, Leeds, 
March 7th. 


AN ADDRESS IN HARLEY STREET 
To the Editor of THE LANCET 


Srr,—I wonder whether any of your readers have 
noticed that within the last year or so the names 
appearing on door-plates in the Harley Street district 
have begun to introduce a continental note, so that 
the kudos of an address in this area is now inter- 
‘national rather than national. When the doors of 
our hospitals and medical schools were thrown open 
a short while ago to medical refugees from another 
country it was expressly stated to those of us who are 
teachers at the medical schools that the Home Office 
were granting permits for these refugees to reside 
in this country for the purpose of obtaining a British 
‘qualification, but that they would not be allowed 
to practise here. 

On this understanding we undertook, wrongly as 
I think, to teach these graduates of a foreign university 
with our undergraduates in the same classes and 
clinics.~ What has been the result? The harvest 
of British diplomas has been gathered, but there are 
no signs of our guests departing from our shores to 
practise elsewhere. On the contrary, hardly a week 
passes without my receiving an application from 
one of the new recruits to British medicine to be one 
of my clinical assistants; there is hardly an election 
for a minor staff appointment without the appearance 
“as candidates of one or more; and, as I stated in 
the beginning, the crop of plates bearing continental 


i 


REGULATION OF PROSTITUTION 


with the greatest assurance, ‘“‘ Oh! 
any idea that it was a rare privilege for him to do so. 
Only yesterday I received a card in an open envelope 


making matters infinitely worse. 


-eloquence ” (the italics are mine). 


[MARCH 14,1936 631 

names increases daily. The reason given by one 
applicant for a clinical assistant post was, not that 
he wished to learn more of a particular subject, but 
that he thought it would help him to improve his 
knowledge of English. Another applying for the 
post of registrar, when asked whether it was his 
intention to practise his specialty in England, said, 
Yes ” without 


from one of these gentlemen in which he acquainted 
me of the fact that he was a gynæcologist and surgeon, 


‘and that he had now established himself. in the 


consulting area. 

Surely this is a matter for investigation by those 
bodies representing medical interests in this country. 
It is already difficult enough for our younger men to 
make a living. The fact that I am on the staff of one 
of our teaching hospitals makes it necessary for me. 
to claim the privilege of anonymity, but I enclose 
my card. I am, Sir, yours faithfully, 

London, March 7th. ALBERICUS. 


= STAMMERING 
To the Editor of THE LANCET 


Sir,—Mr. St. John Rumsey suggests that I seem 
to contradict myself but does not indicate in what 
way. In case, however, I did not make myself 
sufficiently clear in my letter of Feb. 22nd permit 
me to restate the matter. It is now definitely 
established that stammering is a psychic trouble 
which deranges the natural codrdination of the 
muscles of respiration, voice, and articulation, 
bringing about faulty action of all of these. Conse- 
quently neither psychic treatment alone nor elocu- 
tionary instruction alone—nor indeed elocutionary 
treatment at all—can effect cure. Psychic analysis 


‘to remove fear and relaxation treatment to remove 


the muscular contractions caused by the fear are 
essential. These must be followed by re-education 
and codrdination of all the muscles concerned in 
speech. To employ elocutionary measures is to 
focus the stammerer’s attention on the symptoms, 
The most difficult 
cases to treat have in my experience been those 
where elocutionary instruction has been tried. 

The dictionary tells us that elocution is ‘The art 


-of effective speaking, more especially of public 


speaking, regarding solely the utterance or delivery; 
Obviously there- 
fore elocution does not in any way touch the cause 
of stammering.—I am, Sir, yours faithfully, 


KATE EMIL-BEHNKE, | 
Earl’s Court-square, S.W., March 9th. 


REGULATION OF PROSTITUTION 
To the Editor of THE LANCET 


Sir,—Some of your correspondents have expressed 
doubt at my statement (in your issue of Nov. 9th, 


.1935, p. 1078) that the Congress of Dermatology 


-meeting at Budapest last autumn “accepted as 


fully treated.” 


-a fact that syphilis and gonorrhea could be made 


extinct throughout the world within a single year 
if all who suffer from them would have themselves 
It is true that no such direct state- 


-ment was made from the rostrum, but from the 
‘discussion held on Sept. 13th, in No. 4 hall of the 


Hungarian Scientific Academy, on the international 
campaign against venereal diseases the inference 
could be drawn that, with adequately thorough 


treatment, gonorrhea as well as syphilis, at what- 


ever stage of the disease, could be brought within 


632 THE LANCET] 


a year or so to such a phase as not to be infec- 
tious any more. Hereditary syphilis, as stated by 
Hoffmann (Bonn) and Guszmann (Budapest), will 
shortly disappear from all civilised States. I quote 
their statements literatim. 


Prof. J. Guszmann (Budapest): In the domain of 
syphilidology I see the greatest progress in the fact that 
to-day we are justifiedin asserting that congenital syphilis 
will shortly disappear entirely in all cultured countries 
and their terrible consequences will remain unknown to 
the next generation of physicians. 


Dr. E. HoFFMANN (Bonn): As I have already empha- 
sised in articles which have appeared in the Wien. klin. 
Woch. and the Wien. med. Woch., with the aid of our 
present methods of intensive treatment congenital syphilis 
is well avertable and certainly curable. In consequence 
of this fact stillborn and macerated fetuses have entirely 
disappeared at many places (Germany, Denmark) where 
intensive and persistent treatment is applied. 


_ PARLIAMENTARY 


NOTES ON CURRENT TOPICS 


Home Office Administration 


On March 5th, on a vote for the Civil and Revenue 
Departments, Mr. BENSON raised the subject of the 


PSYCHOLOGICAL TREATMENT OF DELINQUENTS 


He acknowledged with gratitude the sympathetic way 
in which the Home Office had dealt with this matter 
in the past. The first official recognition of the 
psychological problem or the possibility of the 
psychological treatment of delinquents and criminal 
offenders was in a Departmental Report issued in 1932. 
The Home Office immediately appointed a psychiatrist 
who he believed was working at Wormwood Scrubs. 
His object in raising the matter that day was 
to appeal to the Home Office to go a little bit 
further. 


It was true, he said, that the psychological treatment 
of delinquents was in a purely experimental stage, but 
so was the treatment of cancer. In practically all medical 
matters treatment and experiment were bound to go 
hand in hand. With regard to psychiatry particularly 
as applied to delinquency it was essential that psychiatrists 
should be encouraged in their work on the subject and 
allowed every possible facility for the treatment of delin- 
quents in order that they might extend and improve their 
technique and bring it out of the experimental stage, 
At present the work was extremely haphazard very largely 
owing to the shortage of facilities. It was not that the 
Home Office was responsible for that. There was a bril- 
liant band of psychological specialists working on this 
matter but unfortunately they had to apply a long, 
arduous, and extremely difficult technique, and they were 
gravely hampered by lack of funds, lack of buildings, and 
lack of almost everything that would make either their 
experiments or their treatment efficient and helpful. 
At the present moment there was a single Government 
psychiatrist he thought at Wormwood Scrubs, and there 
were six London hospitals which had psychological 
clinics, and these occasionally took delinquents. There 
was the Institute of Medical Psychology, where again 
the treatment of delinquency was a side line, though they 
had done most valuable work and had gathered very 
valuable data. There was also one small new body—the 
Institute for the Scientific Treatment of Delinquency— 
which was the only specialist body in the country 
dealing with the psychiatric treatment of crime and 
criminals. 


The type of case that came before these clinics 
for treatment was extraordinarily varied. It was 
not merely the sex case as so many people seemed to 
imagine, In 1934 and 1935 the following cases came 


PARLIAMENTARY INTELLIGENCE 


[mano 14, 1936 


From these premisses we can infer, without undue 
optimism, that sexual diseases could be made extinet 
within a year or so, if during this time we could 
enforce the strict and complete isolation of the patients, 
whereby the source of infection could be blocked, 
It is equally reasonable to imagine that by the 
enforcement of severe procedures—eventually punish- 
ment and internment—adopted internationally against 
venereal patients caught or reported to spread the 
diseases at large and by applying treatment 
on them the infectivity of such patients would 
cease and as a consequence venereal disease would 
disappear. Laws to this effect are already in force 
in Germany and Rumania; a draft Act has Just 
been prepared in Hungary. 


I am, Sir, yours faithfully, 
Your BUDAPEST CORRESPONDENT. 
Budapest, Feb. 27th. 


INTELLIGENCE 


— z 


into the hands of the Institute for the Scientific 
Treatment of Delinquency :— 

Attempted murder Fa 1 | Tbeft (including four bur- 
Violence , ea, On | glars) .. .- - 46 
Attempted suicide a 9 EOE E a PeR rery, l4 
Sex cascs .. . -- 36 and false pretences l., 26 
Wandering Other kinds of cases -» 29 


In dealing with this subject, Mr. Benson con- 
tinued, the IIome Office would have to get the 
coöperation of judges and magistrates. In London 
he was glad to say the magistrates were awakening 
to the importance of the matter. In 1935 they sent 
to the Institute for the Scientific Treatment of 
Delinquency twice as many cases as they sent in 
1934. In the second place the Home Office would 
have to realise the necessity for the provision of 
treatment for cases in which it was recommended 
by the courts. In London the possibilities for this 
treatment were hopelessly inadequate and in the 
provinces they were entirely non-existent. It was a 
really staggering fact that outside London there were 
only four doctors with the qualification of the 
Institute of Psycho-Analysis. All the rest of the 
doctors with that qualification were in London. 
There was one doctor in Manchester, one in Reading, 
one in Southsea, and one in Edinburgh. The Home 
Office would have to face this problem because the 
psychiatric treatment, not merely of delinquents but 
of any neurotic person, was fundamentally different 
from that given by the hospitals. To allow this type 
of treatment to depend on the voluntary work of a 
small handful of specialists was out of the question. 
If this problem was to be thoroughly tackled the 
Home Office sooner or later would have to provide its 
own trained psychiatrists and to regard this as a 
curative branch of the prison service. 


SILICOSIS——MINERS’ NYSTAGMUS 


Mr. IIoLLINS drew attention to the position of 
hundreds of thousands of workers engaged in occu- 
pations in which the dreadful disease of silicosis had 
developed. He would prefer that there should not be 
the present limitation with regard to silicosis because 
Section 47 of the 1925 Act only scheduled the occu- 
pation and not the disease. Wherever a workman 
contracted this dreadful disease as a result of following 
an occupation he should be allowed to make a claim 
for compensation. Under the scheme of Section 47 
of the 1925 Act, and the amending Act of 19831, 
medical boards were introduced and the experience 
of the pottery industry was that these boards were 
operating in a perfectly satisfactory manner. The 
workers would prefer the medical boards to the 
system of medical referees and certifying surgeons. 
They preferred that there should be a second or 
third opinion rather than that the decision should be 


THE LANCET] 


PARLIAMENTARY INTELLIGENCE 


[maron 14, 1936 633 


left to one man. They could see no reason why 
silicosis should not be scheduled as a disease so that 
medical boards would administer the matter. 

Mr. TINKER raised the question of miners’ nystagmus 
and urged that the Home Office should consider 
having more than one medical man to judge these 
cases. He thought there should be at least three. 
The medical referee might be right in his judgment 
poe ae workman always felt that he had not had a 
air deal, 


ACCIDENTS IN FACTORIES AND WORKSHOPS 


Mr. SHORT called attention to accidents in factories 
and workshops. He said that judging from the last 
report of the Chief Inspector of Factories there had 
been a notable increase in the number of accidents, 
particularly of a non-fatal character, and the 
inspector emphasised the growing volume and nature 
of the accidents. There was need for greater care 
and supervision. The accident rate among young 
people was much greater than the rate among adults. 
The inspector’s report also drew attention to the need 
for greater care and supervision in order to deal 
with accidents in connexion with hoists and lifts. 
He thought that they had not enough inspectors and 
he hoped that the Government would agree to appoint 
a larger number. He also called attention to carbon 
monoxide poisoning arising from petrol fumes. Many 
drivers and other workers employed on petrol-driven 
omnibuses suffered from gastric complaints from 
inhaling these fumes. There ought to be a closer 
association with the medical profession as regards 
the health of the workers. There should be a greater 
diffusion of knowledge concerning industrial diseases. 
Medical men ought to be encouraged if they believed 
that a complaint from which a patient was suffering 
arose from the patient’s occupation to communicate 
that fact to the;}Home Office. 


THE UNDER-SECRETARY’S REPLY 


Mr. GEOFFREY LLOYD said that with regard to the 
psychological treatment of delinquents the Home 
Office, while keeping its mind thoroughly open to all 
new schools of thought, would not rashly adopt 
schemes or theories which were not yet thoroughly 
tried out or approved. Psychologists had not 
achieved complete agreement among themselves. 
The Home Office had sent a circular to courts of 
summary jurisdiction in which they drew attention 
to the desirability of obtaining a medical report on 
the offender in any case where the circumstances of 
the offender or his demeanour when before the court 
suggested doubt as to his mental condition. That 
was only one side of the question. It might well be 
that there were some offenders who were not mentally 
normal and who ought to be under some form of 
restraint but who could not be dealt with except by 
being sent to prison. The Home Office had appointed 
a specialist in mental psychology as part-time medical 
officer at one of the London prisons. It was too 
early to arrive at any conclusions as to the type of 
case which was most likely to respond to such treat- 
ment or to give permanent results. 

The Home Office would, he said, look into the 
points raised about industrial disease and accidents. 
There was a committee sitting on the subject of 
miners’ nystagmus. With regard to silicosis, it was 
very slow in its onset and that was one reason why 
it was not suitable to be scheduled under the ordinary 
provisions. The other reason was that it was difficult 
to diagnose. In general the Home Office felt that it 
was not wise to scrap all the work that had been 
done in gradually building up this complex system 
of silicosis schemes which had been added to and 
improved as the result of experience. It was better 
to go on experimenting on and making researches 
into the causes of the disease and they were ready 
to examine any evidence as to the occurrence of the 
* disease in any other occupations or circumstances, 
and so in time to make improvements. At the 
present time the Home Office were conducting a 
number of examinations on silicosis and in particular 


the Medical Research Council was at work on the 
subject. The prevention of silicosis was also receiving 
attention. The Department was alive to its function 
of assisting in the prevention of accidents. He drew 
attention to the Industrial Museum in Horseferry- 
road. The Department had a clearing house for 
knowledge from all parts of the country in relation 
to safety, health, and welfare in factories. The 
question of carbon monoxide poisoning among drivers 
of petrol-driven vehicles was being examined by a 
medical committee at the present time. 


Alcohol and Road Accidents 


In the House of Commons on March 4th, Mr. 
©. C. TAYLOR, moving a resolution urging H.M. 
Government to press forward all possible measures 
to achieve reduction in road accidents, remarked 
that the drunken motorist should be treated as a 


criminal lunatic ; but he submitted that a moderate 


amount of alcohol had no more effect in producing 
accident than had severe shock or excitement, and 
if a man was moderate in his ways it would not affect 
him when he drove a motor-car.—Dr. SALTER, who 
followed, insisted that a far greater danger than 
actual drunkenness was the ‘‘subintoxicated ”’ 
motorist. The British Medical Association, he said, 
improvised this term to indicate a person who though 
not obviously under the influence of drink in the legal 
sense was none the less physiologically under the 
influence of drink. Notwithstanding the expert 
advice given to him the Minister. of Transport, he 
said, had taken no steps to bring the extreme danger 
of consuming alcohol, before driving or when driving, 
before the motoring public, and this in spite of specific 
evidence brought to his notice that the consumption 
of even quite small quantities of alcohol led to a 
reduction in the efficiency and capacity of the driver. 
The Minister having asked for the advice of the 
B.M.A. had not only failed to give publicity to the 
conclusions of its committee but had poured ridicule 
onthem, Other nations, said Dr. Salter, had brought 
the danger of small quantities of alcohol before eve 
driver and every applicant for a license or its renewal. 
In Germany every applicant was handed a card on 
which he was warned not to touch alcohol even in 
small quantities before he started to drive; he had 
to sign a book in the police president’s office declaring 
he had received the card and had read and under- 
stood it. In the judgment of many experts, said 
Dr. Salter, at least 25 per cent. of the fatalities and 
accidents on the roads were due to the fact that 
drivers were subintoxicated.—Sir ERNEST GRAHAM- 
LITTLE, who asked the Minister for a more thorough 
investigation of the causes of accidents on the road, 
said it had been shown that about one-quarter of 
the population at any given time were definitely 
prone to accident, and this accident-proneness could 
be identified by suitable tests. It should be possible, 
he thought, to introduce if only on an experimental 
basis such tests for a portion of the persons con- 
cerned.—Mr. HoORE-BELISHA, in replying, remarked 
parenthetically that the development of roads like 
the growth of forests was a long process. He denied 
suppression of the B.M.A. report, remarking that it 
was published at sixpence a copy, while Dr. Salter 
wanted it to be published at the Government’s 
expense. Doctors having undertaken this work he 
did not see, he said, why the medical profession 
should not get what advantage they could from the 
sale of the report. Anyone who desired to do so 
could read the report and learn that there was no 
proposal emerging from it which the Minister could 
put into operation. Mr. Hore-Belisha added that 
he mentioned the subject in the Highway Code for 
the first time. 


Sir Francis FREMANTLE intervening suggested that 
what the Minister had said did not in the least enforce the 
particular point of the medical inquiry which was to bring 
it home to people that the least quantity of alcohol before 
driving a car involved danger.—The MInIsTER rejoined, 
“ I agree with my hon. friend that the B.M.A. laid it down 


634 THE LANCET] 


that alcohol even in small doses was liable to have a bad 


PARLIAMENTARY INTELLIGENCE 


[manoH 14, 1936 


pose.—Mr, Hore-BrEtisHa replied: I am aware of ono 


effect on the driving of a car, but it does not fall to me to 
operate their recommendation. I cannot prevent people 
who have taken some alcohol from driving cars; I can 
only call attention in general terms to the matter. I have 
indicated in the Highway Code that it is undesirable that 
` motorists should drink when they are going to drive cars, 
and I do not think that I can do more than that.” 


The Minister indicated that in coöperation with 
the Home Secretary and the Secretary for Scotland 
he was this year as from April Ist making an analysis 
of all accidents involving death or injury. 


Milk Supplies and the Problem of Nutrition 


In the House of Lords on March 10th Earl DE LA 
WARR Parliamentary Secretary to the Board of 
Education, moved the second reading of the Bill 
which extends for a further 18 months the provisions 
of the Milk Act, 1934. ` 

Viscount ASTOR said that as chairman of the 
League of Nations Commission he knew what was 
being done under the auspices of the League to 
develop a nutrition policy in this and other countries. 
The movement in that direction was very largely due 
to the work of Earl De La Warr. The fact was 
beginning to be appreciated that if children had an 
ample supply of milk they would become healthier 
and better citizens. It was unlikely that there would 
be a spectacularly large increase in the consumption 
of milk through the supply of cheap milk to schools, 
but he hoped that the increase would be steady. 
Unless the price of milk to the consumer could be 
substantially lowered there would not be the full 
consumption of milk which was desired. Three ways 
by which the price of milk could be lowered were, 
reduction in the price of distribution, reduction in 
the cost of production, and a subsidy. Something 
should be done along these three lines. There was a 
very large, surplus supply of milk because the pro- 
ducers’ price was too high; the aim should be to 
produce as much cheap milk as possible. 

The Bill was read a second time. 


HOUSE OF COMMONS 
WEDNESDAY, MARCH 4TH 
Maternal Mortality in Glasgow and Greenock 


Mr. Davipson asked the Secretary of State for Scotland 
the figures of maternal mortality for 1935 in Glasgow and 
Greenock respectively.—Sir GODFREY COLLINS replied: 
The number of maternal deaths in Glasgow in 1935 was 
155 and in Greenock 11, representing rates of 7-0 and 6:5 
per thousand births respectively. 


Medical Examination of Air Pilots in Scotland 


The Marquess of CLYDESDALE asked the Under-Secretary 
of State for Air whether, in view of the large increase of 
commercial pilots in Scotland and the expense and incon- 
venience to which they were placed in presenting them- 
selves for medical examination in London, he was pre- 
pared to authorise the appointment of a Medical Board 
for Scotland, either in Glasgow or Edinburgh, to include 
an approved resident doctor, which board would refer 
borderline cases to the central board in London Sir P. 
Sassoon replied: I regret that the number of applicants 
from Scottish addresses does not justify the setting up 
of @ special board in Scotland. Medical examination in 
London is ordinarily only insisted upon in connexion 
with the initial grant of the licences, when the candidate’s 
presence in London is in any case necessary, for the 
technical or flying test, and once in every two years 
subsequently. 


Sounding of Motor Horns and Fatal Road 
' Accidents 
' Mr. Bovutton asked the Minister of Transport if he 
was aware that coroners in several cases had made severe 
strictures on accused persons for not sounding their 
motor horns after hours, causing fatal accidents; and if he 
was still satisfied that this law was serving a useful pur- 


such case. I am amply satisfied that the law is serving 
a useful purpose, and I should imagine that coroners 
generally, like other citizens, assist in its observance. 


THURSDAY, MARCH 5TH 
Occupational Diseases Convention 


Mr. CREECH JONES asked the Home Secretary whether 
the Government had given recent consideration to the 
ratification of the Workmen’s Compensation (Occupational 
Diseases) Convention (Revised), 1934, No. 62; and when 
it was proposed that the Convention should be ratified.— 
Sir JoHN Simon replied: The Government propose to 
ratify this convention and the formalities for ratification 
are now being carried out. 


Accidents: Convention 1925 (No. 17) 


= Mr. CREECH Jones asked the Home Secretary whether 
he would now consider, with a view to ratification, the 
Workmen’s Compensation (Accidents) Convention, 1925 
(No. 17).—Sir Jonn Sm™oNn replied: I am advised that 
this convention could not be ratified without far-reaching 
changes in the law and medical arrangements of this 
country, and I see no prospect of such legislation being 
passed at present. 


<- Gas Mask for Civilian Protection 


-= Mr. SHort asked the Home Secretary whether he 
would arrange for Members of this House to attend 4 
demonstration of the gas mask to be used for the protec- 
tion of the civilian population.—Mr. G. LLOYD replied: 
When the design of the respirator referred to is finally 
settled, I shall be very glad to arrange for a demonstra- 
tion, and I hope that hon. Members will not merely attend 
but also test for themselves the efficacy of the respirator 
in various concentrations of poison gases. 


Protection of Public against High Explosive and 
a Incendiary Bombs 


Lieut.-Commander FLETCHER asked the Home Secre- 
tary what precautionary instructions, in addition to those 
against gas attacks, he was sending to local authorities 
with regard to attacks by high explosive and incendiary 
bombs.—Mr. G. Luoyp replied: It is hoped to issue 
handbooks and memoranda making available to local 
authorities, industrial undertakings, and the public 
generally the information at the disposal of the Govern- 
ment on protection against high explosive and incendiary 
bombs; and I can assure the hon. Member that this 
aspect of the subject is being given the careful considera- 
tion which it requires as an integral part of all air raids 
precautions schemes. 


Law and Practice Relating to Coroners 


Viscountess ASTOR asked the Home Secretary whether 
it was proposed to introduce a Coroners Amendment Bill, 
following the recent publication of the report of the 
departmental committee which inquired into the law and 
practice regarding coroners.—Sir JouN Smon replied: 
Legislation would be required to give effect to a number 
of the committee’s recommendations, but I cannot mako 
any statement until there has been an opportunity of 
giving full consideration to the report. 


Boy Patient at Napsbury Mental Hospital 


Mr. Messer asked the Minister of Health if he was 
aware that John Henry Fuller, a boy of 14 years of age, 
was the only boy patient in the Napsbury mental hospital, 
where all the other patients are adults; and if he would 
take steps to obtain his transfer to a more suitable insti- 
tution.—Sir Kinsetey Woop replied: The question of 
this patient’s transfer to another institution has already 
been carefully considered, but I am advised that it is 
not at present desirable or practicable, having regard to 
his mental condition, as to which I am communicating 
with the hon. Member. 


Maternity and Child Welfare in Wales 


Mr, WILFRID RoBERTS asked the}Minister of Health 
whether his attention had been called to figures and 


| 


THE LANCET} 


PARLIAMENTARY INTELLIGENCE 


(marcu 14, 1986 635 


graphs showing the reduction of maternal mortality in 
the Rhondda valley as the result of the provision of addi- 
tional meals as well as milk to expectant mothers; and 
whether he would supply these figures and graphs for the 
information of Members.—Sir KinasLEy Woop replied : 
I have requested the medical officers of my department 
who are investigating the problem of maternal mortality 
to pay careful attention to the information regarding 
Rhondda referred to by the hon. Member. I have no 
doubt that they will deal with it in their report which I 
hope to receive from them when they have completed 
the extensive inquiry they are now making. The report, 
which will be presented to Parliament as soon as it is. 
received, will, I think, be the best way of bringing to.the 
notice of hon. Members the facts in this and other cases, 
and the conclusions to be drawn from them. 


MONDAY, MARCH 9TH 
Health Conditions in a Factory 


Mr. CREECH JONES asked the Home Secretary whether 
his attention had been drawn to the conditions of work 
at the Cotopa mills, Guiseley ; whether he was aware 
of the bad physical effects of such employment ; whether 
he would ask the inspector of factories to give special 
attention to the processes carried on in this mill and 
consider scheduling the work under the list of dangerous 
trades; and in the meantime if he would impose rigid 
rules to govern the period of actual work on the respective 
processes, insist on mechanical. draught by fan being 
employed to remove fumes and gases and the provision 
of adequate washing facilities, and the taking of meals 
by the workpeople in places other than in the mills.—Mr. 
GEOFFREY LLOYD replied: It appears from a report by 
one of the medical inspectors of factories who has visited 
these mills that no serious trouble has arisen, but that 
some of the employees have suffered from sore eyes due 
to fumes. It would seem that this can be prevented by 
improved ventilation in the process room, together with 
more care on the part of some of the men to wear the 
goggles provided for them, and methods of improving 
the ventilation are to be discussed with an inspector. 
A canteen with messroom and washing accommodation 
is being built. There appears to be no case on grounds 
of health for restricting the hours of work or for prohibiting 
the taking of meals on the premises, but the works will 
continue to receive special attention. 


Bombing of British Red Cross in Abyssinia 


Mr. Cocxs asked the Secretary of State for Foreign 
Affairs whether he could give the House any information 
regarding the bombing of the British Red Cross hospital 
at Karen; and whether H.M. Government had made a 
protest to the Italian government against this breach of 
international law ? 7 

Sir ASSHETON PownaLL asked the Secretary of State 
for Foreign Affairs whether he had any information with 
regard to the bombing by the Italians of a British Red 
Cross ambulance.—Viscount CRANBORNE, Under-Secre- 
tary for Foreign Affairs, replied: On March Sth H.M. 
Minister at Addis Ababa telegraphed a message from 
Dr. Melly, the leader of the British Red Cross ambulance 
in Northern Ethiopia, stating that the British ambulance 
was heavily and deliberately bombed at midday on 
March. 4th while situated in the open on Korem plain, 
two miles from the nearest troops. There was a Red 
Cross ground flag 40 feet square in the centre of the camp, 
and red crosses on the tents and the flagstaff. The opera- 
tion, sterilisation, and three ward tents were destroyed, 
as well as one lorry. Three patients were killed and 
several wounded. There were no casualties amongst the 
personnel. ‘The aeroplane, according to the message, 
circle low over the camp nine times, dropping about 
forty bombs, one of which fell on the ground flag. The 
message added that the camp had previously been observed 
many times at Waldia, Allamata and Morem by low- 
lying aeroplanes. It has subsequently been reported 
that the ambulance was again bombed on March Sth. 
On the receipt of the first telegram from H.M. Minister 
it Addis Ababa, H.M. Ambassador at Rome was instructed 
o lodge an immediate protest with the Italian Govern- 


ment on the facts as stated by Dr. Melly, and to make’ 
it plain that H.M. Government expect them to order an 
immediate investigation and, in the meantime, to issue 
the strictest instructions against a recurrence of this 
incident. In reply to this communication, Signor Suvich, 
while not prepared to admit the accuracy of Dr. Melly’s 
report, nevertheless stated that an inquiry would be 
instituted, and that instructions would be issued to avoid 
@ repetition of the incident. On receipt of the news that 
the second bombing incident had taken place, my right 
hon. friend instructed Sir E. Drummond to renew his 
representations in the strongest manner and to ask for 
an assurance that the necessary instructions had been 
issued and their receipt acknowledged by the Italian 
military authorities. The result of these further. repre- 
sentations is not yet known. ' f oe 
Sir A. Pownatu: Has the noble lord any information 
with regard to the death of Major Burgoyne and has his 
attention been called to a statement in the Times on 
Saturday by their Special Correspondent who himself. 
saw this episode, that the bombing was unquestionably. 
deliberate ? 7 a eee Pe, 
Viscount CRANBORNE: That is a different question. _ 


E TUESDAY, MARCH l0TH 
Erysipelas Deaths 


‘Mr. Viant asked the Minister of Health whether his 
medical staff had formed any opinion as to the cause of 
the marked increase in the number of deaths certified 
as being due to erysipelas during the years 1930 to 1934.— 
Mr. SHAKESPEARE (Parliamentary Secretary to the 
Ministry of Health) replied : The incidence of this disease, 
the increase of which is only one manifestation of the 
increased prevalence of a group of diseases of similar 
causation which has tended to occur in waves of a few 
years’ duration, is receiving the attention of my right hon. 
friend’s medical advisers, but he is advised that no firm 
conclusions are at present possible as to the reasons for 
this periodicity. l 

Voluntary Patients in Public Mental Hospitals 

Mr. SORENSEN asked the Minister of Health the number 
of voluntary patients in public mental hospitals during 
the last week of 1935.—Mr. SHAKESPEARE replied: The 
figures are not available for the last week of 1935, but on 
Jan. lst last there were 4296 voluntary patients in public 
mental hospitals, and 229 in the Maudsley Hospital. 


Medical Opinion and Fitness for Light Work 


Mr. HARDIE asked the Secretary of State for Scotland 
whether, in view of the number of cases coming under 
the Scottish Health Department, where men were being 
told by medical opinion that they were only fit for light 
work, he could give a definition of what constituted light 
work; and on what grounds his department said that a 
man was fit for work when certified as suffering from 
mitral stenosis.—Sir GODFREY Corrs replied; The 
cases which the hon. Member has in mind are presumably 
those of persons who have been examined by the regional 
medical officers of the Department of Health on the 
question of their incapacity for work. If and when the 
opinion is expressed that the persons concerned are only 
fit for light work the phrase “light work ” is used in its 
ordinary sense, that is, as indicating work not involving 
physical effort of an arduous nature. With regard to the 
last part of the question, I am advised that mitral stenosis 
does not necessarily involve ineapacity for all kinds of 
work, - 


AN ANONYMOUS DoNoR.—On March 6th Mr. Henry 
Ward, formerly well known as a civil engineer, died at 
the London Hospital at the age of 87. In 1923, under 
a condition of strict anonymity he had given to the 
hospital £100,000, of which £80,000 was devoted to the 
general endowment and the remainder to general pur- 
poses. Mr. Ward was for 33 years a member of the 
London County Council and for 30 years he served on 
the Metropolitan Water Board. 


636 THE LANCET] 


[mancH 14, 1936 


OBITUARY 


JOHN WHEELER DOWDEN, M.B., LL.D., 
F.R.C.S. Edin. 


LATE PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF 
EDINBURGH 


THE death occurred on March 8th of Mr. John 
Wheeler Dowden, the well-known Edinburgh surgeon, 
after a brief illness. Born in 1866, the son of the 
Right Reverend John Dowden, bishop of Edinburgh, 
he was educated at Merchiston Castle School and the 
University of Edinburgh. He graduated as M.B., 
C.M. in 1890 and served as resident surgeon and 
resident physician at the Royal Infirmary from 
1890-92, and in the latter year was appointed resident 
physician at the 
Edinburgh Royal 
Hospital for Sick 
Children. He took 
the diploma of 
F.R.C.8. Edin. in 
1894 and was 
appointed assistant 
surgeon to the 
Hospital for Sick 
Children, tutor in 
clinical surgery at 
the University 
Medical School, and 
surgeon to the New 
Town Dispensary. 
In 1912 he was 
appointed surgeon 
to the Infirmary 
and lecturer on 
clinical surgery 
in the school of 
medicine of the 
Edinburgh Royal 
College of Surgeons, while he was appointed 
surgeon to the Chalmers Hospital. He served the 
Royal College of Surgeons of Edinburgh and the 
University of Edinburgh as an examiner in surgery, 
pathology, and operative surgery, and examined also 
in surgery at the University of Durham, while over 
a long period of years he made valuable clinical 
contributions. to medical journalism, principally 
to the Edinburgh Medical Journal, the Scottish 
Medical Journal, and the Transactions of the Medico- 
Chirurgical Society of Edinburgh. 

Alike as surgeon and teacher Dowden was con- 
spicuously successful. He had a fine apprenticeship 
under Annandale, Cotterill, and Joseph Bell, and he 
maintained the high standard of the Edinburgh school 
of surgery on both academic and practical lines. 
His classes were fully attended and the students 
learned from him much that he knew would be 
useful to them in meeting the calls of daily practice. 
His instructions both in the wards and in the lecture 
theatre were marked with particular attention to 
common surgical ailments, and he brought out this 
side of his teaching well in a manual written in 1928 
entitled ‘‘ Clinical Surgery for Junior Students.” 
His published records of operative work displayed its 
all-round character and high technical skill, while 
in his war service he was found to be particularly 
successful in orthopedic surgery during his attach- 
ment to the Edinburgh war hospital at Bangour and 
the 2nd Scottish General Hospital at Graigleith. In 
the International Journal of Surgery he wrote of the 
surgical lessons learned during the war. His pro- 
fessional distinction was realised by his position in 


MR. DOWDEN 
[Photograph by Swan Watson 


the Royal College of Surgeons of Edinburgh, by his 
honorary fellowship of the Royal College of Physicians 
of Edinburgh, and by the LL.D. degree given to 
him by the University on its 350th anniversary, 
while at the time of his death he was Manager of 
the Edinburgh Royal Infirmary. ý 


We quote the following tribute from one of his 
colleagues: ‘“‘To those who had the privilege of 
knowing Dowden intimately, his personality, his 
upright character, and his vitality made a strong 
appeal. In him they possessed a loyal and genuine 
friend who had many attractive qualities : a kindly 
and sympathetic nature; a whole-hearted infectious 
enthusiasm for work and recreation ; a genial humour, 
free from any suggestion of cynicism or satire, illu- 
minating his faculty and facility as a story-teller.” 


Outside his professional interest Dowden was 
remarkable for the regard in which he held his old 
school of Merchiston. He was for a long period on 
the governing body and was at the time of his death 
chairman. He was mainly instrumental in bringing 
to a successful issue a scheme for transferring the 
school from Merchiston Castle to its present site at 
Colinton. As a young man he had been a prominent 
sportsman representing his school and university 
both in cricket and football, while in later life his 
holidays were devoted to angling. 

Mr. Dowden married in 1907 Edith Georgina, 
daughter of the late Surgeon-General H. R. Oswald, 
and she survives him. 


HENRY JOHN BANKS-DAVIS, M.B. Camb., 
F.R.C.P. Lond. 


WE regret to announce the death of Mr. Banks- 
Davis, well known as otologist and laryngologist, 
which occurred on March 5th at his London address. 

Henry John Banks-Davis was the son of the 
distinguished artist and Academician, H. W. B. Davis, 
and was born in 1867. He was educated partly 
in France and partly at Marlborough and entered 
Trinity College, Cambridge, where he graduated 
in arts in 1888. He proceeded to St. Thomas's 
Hospital, took the medical degrees of M.B., B.Ch. 
in 1895, and served in the hospital as house surgeon 
and for a time as demonstrator of practical surgery 
in the medical school. For a time he was resident 
medical officer to the West London Hospital, and 
at this period of his career saw considerable post- 
graduate practice in Paris, Berlin, and Vienna. 
He then decided to specialise in diseases of the ear and 
throat. He became chief assistant in the throat and 
ear department of the Middlesex Hospital and in 1904 
was appointed surgeon to the throat, nose, and ear 
department of the West London Hospital, having 
been originally elected as assistant physician. His 
scientific attainments as well as his sympathetic per- 
sonality soon obtained for him a considerable practice, 
while contributions of a practical nature to medical 
journals and to the Proceedings of the Royal Society 
of Medicine confirmed his expert position. In 1912 
he was elected F.R.C.P. Lond. His military services 
were varied and extensive. Some 40 years ago he 
acted as surgeon to the national fund of the Red 
Cross in the Greeco-Turkish war and received from 
the King of the Hellenes the order of the Redeemer 
of Greece; in the South African war he did useful 
work to the invalided soldiers and nurses as a member 
of committees administering funds for those purposes; 
and during the recent war he held appointments in 


THE LANCET] 


several hospitals receiving injured naval officers, 
where he maintained a high position as a specialist. 
He had a wide reputation outside his own country 
due to his frequent selection as a delegate for 


Cambridge University to international conferences, 


attending in this capacity conferences on laryngology 
and otology in Boston, Vienna, and Berlin. He was 
aural referee to the Civil Service at the time of his 
death, and had been president of the otological and 
laryngological sections of the Royal Society of Medicine. 


A personal friend writes: ‘‘ Banks-Davis was 
appointed to the West London Hospital as assistant 
physician but relinquished the post to take up work 
in the ear, nose, and throat department in the days 
when such work was not regarded as so definitely 
surgical as it now is; he was assistant to Dr. J. Barry 
Ball, the physician on the staff of the hospital who had 
charge of the department, and he succeeded him. 


MEDICAL 


University of Oxford 

An election of two members of the board of the faculty 
of medicine of this university will be held on June 5th. 
Nominations must be signed by six members of the general 
medical electorate and reach the secretary of faculties 
at the University Registry, Oxford, before May 15th. 


University of Birmingham 

It is announced that an anonymous donor has placed 
considerable funds at the disposal of the University for 
an investigation by Prof. W. N. Haworth, F.R.S., head 
of the department of chemistry, into the possibility of 
producing an improved form of insulin. 

During the summer term five Wiliam Withering 
lectures will be given on the chemical and biological 
aspects of immunology. On April 30th, May 14th and 
28th Prof. W. W. C. Topley, F.R.S., will speak and on 
May 7th and 2lst Mr. Percival Hartley, D.Sc. The 
Ingleby lectures will be given this year on May 20th and 
22nd by Dr. Walter Schiller, pathologist to the Frauen- 
klinik of the University of Vienna, who will speak on 
ovarian tumours (granulosa-cell, Brenner, and a new 
variety, mesonephroma ovarii). He is taking the place 
of Prof. Frankl who is unable to come as arranged. Prof. 


Arvid Wallgren, physician-in-chief to the Children’s 
Hospital at Gdoteburg, has been appointed Ingleby 


lecturer for 1937. All these lectures will be given at 
4 P.M. in the University. 
Post-graduate courses in neurology will be held from 


May to July and in industrial hygiene and industrial 


medicine from July 13th to 24th. Further information 


- may be had from the dean of the medical faculty. 


. International Cancer Congress 


The Second International Congress of the Scientific 


' and Social Campaign against. Cancer will be held in 
/ Brussels from Sept. 20th-26th, under the patronage of 
, the King of the Belgians and Queen Elizabeth. The 
_ national executive committee of the Congress consists of 


Dr. Lerat (chairman), Profs. Delrez, Dustin, Goormagh- 
tigh, and Maisin (directors of the anti-cancer centres of 


_ Liége, Brussels, Ghent, and Louvain respectively), Dr. 
‘ Sluys, Dr. Timbal (director-general of the Government 
. Department of Hygiene), Mr. H. Marchal, and Mr. W. 
- Schraenen (general secretary of the Congress). 


The programme has been divided into two main parts, 


embracing the scientific campaign and the social campaign 


- against cancer. 


4 
J 


In the first part the subjects on which 
otficial reports will be prepared and upon which individual 


“communications are invited are grouped together under 
the following headings: 


experimental investigation 


. (including the study of predisposing factors); diagnosis ; 
' and treatment. In the second part, on the social campaign 
. against cancer, the subjects dealt with are: access of 


. patients to diagnosis and treatment; 
: assistance to incurable cases; 


medico-social 
and cancer and demo- 


. graphy, including statistics and racial incidence. The list 


MEDICAL NEWS 


[maron 14,1936 637 


His enthusiasm for his specialty, kindly treatment of 
the patients, and uniform courtesy combined to build 
up a large clinic to the great benefit of the hospital. 
His lectures to the post-graduate college were well 
attended and much appreciated. He held no other 
hospital appointment, and was able to devote the 
whole of his energies to the West London which he 
served so well. Banks-Davis never married. Once, 
when I asked him why, he replied that he was wedded 
to his profession. Conservative by nature he was a 
man of settled habits. At college he had been a 
prominent oar. He was a keen fisherman and 
delighted in salmon-fishing on the Wye, a sport in 
which he was very proficient, while he had a pro- 
perty in Wales to which he was very attached. With 
Banks-Davis a friendship once formed was ever loyal 
and unswerving. He was a man of outstanding 
personality and gifted with charm and a subtle sense 
of humour.” 


NEWS 


of official rapporteurs is not yet complete, but among 
those who have agreed to present reports are: M. Borst, 
J. W. Cook, W. Cramer, H. F. Deelman, L. Dublin, A. P. 
Dustin, J. Ewing, W. E. Gye, H. Holthusen, E. L. Kenna- 
way, J. Maisin, M. Nagayo, F. Pentimalli, Cl. Regaud, 
P. del Rio Hortega, G. Roussy, C. Rowntree, H. Schinz, 
and F. Carter Wood. 

Further particulars may be had from Mr. W. Schraenen 
at 13, rue de la Presse, Brussels, Belgium. 


Public Analysts and Other Analytical Chemists 


Although the Society of Public Analysts (since widened 
to include other analytical chemists) was founded in 
1875, two original members—Dr. Bernard Dyer and 
Dr. J. A. Voelcker—were present at the annual dinner 
on March 6th and responded to the informal toast of their 
healths. Mr. John Evans, M.Sc., who presided, proposed 
the toast of H.M. Ministers to which Sir Kingsley Wood 
responded, remarking that the first Minister of Health in 
history seemed to have been Moses, who issued wise 
enactments for the bodily well-being of the Israelites. 
Sir Kingsley thought that the responsibility of Ministers 
was increasing and among them the public health service 
was of prime importance as a defence and insurance against 
ill-health. Referring to food which came within the scope 
of the society’s work, 25 million tons a year, he said, were 
consumed, and it was necessary that nothing should 
be added to or taken from it, which might lower its 
quality. The public analysts were the chief defenders 
of the people’s food ; the burden laid on them was increas- 
ing, but although he had much to do with their work 
he took no part in their remuneration. The Public 
Prosecutor, Sir E. Tyndal Atkinson, in proposing the 
health of the Society, referred to the complicated problems 
analysts had to solve, both as to what foods should be 
and in finding out what they were. He spoke with 
appreciation of the work of the president elect, Dr. Roche 
Lynch, and said how much the problems of food analysis 
had changed since Frederick Accum wrote his book on 
food adulteration some hundred years ago, when bakers, 
brewers, and druggists were engaged in a vicious circle 
of poisoning one another with their respective products. 
The President, in replying, spoke of the many branches 
of analytical work, instancing the compendious knowledge 
of the editor of the Analyst, Dr. C. Ainsworth Mitchell, who 
was present as president of the Medico-Legal Society and 
was an authority on such things as the detection of 
forgery and the examination of inks. The toast of 
Kindred Societies, proposed by Mr. Edward Hinks, a past- 
president, was responded to by Dr. R. H. Pickard, 
F.R.S., president of the Institute of Chemistry, and 
Dr. E. Mellanby, secretary of the Medical Research 
Council, who described himself as, at heart, a laboratory 
worker. The Master Cutler, Sir Samuel Roberts, a fellow 
citizen of the President, and Sir Harry Lindsay, director 
of the Imperial Institute, responded for the Guests, a 
toast proposed by Prof. W. H. Roberts. 


638 THE LANCET] 


MEDICAL NEWS.—MEDICAL DIARY 


[MARCE 14, 1936 


; 


Post-graduate Work in Aberdeen 


, A course devoted to endocrinology will be held at 
Marischal College, the Royal Infirmary, and the Royal 
Hospital for Sick Children, Aberdeen, from April 2lst 
to June 18th. The lectures and demonstrations will be 
given at 3.15 P.M. on Tuesdays and repeated at the same 
time on Thursdays. Applications should reach the secretary 
of the University not later than April 15th. 


Royal Society of Arts i 

The Thomas Gray prize of £100 for an invention 
“ considered to be an advancement in the science or 
practice of navigation ” has been divided between Mr: H. J. 
Buchanan-Wollaston, for his current meter, and Dr. F. W. 
Edridge-Green, F.R.C.S., for his colour perception lantern. 
The latter is an improved form of the Edridge-Green 
lantern used in the Navy and mercantile marine, and by 
railways, for ascertaining defects in colour perception. 


Beit Memorial Fellowships 


An election of junior fellows will take place in July. 
The fellowships are normally of the annual value of £400 
and are usually tenable for three years. Some preference 
will be given to candidates proposing researches in mental 
diseases. Candidates should be prepared to begin work 
on Oct. Ist, and applications should be sent to Prof. T. R. 
Elliott, F.R.S., University College Hospital medical 
school, London, W.C.1. 


‘Oto-rhinolaryngology in Austria 

A second congress of Austrian ear, nose, and throat 
specialists will be held at Graz on June 12th and 13th. 
The principal subjects for discussion will be conservative 
and operative treatment of suppuration in the frontal 
sinuses and of laryngeal stenosis, metabolic disturbance 
in relation to diseases of the ear and the operative treat- 
ment of chronic suppurative otitis media. Further infor- 
mation may be had from Ernst Urbantschitsch, Schotten- 
ring 24, Vienna I. 


Incorporated Society of Chiropodists 

The annual convention of this society will be held at the 
Langham Hotel, Portland-place, London, W., on Friday 
and Saturday, March 20th and 2lst. During the course 
of the meeting lectures will be given by Dr. H. W. C. 
Vines (bacterial virulence), Mr. C. Lambrinudi (mechanical 
disabilities of the foot), and Mr. T. Pomfret Kilner (the 
scope of plastic and reconstructive surgery). Further 
information may be had from the secretary of the society, 
21, Cavendish-square,. London, W.1. 


University of London Animal Welfare Society 

On Tuesday, March 17th, at 8 P.M., at Birkbeck College, 
Breams Buildings, London, E.C., Prof. Walter Garstang, 
emeritus professor of zoology in the University of Leeds, 
will speak on the songs of birds. The lecture will be 
illustrated by gramophone and other instruments. 
Admission is free, without ticket, 


The Sir Charles. Hastings Lecture 

This lecture was delivered on Tuesday evening in the 
hall of the British Medical Association by Prof. Winifred 
Cullis, the title being ‘‘ Keeping Fit.” Dr. R. Cove- 
Smith followed with a joint address on the same subject. 
‘Prof. Cullis discussing particularly the diet of children 
said that in artificially fed babies 70 per cent. were found 
‘recently to suffer from lack of vitamin C and iron, and 
added, speaking generally, that the diet of children should 
be varied’ but moderate, while every child should have at 
‘least a pint of milk a day. Dr. Cove-Smith was drastic 
in his criticism of modern habits. He regarded tobacco 
and alcohol as drugs-and therefore not to be used 
indiscriminately ; he described much restaurant food 
as “‘ twice cooked mush ” ; he pointed to the risk to young 
people of dancing late into the night in overcrowded 
rooms from which they emerged inadequately clothed ; 
he pointed out that the frequent use of baths at too high 
a temperature had its perils; and he coupled a commenda- 
tion of the open-necked fashions in women’s clothes with 
a denunciation of the too tight collar worn by many men. 
The chair was taken by Dr. Adophe Abrahams, consulting 
medical adviser to the British Olympic athletic team, 
and both the deliveries making up jointly the Hastings 
lecture were vigorous and practical. 


Mental After-Care Association 


The annual meeting of this association will be held at 
the Stationers’ Hall, Ludgate Hill, London, E.C., on 
Wednesday, March 18th, at 3 P.M., when the speakers 
will include Sir Hubert Bond, Dr. G. W. B. J ames, 
K Me D. Nicol, Dr. J. F. E. Prideaux, and Dr. Reginald 

orth. 


King’s College Hospital 

A petition is to be presented to The King to continue 
the patronage to the hospital granted by previous 
sovereigns. Progress is being made here with the new 
nurses’ home and private patients block. Expenditure 
last year had been very heavy and but for the exceptionally 


large legacies received during the year the deficit would 
have been much greater. | 


A Birmingham Welfare Centre 


On Feb. 24th Mrs. W. A. Cadbury opened a new centre 
to extend the work of the public health, maternity and 
child welfare committee among the hundreds of families 
living on the Weoley Castle estate, Birmingham. At 
the new centre there are facilities for light meals and a 
class-room for instruction in cooking and nursery work. - 


Medical Diary 


SOCIETIES 


ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W. 
TUESDAY, March 17th. 

General Meeting of Fellows. 5.30 P.M. 

Pathology. 8.15 P.M. for 8.30 P.M. Annual General 
Meeting. L. B. Holt: The Antitoxin Response to 
Varying Doses of Staphylococcus Toxoid. J. Patter- 
son: The Quantitative van den Bergh Reaction and 
the Separate Evaluation of the Two Types of Pigment 


when present together in Serum. J. B. Duguid: 
Histogenesis of Experimental Tubular Nephritis. 
D. M. Pryce : Case of Tuberculous Arteritis. E. Hardy: 


Pneumococcal Septicemia with Organisms in the 
Blood Film. <A. B. Rosher: Streptothrix Morpho- 
logically Resembling C. diphtheri=. B.H. E. Cadness: 
Case of Sickle-cell Anemia. 

THURSDAY. 


G. e 
Fordyce Disease. Dr. E. M. Wigley : 
Psoriasis. Dr. J. Twiston Davies: 4. Case for Diag- 
nosis: ? Kyrle’s Disease. Dr. aber and Dr. 


Freudenthal: 5. 
Neevi (Jadassohn), Dr. 
Adenoma Sebaceum. 7. 
Pityriasis Rosea. Dr. G 
Hereditaria Heemorrhagica. Dr. R. T. Brain: 9. Der- 
matolysis and Neevus Pigmentosus. 10. Urticaria 
Pigmentosa Dating from Birth. 

Neurology. 8 P.M. Mr, Geoffrey Jefferson : Compres- 
sions of the Chiasma, Optic Nerves and Optic Tracts 
by Intracranial Aneurysms. Film (made by Dr. 
H. L. Gordon in Kenya) of Huntington’s Chorea will 
be shown by Dr. C. Worster-Drought. 


AY. 
Radiology. 8.15 P.M. Report of the council of the 
section making recommendations to the General 
- Medical Council as to the place of radiology in the 
medical curriculum. Dr. E. W. ining and Mr. 
Hugh Cairns: Value of Radiology in Neurosurgery. 
Dr. M. H. Jupe, Mr. G. Jefferson, Mr. D. W. Northtield, 
and Dr. J. Purdon Martin will also speak. 
HUNTERIAN SOCIETY. 
MONDAY, March 16th.—8.30 P.M. (Simpson’s Restaurant, 
Bird-in-Hand Court, 76, Cheapside), Dr. Adolphe 
Abrahams, Dr. C. S. Myers, F.R.S., and Dr. J. ©. 
Bridge: Fatigue. | 


I. Muende: 6. Pringle’s 
Lichen Planus Simulating 
ber: 8. Telangiectasia 


“ROYAL MICROSCOPICAL SOCIETY. : 


WEDNESDAY, March 18th.—4.30 P.M. (London School of 
Hygiene, Keppel-street, W.C.), Joint Discussion with 
Food Group of the Society of Chemical Industry on 
the Microscopy of Foods, . ' 


‘CHELSEA CLINICAL SOCIETY. 


TUESDAY, March 17th.—8.30 P.M. (Hotel Rembrandt, 
Thurloe-place, S.W.), 


Mr.” Hugh Cairns: Modem 
Cranial Surgery. ‘ 


ROYAL SOCIETY OF TROPICAL MEDICINE AND 
HYGIENE, Manson House, 26, Portland-place, W. 
THURSDAY, March 19th.—8.15 P.M. (Royal Army Medica! 
plege, Grosvenor-road, Millbank, S.W.), Laboratory 
leeting. 
SOCIETY OF MEDICAL OFFICERS OF HEALTH, 1, Thorn- 
haugh-street, W.C. 

FRIDAY, March 20th.—5.30 P.M., Prof. S. J. Cowell and 
Dr, G. C. M. M‘Gonigle: Nutritional Factors in the 
Prevention of Disease. 

Maternity and Child Welfare Group.—8.30 P.M., Dr. 

pne eee: Bre apr aon Wis its Causes, 

evention, an reatment. r. ginia Saunders- 
Jacobs will also speak. | 


.THE LANCET] 


EUGENICS SOCIETY. 
TUESDAY, March 17th.—5.15 P.M. (Rooms of the Linnean 
Society, Burlington House, Piccadilly, W.), Mr. D. 
Caradog Jones: Eugenics and the Merseyside Inguiry. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 


ROYAL COLLEGE OF PHYSICIANS, Pall Mall East, S.W. 
TUESDAY, March 17th, and THURSDAY.—5 P.M., Dr. John 
Parkinson: Enlargement of the Heart. (Lumleian 


Lecture. ) 
ae COLLEGE OF SURGEONS, Lincoln’s Inn Fields, 


Monpay, March 16th.—5 P.M., Dr. L. W. Proger: Speci- 
. mens illustrating Tumours of the Kidney. 

FRIDAY.—5 P.M., Dr. A. J. E. Cave: The Anatomy of 

Certain Vertebral Joints. l 
ROYAL INSTITUTION, 21, Albemarle-street, W. 

TUESDAY, March 17th.—5.15 P.M., Prof. Edward Mellanby, 

F.R.S.: Drug-like Actions of some Foods. 
INSTITUTE OF HYGIENE, 28, Portland-place, W.1. 

WEDNESDAY, March 18th.—3.30 P.M., Dr. G. W. Theobald : 

Some Effects of Emancipation on the Health of Women. 
CHADWICK PUBLIC LECTURE. 

THURSDAY, March 19th.—5.30 P.M. (Royal United Service 
Institution, Whitehall, S.W.), Dr. Arthur MacNalty : 
Epidemic Poliomyelitis. | 

ant as POSTGRADUATE MEDICAL SCHOOL, Ducane- 
road, W. 

MONDAY, March 16th.-—2.30 P.M., Dr. Gordon Holmes: 
Cerebro-spinal Syphilis. 3.30 P.M., Prof. F. J. 
Browne : Toxeemias of Pregnancy. 

TUESDAY.—2.30 P.M., Dr. Leonard Colebrook: Puerperal 
Sepsis. 2.30 P.M., Dr. Janet Vaughan: Tests for 


gnancy. 

WEDNESDAY.—Noon, Clinical and pathological conference 
(medical). 2.30 P.M., Clinical and pathological con- 
ference (surgical). 3.30 P.M., Mr. Aleck Bourne : 
Disproportion and Difficult Labour. 

THURSDAY.—2.15 P.M., Dr. Duncan White: Radiological 
Demonstration. 

FRIDAY.—3.30 P.M., Dr. R. E. Roberts: Radiology in 
Obstetrics. 5 P.M., Sir James Walton: The Surgical 


papens of Dyspepsia. . 
Medi clinics, surgical clinics or operations, obstetric 
daily from 


and gynæcological clinics or operations 
. 10 A.M. to 4 P.M. 
FELLOWSHIP OF MEDICINE AND POST-GRADUATE 
MEDICAL ASSOCIATION, 1, Wimpole-street, W. 
Monpay, March 16th, to SUNDAY, March 22nd.—ROYAL 
NATIONAL ORTHOPZDICO HOSPITAL, Great Portland- 
street, W. Post-graduate course jin orthopsedics.— 
INFANTS HOSPITAL, Vincent-square,S.W. Mon., Wed. and 
Fri., 8 P.M., primary F.R.C.S. course in anatomy and 
physiology.— BROMPTON HOSPITAL, S.W. Mon., Tues., 
Wed., and Thurs., 5 P.M., special M.R.C.P. class.— 
Royal CHEST HOSPITAL, City-road, B.C. Mon., 
Wed., and Fri., 8 P.M., special M.R.C.P. class in chest 
and heart diseases.—MIMLER GENERAL HOSPITAL, 
Greenwich-road S.E. Week-end course in general 
medicine.—Courses are open only to members of the 
Fellowship. 
PRINCESS BEATRICE HOSPITAL, Richmond-road, S.W. 
THURSDAY, March 19th.—8.45 P.M., Dr. B. Buckley Sharp: 
Demonstration of Cases. Mr. Kenneth Heritage: 
The Treatment of Prostatic Obstruction. Mr. A. 
Lawrence Abel: The Pavex Treatment of Vascular 
Disease. Mr. Abel: Surgical Travels in North America, 
illustrated by cinematograph films. 
NATIONAL HOSPITAL, Queen-square, W.C. 
Monpbay, March 16th.—3.30 P.M., Dr. Symonds: 
Injuries (II.). 
TUESDAY.—3.30 P.M., Dr. Grainger Stewart: Meningitis 


and Cerebral Abscess. 
Dr. Kinnier Wilson: Clinical 


WEDNESDAY.—3.30 P.M., 
Demonstration. 

THURSDAY.—3.30 P.M., Dr. Riddoch: Cerebral Tumours. 

Fripay.—3.30 P.M., Dr. Denny-Brown: Neuritis. 
Out-patient clinic daily at 2 P.M. 

HAMPSTEAD GENERAL AND NORTH-WEST LONDON 

HOSPITAL, N.W. ; ri 

e 


WEDNESDAY, March 18th.—4 P.M., Mr. A. Sorsby : 
Ophthalmoscope in Cardiovascular Disturbances. 
so ata FOR SICK CHILDREN, Great Ormond-street, 
WEDNESDAY, March 18th.—2 P.M., Dr. Reginald Light- 
wood: Survey of Pulmonary Tubercle. 3 P.M., 


Dr. A. Signy: The Value of the Mantoux Test. 
Sul pariont clinics daily at 10 A.M. and ward visits at 


P.M. 
ST. JOHN CLINIC, Ranclagh-road, S.W. 
FRIDAY, March 20th.—41.30 P.M., Demonstration of Chest 
Remedial Exercises for Asthma, Remedial Exercises 
for Sciatica, Rheumatic Diseases. 
LEEDS GENERAL INFIRMARY. 
TUESDAY, March 17th.—3.30 P.M., Dr. Cooper: 
Developments in X Ray Therapy. 
MANCHESTER ROYAL INFIRMARY. 
TUESDAY, March 17th.—4.15 P.M., Mr. 
S. D. Don: 


Head 


Recent 


Platt : 


Demonstration of 


Harry 
Common Disabilities of tbe Foot. 
FrRIDAY.—4.15 P.M., Dr. C 
Medical Cases. 
UNIVERSITY OF DURHAM. 
SUNDAY, March 22nd.—10.30 a.M. (Newcastle General 
Hospital), Dr. k. B. Wright: Selected Cases. 
GLASGOW POST-GRADUATE MEDICAL ASSOCIATION 
WEDNESDAY, March 18th.—4.15 P.M. (Ophthalmic Insti- 
tution), Dr. T. Stewart Barrie: The Red Eye. 


MEDICAL DIARY.— BIRTHS, 


MARRIAGES, AND DEATHS [marca 14,1936 639 


INFECTIOUS DISEASE 


IN ENGLAND AND WALES DURING THE WEEK ENDED 
FEB. 29TH, 1936 


Notifications.—The following cases of infectious 
disease were notified during the week: Small-pox, 0 ; 
scarlet fever, 2386; diphtheria, 1200; enteric fever, 
29; acute pneumonia (primary or influenzal), 1529 ; 
puerperal fever, 41; puerperal pyrexia, 126 ; cerebro- 
spinal fever, 35; acute poliomyelitis, 5; acute polio- 
encephalitis, 1 ; encephalitis lethargica, 4; dysentery, 
17; ophthalmia neonatorum, 96. ‘ No case of cholera, 
plague, or typhus fever was notified during the week. 


The number of cases in the Infectious Hospitals of the London 
County Council on March 6th was 5194, which included : Scarlet 
fever, 968; diphtheria, 1033 ; measles,1774; whooping-cough, 704; 
puerperal fever, 18 mothers (plus 14 babies); encephalitis 
lethargica, 283 ; poliomyelitis, 4. At St. Margaret’s Hospital 
there were 25 babies (plus 13 mothers) with ophthalmia 
neonatorum. 


Deaths.—In 121 great towns, including London, 
there was no death from small-pox, 2 (0) from enteric 
fever, 88 (20) from measles, 6 (0) from scarlet fever, 
45 (10) from whooping-cough, 40 (6) from diphtheria, 
68 (23) from diarrhoea and enteritis under two years, 
and 107 (17) from influenza. The figures in paren- 
theses are those for London itself. 


The mortality from influenza has varied but little during the 
present year, the total deaths for the last 13 weeks (working 
backwards) being 107, 119, 97, 85, 98, 104, 89, 110, 110, 8 
67, 62, 45. The deaths this week are scattered over 53 great 
towns, Birmingham reporting 9, Manchester 7, Croydon 5, no 
other great town more than 3. Liverpool reported 11 deaths 
from measles, Manchester 9, Salford 7, Birkenhead and Sheffield 
each 5, Bristol 4. Liverpool also reported 8 deaths from 
whooping-cough, Manchester and Birmingham each 5. Deaths 
from diphtheria were reported from 24 great towns: 5 from 
Manchester, 3 from Bradford, 2 each from Ilford, Leyton, Hull, 
West Hartlepool, and Birmingham. 


The number of stillbirths notified during the week 
was 296 (corresponding to a rate of 45 per 1000 total 
births), including 52 in London. | 


_ Births, Marriages, and Deaths 


BIRTHS 


DEIGHTON.—On March 5th, at Cleethorpes, the wife of Dr. 
A. H. Deighton, of a son. : 

GrBpson.—On March 3rd, at Torquay, the wife of Paul C. Gibson, 
M.D. Lond., Torquay, of a son.. . 

GLANVILL.—On March Ist, at Devonshire-place, W., the wife. 
of Dr. Reginald Glanvill, Windsor Forest, Berks, of a 
daughter. 

HALLEY.—On March 7th, at Ascot, the wife of G. Stiven Halley, 
M.D. St. And., of a son. : 

MaRRACK.—Oh March 8th, at Bishop’s Stortford, the wife of 
John Marrack, M.D. Camb., of a son. 

PRYCE.—On March 3rd, at Welbeck-streect, W., the wife of 
Dr. D. Merlin Pryce, of a daughter. 

RuHys-JONES.—On March 3rd, the wife of Dr. Gwilym C. Rhys- 
Jones, of Dartford, of a son. 

UPJOHN.—On March 4th, at Haverhill, Suffolk, to Dr. Margaret 
Carnegie Simpson, wife of F. H. Upjohn—a son. 


MARRIAGES 


JOLL—RAMSDEN.—On Feb. 29th, at St. George’s, Hanover- 
square, Cecil A. Joll, M.S. Lond., F.R.C.S. Eng., of Harley.- 
strect, W., to Antonia (Toni), younger daughter of Mr. 
F. H. Ramsden, of Cambridge-terrace, W. 


DEATHS | 


Banxks-DaAvis.—On March 5th, at Portman-street, W., Henry 
John Banks-Davis, M.B. Camb., F.R.C.P. Lond. 

CLARKE.—On March 5th, at St. Albans, of pneumonia, Sidney 
Herbert Clarke, M.D. Camb. 

CraIG.—On March 8th, suddenly, at Littlehampton, Daniel 
Craig, M.D. Glasg. 

Davis.—On March 3rd, at Brighton, Ivor Davis, M.D. Durh. 

DowDEN.—On March 8, at Edinburgh, John Wheeler Dowden, 
LL.D., F.R.C.S. Edin. 

GIBBENS.—On March Ist, at Barking, Essex, Frank Edward 
Gibbens, M.R.C.S. Eng. 

MAGILL.—On March 9th, at a nursing home in London. Sir 
James Magill, K.C.B.,M.D.,M.S.,Q.V. Irel.,M.R.C.S. Eng., 

= Col., late R.A.M.C. . 

MENZIES.—On March 7th, at Farnborough, Henry Menzies, 
M.B. Camb., of Hobart-place, S.W. 

SHEARER.—On March 7th, suddenly, Thomas Pitcairn Shearer, 
L.R.C.P. Edin., of Leicester, in his 79th year. 

THOMSON.—On Feb. 27th, at Menton, Brevet-Col. Samucl John 
Thomson, C.I.E., C.B.E., I.M.S. 


N.B.—A fee of 78. 6d. is charged for the insertion of Notices of 
Births, Marriages, and Deaths. 


640 


THE LANCET] 


[marcu 14, 1936 


NOTES, COMMENTS, AND ABSTRACTS 


PAINLESS DENTISTRY |. 


A FEW weeks ago a report was widely circulated in 
the lay press announcing the discovery by Dr. Leroy 
Hartman, of Columbia University, of a densitising 
solution by means of which the preparation of carious 
teeth for filling could be made painless in a few 
moments. It may be permitted to discount the 
somewhat sensational way in which the announce- 
ment was made and to believe that Dr. Hartman, 
who is a well-known dental surgeon in America, was 
not responsible for the flamboyant terms in which his 
discovery was made public. The solution consisted 
of thymol 1} parts, ether 2 parts, and 95 per cent. 
pure ethyl alcohol 1 part. The solution should be 
applied with cotton-wool to the dentine of the tooth 
to be filled and allowed to remain for 14 minutes 
for adults. It was claimed that this made the 
cavity preparation genuinely- painless. We learn 
from newspaper reports that an unprecedented rush 
on chemists by American dentists has caused the 
supply of thymol to run short. 

No doubt in this country many dental surgeons 
have felt it their duty to try this method, for although 
the manner of its announcement was not entirely 
calculated to dispel doubt, it would have been foolish 
to neglect any method which might render the use of 
the dental engine less unpleasant. Several letters 
have appeared in succeeding issues of the British 
Dental Journal which show that many have given 
Hartman’s solution a trial with results on the whole 
unsatisfactory, though some have recorded successes. 
The varying results suggest that the psychical factor 
may not have been entirely absent, for there is no doubt 
that many patients are extremely suggestible where 
pain is concerned. announcement that the 
marvellous new drug, guaranteed to make dentistry 
painless, was about to be tried, would doubtless be 
sufficient in many cases to make the patients believe 
that it was as effective in their case. 

Topical applications to a carious cavity before 
cutting it out have long been used by dental surgeons 
and various drugs alone or in combination have been 
employed. The composition of Hartman’s solution 
suggests that it may act by producing cold in the 
tooth. In so far as it does this there is no doubt 
that it would reduce pain. But it may be said of 
all drugs or preparations known to the dental 
profession that none of them can be relied upon to 
act as obtundents in every case. One of the best 
ways of making cavity preparation comparatively 
painless is by spraying a fine jet of cold water on the 
tooth to be prepared. In many cases, though not all, 
this will make a tooth so insensitive that it is possible 
to cut out the cavity without pain. Its disadvantage 
is that it requires the services of an assistant and is 
not very easily applied to back teeth. 

Paraform, a polymer of formaldehyde, is a valuable 
obtundent. A minute quantity sealed in a carious 
cavity for a few days is often effective in reducing 
the sensitiveness. But it is a highly irritating drug 
and must be used with caution in case it brings about 
death of the dental pulp. For this reason it can only 
be used in shallow cavities. Eugenol, phenol, ethyl 
chloride as topical applications are all among the 
methodsin use. They may have a temporary effect, 
always transient and frequently disappointing. 

A local injection as used for the extraction of teeth 
is one of the best methods of rendering cavity 
preparation painless; but the anesthesia may take 
some time to develop. A good result can usually be 
promised for front teeth, but for the molars the results 
are so variable as to rob this method of a good deal 
of its value. There is a natural tendency on the 
part of some patients to think that specific methods 
to relieve pain must be effective and that if they are 
not, the fault may be that of the dentist. While 
painless dentistry is still an ideal much can be done 
to diminish the pain attendant on the process of 


filling teeth. Drugs have their place, but it still 
remains true that sharp instruments, a gentle touch, 
a sympathetic manner, and a clear knowledge of 
what has to be done are perhaps the most effective 
methods known to dentists of making conservative 
dentistry as little unpleasant as possible to the 
patient. 


MORAL PROBLEMS IN HOSPITAL PRACTICE 
BY ROMAN CATHOLICS 


A WORK 1 which has the Imprimi Potest the Nihil 
Obstat and the Imprimatur of various Roman Catholic 
episcopal authorities is written for sisters in charge 
of hospitals who may at times be placed in sudden 
and grave doubts about the moral legitimacy of 
certain surgical operations. ‘‘ The cases giving rise 
to these doubts,” says the author, ‘‘are very often 
urgent cases and they not infrequently involve 
questions of life and death, and hence call for an 
immediate decision which the Sister finds it impos- 
sible to give in existing circumstances.” 

The conduct which is enjoined upon hospital 
sisters by Father Finney certainly may involve 
questions of what can broadly be described as 
hospital discipline. Thus, we are told that it is 
never lawful, even for medical or therapeutic reasons, 
to produce direct abortion, and that it is unlawful 
to sterilise a woman whose reproductive organs are 
normal but whose life might be threatened by diseases 
of other organs such as the heart, lungs, or kidneys, 
if she were to become pregnant. The book is written 
in the form of a series of questions and answers, the 
moral basis of which are expounded. 


Q. 54.—“ Has a Sister in charge of an operating-room 
the right to question a surgeon, as to the purpose of the 
work he is doing, in the course of an abdominal opera- 
tion ?”’ A.—‘* Yes, she has not only the right, but it is 
also her duty to question him, if she has reasonable grounds 
to suspect that he is doing something that is not morally 
lawful.” 

Q. 55.—“ Has a Sister the right to question the surgeon, 
or tell him not to remove ovaries, or to do a complete 
hysterectomy ? ” A.—‘ Ordinarily a Sister has no right 
to tell a surgeon not to remove ovaries, or to do a com- 
plete hysterectomy, because if these organs are at all 
diseased, the surgeon must be the sole judge of what is 
to be done regarding their removal. However, if these 
organs are evidently healthy, and a Sister has reasonable 
grounds for suspecting that the surgeon is removing 
them for the purpose of sterilising the patient, the Sister 
has not only the right but the duty to question him.” 

Q. 56.—‘‘ If curettage is slated on the board, how is the 
Sister to know whether it is for the purpose of abortion 
or not?” A.—‘‘This question is best answered by 
stating that a Sister in charge of an operating-room has 
a right to know, in advance, the exact nature of each 
operation that is to be performed. Therefore it should be 
an established rule, not only with regard to curettage, 
but with regard to any other operation, that a surgeon 
should state in advance to the Sister in charge of the 
operating-room the nature of the operation he intends to 
perform, at least as far as his diagnosis will enable him 
to do so.” 


In view of the fact that the views of the Roman 
Catholic church concerning the conditions which 
justify termination of pregnancy and sterilisation 
do not always harmonise with those which govern 
orthodox medical practice, it is possible to envisage 
that a difficult situation might arise in the course 
of an operation if Roman Catholic hospital sisters 
were invariably to perform. their moral duty as 
specified in this book. The divergences of Roman 
Catholic moral teaching from orthodox medical 
A Practical Hand- 
By the Rev. Patrick A. Finney, C.M., 
London: B. Herder Book Company. 


1 Moral Problems in Hospital Practice. 
book. Fifth edition. 
University of Dallas. 
1935. Pp. 208. 6s. 


THE LANCET] 


teaching can be illustrated by the following questions 
and answers :— 


Q. 8.—“ If it is morally certain that a pregnant mother 
and her unborn child will both die, if the pregnancy is 
allowed to take its course, but, at the same time, the 
attending physician is morally certain that he can save 
the mother’s life by removing the inviable fetus, is it 
lawful for him to do so?”” A.—*‘‘ No, it is not. Such a 
removal of the fetus would be direct abortion.” 

Q. 34.—“ In a case of ectopic pregnancy, in which the 
presence of the fetus is regarded as endangering the 
mother’s life, is it lawful to remove an inviable ectopic 
fetus?” A.—‘‘ No, it is not lawful.” 


A hospital sister’s duties with regard to extraction 
of the fetus after the death of the mother and 
baptism may also be found surprising. They are 
governed by a principle stated by Dr. Austin O’Malley 
in the following words :-—. : 


“ When we began to vegetate, our life began; we had 
@ soul; and this as soon as the pronucleus of the sper- 
matozoon fused with the pronucleus of the ovum, and 
made the first segmentation-nucleus. Before the first 
fission of that segmentation nucleus was completed into 
two distinct cells the soul was present, for that fission was 
independent life; and any life is impossible without a 
soul, or, what is the same thing, a vital principle. Since, 
moreover, the soul with the body is man, and since the 
process. of vegetation in our present state is identical 
with that first cell-fission, this splitting primordial cell 
is a human being. The active primordial cell in this stage 
is as much a complete phase of human life as are the body 
and soul of a person at puberty, or at adult ago.” 


It follows from this statement that ‘if a mother 

dies during pregnancy, the fetus should be extracted 
by those upon whom this duty devolves.” ... ‘ 
buman embryo is distinguishable and has the form 
of a fetus as early as the end of the fourth week of 
gestation.” 
-~ This fourth provision of the canon is based upon 
the fact that the fœtus often survives the mother 
who dies before delivery, and therefore nothing 
should be left undone to extract the foetus without 
delay, because, under the circumstances, there is 
nearly always a chance to administer baptism, and 
thereby secure eternal life for the fœtus, and, in 
cases where the fœtus has reached the term of via- 
bility, there is also a chance to preserve its temporal 
life. Regarding the operation for the extraction of 
the fœtus, Father Ferreres writes as follows:— — 


“ Since cases of apparent death are not uncommon in 
pregnant women, and since it is important—in order to 
secure the fetus alive—that the cesarean operation should 
take place as soon as possible, two points are to be borne 
in mind: 
death; (2) that the cesarean operation, or any other 
operation deemed necessary, be performed with the same 
caution and care as in the case of a living mother, so 
that, if alive, she may not be killed, as unfortunately 
has taken place more than once.” (“ Death Real and 
Apparent,” pp. 38-39.) 


The duty is also imposed of baptising an unborn 
child. The following instructions are given :— 


Use a syringe which has been rendered aseptic and fill 
it with boiled water. If the membranes have not broken, 
they must be ruptured and the amniotic fluid discharged. 
The syringe is then carefully inserted in the vagina, and 
the water directed against the child’s head, while at the 
same time you say the form of baptism. Do this without 
hurry, and be careful not to injure the parts. The water 
should be boiled and cooled to the temperature of the 
body before use. If the syringe is aseptic and the water 
boiled, there will be no danger of infecting the mother. 
If the os uteri be only partially dilated, it will be better 
to eject the water during “a pain.” If the os uteri be 
undilated, a valid baptism is practically impossible. 
As there is always a doubt with regard to the validity 
of intra-uterine baptism, in practice you should baptize 
again conditionally after it is born, pouring water on the 


NOTES, COMMENTS, AND ABSTRACTS 


(1) that there be certainty of the mother’s. 


[maron 14,1936 641 


child’s head and saying, “If thou are not baptized, I 
baptize thee in the Name of the Father, and of the Son, 
and of the Holy Ghost.” If the child’s head is born, but 
not the rest of the body, and death is feared, you will 
baptize in the ordinary way, and conditional baptism 
will not be required afterwards. The umbilical cord is 
only a temporary part of the child, and baptism performed 
upon it is certainly invalid. 


Difficulties may, however, arise as to the sister’s 
duty in the event of an early miscarriage. e 
following instructions given by the Rev. John 
Fletcher are quoted by the author as authoritative :— 


“If, however, the immature product of conception be 
passed, the question—and the most difficult question—is 
to determine whether it be living or dead. As every 
embryo has a rational soul, it follows that every fetus, 
prematurely expelled from the womb, should be baptized, 
if living ; baptized conditionally (‘if thou are alive,’ etc.) 
if life be uncertain, and left alone if certainly dead. Make 
sure that what is passed is an embryo before you baptize 
it conditionally. Do not try and give the Sacrament to. 
a large, decomposed blood clot, for instance. The ovum 
varies in size according to its age, and is generally covered 
with its membranes when expelled. If passed covered 
with the membranes, these must be quickly opened, and 
the fetus baptized conditionally. If small, it may be 
baptized by immersion. Place it in a small bowl of water, 
rupture the membranes with your thumb and forefinger, 
and at the same time say, ‘If thou art alive, I baptize 
thee,’ etc., and take it immediately out of the water. The 
advantage of this method is that you lose no time, and 
you have not to search for the head. With regard to 
abnormal fruits of conception, these misfortunes are 
fortunately very rare and die soon after birth. If they 
possess @ head and breast, they should be baptized. 
Unless there be immediate danger of death, leave the 
question of baptism to the priest.” 


In addition to the above, the Rev. John Fletcher. 
from whom Father Patrick Finney here quotes 
gives the following note :-— 7 


“ In cases of intra-uterine baptism, by a decree of the 
Sacred Office, August 21, 1901, a solution of one part 
bichloride of mercury in 1000 parts of water is allowed, 
if the use of plain water would be dangerous to the mother— 
not unless danger be present. The author, in any case, 
prefers the boiled water recommended in the text.” 


MASQUE OF SPRING 


SPRING and its new fashions will be seen together 
in a ‘“ Masque of Spring ”’ to be presented next week 
in the fashion theatre of Messrs. Derry and Toms of 
Kensington by a clever company of artistes recruited 
from Covent Garden and other theatres, who will 
dance, mime, and parade to incidental music by 
classic and modern British composers, in three scenes 
—Morning, Afternoon, and Night. The masque, 
with expert choreography and designs by Andree 
Howard, will be an ambitious attempt to present new 
fashions in an artistic setting, and the Westminster 
Hospital is indebted to Messrs. Derry and Toms for 
the generous offer of the proceeds of the, first 
performance. 


‘* SYNTROPAN IN SEA-SICKNESS.’’—Several inquiries 
have reached us about the preparation mentioned 
by Prof. C. Stanton Hicks in his letter on the treat- 
ment of sea-sickness (THE LANCET, Jan. 25th, p. 226). 
We are informed that this preparation is not actually 
on the market, but the Hoffmann-La Roche Chemical 
Works Ltd. (51, Bowes-road, London, N.13) are 
willing to hand trial supplies free of charge to medical 
men who are specially interested, and, if need be, 
are in a position to execute orders from wholesale 
or retail chemists. The preparation is a combination 
of Syntropan and Sedormid, the latter being a widely 
used sedative belonging to the open-chain ureides. 
Syntropan itself, a synthetic drug primarily intended 
for the relief of spasm, is obtainable in the ordinary 
form of oral tablets of 1 c.cm. ampoules. 


THE LANCET 


642 


‘AAPPOINTMENTS.— VACANCIES 


[MARCH 14, 1936 


THE RISK OF DIRT 


A NEw poster shortly to be issued by the Health 
and Cleanliness Council reproduces their slogan 
** where there’s dirt there’s danger ’’ in an arresting 
manner. The secretary of the movement (5, Tavistock- 
square, London, W.C.) will be pleased to send speci- 
mens of the poster free of charge, together with 
particulars of an , offer of supplies of posters for 
distribution. The affixing of these bills in conspicuous 
Places in certain districts should be of public utility. 


Messrs. J. AND A. CHURCHILL LTD. inform us 
that the London County Council have renumbered 
the houses in Gloucester-place and that in future all 
communications about their publications, includ- 
ing The Medical Directory, should be directed to 
104, Gloucester-place, W.1. 


[i 


Anyoininents 


BARNETT, T. S. M., M.D. Melb., F.R.C.S. Eng., has been 
appointed Visiting Consultant Obstetrician for Portsmouth. 

BELL, A. C. H., M.B. Lond., F.R.C.S. Eng., M.C.O.G., Assistant 
Obstetric Surgeon to the Westminster Hospital. 

HUGHES, EDWARD, M.D. Liverp., D.P.H., Deputy Medical 
Officer of Health for Plymouth. .- 

KERR, J. A., B.Sc. Birm., F.R.C.S. Eng., Hon. Surgeon to the 
Buchanan Hospital, St. Leonards-on-Sea. 

TIPPETT, G. O., M.B. Lond., F.R.C.S. Eng., Surgical Registrar 
at the London Lock Hospitals. 


London Hospital.—The following appointments are announced : 
NELSON, H. P., M.D. Camb., F.R.C.S. Eng., Hon. Assistant 


Surgeon 
BROWN, A. T. PARRY, M.B. Lond., D.A., Hon. 
Anæsthetist ; >; and 
COOPER, AUSTIN, M.D. Dub., Consulting Ansesthetist. 
Queen Charlotte’s Maternity Hospital. —The following appoint- 
ments are announced :— 
aaa ate S. W. J., M.B. N.Z., Senior Resident Medical 
cer; 
WELLS, C. P. B., M.R.C.S. Eng., Assistant Resident Medical 
cer; 
KARRAN, C. W. C., M.B. Camb., District Resident Medical 


fficer ; 
‘ FORSTER, D. I., M.R.C.S. Eng., Resident Anesthetist and 
District Resident Medical Officer; and 


OLDFIELD, J. M., M.R.C.S. Eng., Resident Ansesthetist. 


Cortity ing Surgeons under the Factory and Workshop Acts: 
J. T. GRASSIE (Cheltenham District, Gloucester) ; 

br G. I. Grirriras (Bangor District, Caernarvon); Mrs. 

E. A. HuGHes, M.D. Lond. (Ruthin District, Denbigh). 


Assistant 


‘Vacancies 


_ For further information refer to the advertisement columns 
Aberdeen Royal Infirmary.—Surgical Registrar. £200. 
Aberdeen Royal Mental Hospital.—Asst. Physician. £300. 
Altrincham General Hospital.—Sen. H.S. At rate of £150. 
AUTO Y, gion Buckinghamshire Hospital.—Second Res. 


Beckenham, Bethlem Royal Hospital, Monks Orchard. —Two Res. 
H.P.’s. Each £175. 

‘Birmingham, Erdington House.—Deputy M.O. £800. 

ali a Little BE Hospital for Infectious Diseases.— 

un. Res. M. 

maa iA coma Borough.—Asst. M.O.H. and Asst. School 

Bristol City and County, Child Guidance Clinic. —Psychiatrist. 
At rate of £500. Also Social Worker. 275. 

Canterbury, Kent County Mental Hospital, Chartham Down.— 
Med. Supt. £1000. 

Cardiff, King Edward VII. Welsh National Memorial Associa- 
tion.—Res. Asst. Tuber. M.O. £500. Res. M.O. £350. 
Also Asst. Res. M.O. £200, for Suly Hospital, Glam. 

Central London Throat, Nose, and Ear Hospital, Gray’ s Inn-road, 

.C.—Hon. Third Assts. to Out-patient Dent. . 

Charing Cross Hospital.—Registrar to Nose, Throat, and Ear 
Dept. £100. Also Hon. Clin. Asst. to Dermatological Dept. 

Chelsea Hospital for Women, Arthur-strect, S.W .—Surgeon for 
Kar, Nose, and Throat. 

Cheshire, Institution for Mental Defectives, Cranage Hall.—Res. 
Med. Supt. £800. 

Chester, Barrowmore Hall, Great Barrow.—H.P. At rate of £150. 

Chester Royal Infirmary. H.S. £150. 

Derby, Bretby Hall Orthopredic Hospital, near Burton-on-Trent. — 
Asst. M.O. and Res. H.S. Each at rate of £150. 

Dewsbury and District General Infirmary.—Second H.S. £150. 

Dewsbury, Infectious Diseases Hospital.—Res. M.O. £200. 

Durham County Council.—Asst. Welfare M.O. £500. 

Eastbourne, Princess Alice Memorial Hospital.—les. H. 7 £150. 

Eastbourne Royal Eye Hospital, Pevensey-road.—H.S. £100. 

Elizabeth Garrett Anderson Hospital, 144, Euston-road, N.W.— 
Hon. Clin. Assts. Also Hon. Asst. Obstetrician. 


Evelina Hospital for Sick Children, Southwark, S.E.—Dental 
Surgeon. Also H.S. At rate of £120. 

Grent I estern. Taiwan, Medical Fund Society, Swindon. —Chief 

Great Yarmouth General Hospital.—H.S. £140. 

Guildford, Royal Surrey County Hospital.—Res. Surg. O. £250. 

Harrow Urban District.—Asst. M.O. 00. i 

Hospital for Sick Children, Great Ormond-strest, W.C.—Res. H.P. 
and Res. H.S. Each at rate of £100. 

Hospital of St. John and St. Elizabeth, 60, Grore End-road, N.W.— 
Res. H.S. At rate of £75. 

Huddersfield County Borough.—Asst. M. O.H. £500. 

Huddersfield Royal Infirmary.—H.P. and Res. Anesthetist. 
Also H.S. Each at rate of £150. 

Ilford, King George Hospital.—H.P. and two H.S.’ 

Institute of Ray Therapy, Camden-road, N.W. part- -time M.O. 
At rate of £100. 

Isolation Hospital, Muswell Hil.—Res. M.O. £400. 

Kent Education Committee. —Asst. M.O. £500. 

Kent and Canterbury Hospital.—Hon. Dermatologist. 


King’s College Hospital, S.E.—Asst. Surg. and Asst. Ortho» 
peedic Surgeon 

Lancaster County Mental Hospital. —Asst: M.O. £500. 

Liverpool Sanatorium, Delamere Forest, Frodsham. Second 
Asst. to Med. Supt. £200.--.. : i 

London County Council. —Two Asst. M.O.’s (Grade I). Each 
£350. Four Asst. M.O.’ 8 (Grade mie Each £250. Also five 


Temp. District M.O.’s. #£300-£100 
London Lock Hospitals.—Two Res. M. O.’s. One for Male Dept. 
Qne for Female Dept. Each at rate of £175. 
London University. ZR niversity Chair of Biochemistry. &1000. 
Also University Readership in Anatomy. £600. 
Macclesfield General Infirmary.—Second H.S. At rate of £150. | 
Manchester, Ancoats Hospital.—H.S. At rate ef £100. 


Blanchester, Withington Hospital and Instilultion.—Jun. Asst. 
M.O. At rate of £200. ; 

Mansfield, Harlow Wood Orthopedic Hospital.—Two H-S.’s. 
At rate of £200. 

Mount Vernon Hospital, Northwood, Middiesexr.—Asst. Radio- 
logist. £350. 

Newport, Mon, Royal Gwent Hospital.—Cas. O. At rate of 


£175. Asst. Cas. O. Also two H.S.’s and H.P. Each 
at rate of £135. 


Northumberland County Council.—Asst. County M.O.H. £500. 


Norwich, Jenny Lind Hospital for Children.—Res. M.O. £120. 
Nottingham General Hospital.—H.P. At rate of £150. 
‘Paddington Green Children’s Hospital, W.—H.P. and BS. 


Each at rate of £150. 

Plymouth, Prince of Wales’s Hospital, Greenbank-road.—HS, 
At rate of £120. 

Port Said. British Wosvital.—Principal M.O. £700. 

Preston and County of Lancaster Royal Infirmary.—H.P., Cas, 
H.S., also H.S. Each at rate of £150. 

Princess Beatrice Hospital, Earl’s Court, S.W.—Hon. athe: thetist. 


Princess Louise Kensington Hospital for Children, . Quintin- 
avenue, W.—Clin. Asst. for Out-patient Rept . 

Rochdale Infirmary and Dispensaru.—Second H.S. £150. 

Rotherham Hospital.. Cas. H.S. £156. 

Rotherham, Oakwood Hall Sanatorium. —Asst. Res. M.O. £250. 

Royal Chest Hospital, City-road, E.C.—Clin. Assts. 

Royal Northern /lospital.— Asst. Pathologist. £500. 

Royal Waterloo Hospital for Children and Women, S.E. —-Hon. 
Asst. Orthopedic Surgeon. 

St. Albans, Hill End Hospital for Mental and Nervous Disorders.— 
H.P. At rate of £165. 

St. Andrew’s Hospital, Devons-road, Bow, E.—Asst. M.O. £350. 

St. Marzy’s Hospital, W.—Med. Reg. £200. 


Salford Royal Hospital, Hon. Asst. Physician. 

Salisbury General Injirmary.—H.S. At rate of £125. 

Sheffield Children’s Hospital.—H. P. At rate of £100. 

Sheffield University, Dept. of Bacteriology.—Jun. Asst. Bacterio- 
logist and Demonstrator. £300. 

Southampton, Isolation Hospital and Sanatorium.—Jun. Res. 


M.O. £200, 

Southend-on-Sea General Hospital.—Obstet.-Reg. £125. Also 
H.S. At rate of £100. , , 

Stoke-on-Trent, North Staffordshire Royal Infirmary.—Radium 
Officer. £500. 

Taunton and Somerset Hospital.—H.S. At rate of £100. 

Tottenham Diagnostic Clinic. —Gynæcologist. £125. 

umer ey aR Hospital, Gower-street, W. A — Asst. Radio- 
ogis i 


University College Hospital Medical School, W.C.—Jun. Fellows 
for Beit Memoria] Fellowships. Each £400. 


Uxbridge, Hillingdon County Hospital.—Jun. Res. Asst. M.O. 
At rate of £250. 
Walsall, Manor Hospital.—Jun. Res. Asst. M.O. £150. 


West pronu and District General Hospital. —Cas. O. At 
rate of £ 

Western Ophthalmic Hospital, Marylebone-road, N.W .——Sen. and 
Jun. Res. H.S.’s. At rate of £150 and £100 respectively, 

West London Hospital, Hammersmith-road, W.—H.P. and H.S. 
to Spec. Depts. and Res. Cas. O. Each at rate of £100. 
Non. Res. Cas. O. £250. Also Physician. 

ee eee County Council, d&:c.—Asst. County M.O.H., &c. 


800 
Wigan, Royal Albert Edward Infirmary and Dispensary,—H.S. 
t rate of £150. 
Willesden General IT ospital, Harlesden-road, N.W.—Res. Cas. 0. 
At rate of £100. 
York County Hospital. —H.S. to Eye, Ear, Nose, and Throat 
Dept. £150. 
The Chicf Inspector of Factories announces a vacancy for a 
Certifying Factory Surgeon at Pontesbury, Salop. 


Medical Referee under the Workmen’s Compensation Act, 
1925, for the Halifax County Court District (Circuit No. 12). 
Applications should be addressed to the Private Secretary, 
Home Oflice, Whitehall, London, S.W.1, before March 28th. 


THE LANCET] 


{mancH 21, 1936 


ADDRESSES AND ORIGINAL ARTICLES 


MEDICAL PROBLEMS IN MINERAL 
METABOLISM * 


By R. A. McCancet, M.D., Ph.D. Camb., 
F.R.C.P. Lond. 


ASSISTANT PHYSICIAN IN CHARGE OF BIOCHEMICAL RESEARCH, 
KING’S COLLEGE HOSPITAL, LONDON 


I.—LEGACIES OF EVOLUTION 


“ That the physician of another age will be as familiar 
with the operations of the animal economy as he is at 
spat with its anatomy I have not the least doubtand... 

will venture to predict that what the knowledge of 
anatomy at present is to the surgeon, in conducting his 
operations, so will chemistry be to the physician in 
directing him generally, what to do and what to shun; 
and, in short, in enabling him to wield his remedies with 


@ certainty and precision of which in the present state 


of his knowledge he has not the most distant conception.” 88 


THE words are those of William Prout, Goulstonian 
lecturer in 1831. That prophesy was a bold one to 
make over one hundred years ago, but I think it 
has been justified by the events of the last few years. 
Chemistry is one of the “‘ growing points ” of medicine 
to-day, and I make no apology that my subject is 
a biochemical one. You have heard from recent 
Goulstonian lectures something of the metabolism 
of calcium, phosphorus,‘® and iron.1°? My theme 
is also one of mineral metabolism, and while I propose 
to say something of the above elements in my first 
lecture, I hope to deal mainly with the importance 
of sodium in physiology and medicine. 

The minerals in the world to-day are those which 
were there when life began. Their properties have 
not changed in any way. As life evolved some 
twenty or thirty of them have been incorporated into 
living matter, some in very small amounts, and this 
‘< mineral basis of life ” ®1 is one of the most interesting 
aspects of evolution. Some elements are almost 
universally present in living matter; others—e.g., 
vanadium and cadmium— only seem to have been used 
by one or more families. Sometimes the same 
element has been used to fill many functions, some- 
times the same function has been served by two or 
more elements. Our own mineral metabolism is the 
legacy of the ages. We can only appreciate it by 
a study of the past. 


The Mineral Background of Evolution 
. CALCIUM AND IRON 


Puzzling and diverse as some of the functions of 
the elements seem to be, their chemical properties 
must govern and have always governed their bio- 
logical behaviour. Of the six metals (sodium, 
potassium, calcium, magnesium, iron and copper) 
commonly present in living matter in considerable 
quantities, calcium is the one with the greatest 
tendency to form insoluble salts. The carbonate, 
phosphate, oxalate and stearate at once come to 
mind. Now of these the carbonate and phosphate 
have been very widely used as hardening agents, the 
former by the invertebrates for their protective 
exoskeleton, the: latter by the vertebrate phylum 
for their bones ard teeth. Birds have utilised both 


*The Goulstonian ‘lectures for 1936, delivered before the 
Royal College of Physicians of London on March Sth, 10th, 
and 12th. Lects. II. and III. will appear in forthcoming issues 
of por E t 


the phosphate and carbonate. On the other hand 
calcium is not the only biological metal with insoluble 
salts. Sodium and potassium form none, but iron 
possesses an insoluble phosphate and some of the 
organic phosphate esters have iron salts which are 
quite insoluble even in hydrochloric acid. Very 
insoluble forms of ferric oxide are also known. There 
is therefore no theoretical reason why iron should 
not have been adopted as the universal hardening 
agent, although its scarcity is a sufficiently practical 
one. It hasas a matter of fact been so used by some 
of the marine invertebrates, and this. is a beautiful 
example of Nature’s ability to solve a similar problem 
in two quite different ways. The radular teeth of 
the Chitonidæ contain ferric oxide embedded in a 
stroma of unproven nature, and the Patellidz also 
possess teeth so impregnated with this same insoluble 
ferric oxide that beautiful X ray photographs can 
be taken of them.44 These animals are particularly 
interesting because they illustrate the use of another 
hardening agent, silica, which has been extensively 
used by the sponges and other lower forms of marine 
life, but which has found no place in the structure 
of the vertebrates. Their central teeth consist of 
a siliceous framework, packed with ferric oxide, 
which is so insoluble that it can only be removed 
by prolonged heating with concentrated hydrochloric ` 
acid. ; 

There is some evidence that calcium and iron may 
be biologically associated—but not of course in 
all their functions. Iron is a constant impurity 
in marine shells,!* 51 and there is evidence that 
iron may be present in normal and pathological 
calcification.1°° Ramage et al.67 79 have found 
that in the livers of foetuses and young animals there 
is a tendency for iron and calcium to rise and fall 
together. In hemochromatosis also there may be some 
associated disturbance of calcium metabolism.®® 92 93 
On the other hand calcium is not apparently 
necessary for life even in highly developed forms. 
Lower plants containing no chlorophyll may be 
successfully grown on calcium-free media, and it 
has recently been shown that drosophila, a fly, 
may have 99 per cent. of its calcium removed without 
loss of function. This interesting work of Rubinstein 
et al.7® on yeast and drosophila show how unwise it is 
to generalise from the frog or mammal as to the rôle 
of ions in neuromuscular physiology. 

The very property which makes an element so 
invaluable in one respect may make it a source of 
difficulty or even danger in another. I need not 
recall to you the way in which insoluble: calcium 
salts form concretions in the urinary and biliary 
systems, the salivary ducts and other embarrassing 
situations. That iron does not do so also is, I think, 
only due to the fact that so little free iron is present. 
in the body fluids. 

There can be no doubt that the development of 
a satisfactory method of excreting these elements 
with insoluble salts must have been a sine qua non 
of evolutionary survival. In considering evolution 
we are inclined to think anatomically. Thus loss 
of shell is a frequent event in the evolution of some 
of the invertebrate phyla. We regard it as a common- 
place, but just consider for a moment what a strain 
must have been thrown on the mechanisms for 
excreting calcium when such an evolutionary step 
occurred. Many species have managed it success- 
fully, but I feel sure that the calcium metabolism 
of allied species with and without shells would prove 

M 


644 THE LANCET] 


an interesting study. I have found, for example, 
that one of the nudibranchs (Archidoris britannica) 
contains 2 per cent. of calcium. This is not organised 
into any useful structure but seems to be present 
throughout the tissues in the form of the carbonate, 
which forms 20 per cent. of the total dry weight of 
the animal. I believe that this may well be the 
result of inefficient excretion coupled with the loss 
of the power to form a shell. I venture to suggest 
that man would never have been evolved at all if the 
early mammals had not acquired the property of 
excreting almost all their unwanted calcium by the 
bowel, where the insolubility of its salts could not 
cause mechanical obstruction. 


The insolubility of so many of the calcium salts 
may be a source of danger for another reason, for 
it may prevent enough of the food calcium being 
absorbed to supply the needs of the animal. Excess 
of inorganic phosphates may do this, especially if 
the stomach juices are not acid. The masses of 
fatty acids which pass through the gut in sprue and 
coeliac disease without being absorbed bind calcium 
as the insoluble soaps 8° and prevent its absorption. 
The calcium in spinach is said to be quite unavail- 
able 24 because of the excess of oxalic acid present 
in this plant. I think it quite likely that there may 
be enough oxalic acid in a helping of rhubarb or 
strawberries to immobilise all the calcium eaten at 
that meal. 

There is no doubt that the physiological and patho- 
logical chemistry of calcium is largely bound up with 
that of the associated ions. Consider for example 
the extraordinarily low serum calciums which have 
been recorded in chronic interstitial nephritis 81 101 
and which are almost certainly secondary to the 
high levels of inorganic phosphate which are met 
with in that disease.®® Concretions form because 
free fatty acids, or bile-pigments, or phosphates, 
accumulate and precipitate themselves out with the 
calcium which is universally present. I will give you 
what I consider to be a good example of this. In the 
rare disease known as calcinosis plaques of calcium 
phosphate accumulate beneath the skin. They are 
sometimes surrounded by fluid. I have had the 
opportunity of examining one of these cases in which 
fluid was withdrawn on two occasions within a few 
weeks of each other. The results of the chemical 
examinations are shown in Table I., and you will 


TABLE I 
Ca/P. Ratios in Calcinosis Fluid 
First Second 
withdrawal. withdrawal. 
Calcium 580 mg./100 c.cm. 123 mg./100 c.cm. 
Phosphorus .. 260 mg./100 c.cm. 227 mg./100 c.cm. 
Ca/P. ratio 2°22 0°54 


see that on the first occasion the calcium and 
phosphorus were present in large amounts and in the 
ratio in which they are found in bone, while on the 
second the fluid was rich in phosphorus but contained 
relatively little calcium. I conclude that the calcium 
had not yet had time to accumulate, for I believe 
from other examinations of internal deposits which 
I have made that calcium would have been deposited 
until a calcium/phosphorus ratio approaching that 
of bone had been achieved.1% 103 


IRON AND COPPER 


We do not know whether iron was a part of the 
first globule of living matter or not, but we do know 
that it is one of the most important elements in our 
own life processes. From the evolutionary and 


DR. R. A. MCCANCE : MEDICAL PROBLEMS IN MINERAL METABOLISM 


[maRnon 21, 1936. 


medical points of view the relationships of iron and 
copper are most interesting. I need only refer to 
the fact that the latter is in some way essential for 
the synthesis of hemoglobin in the higher animals.® 
The two metals have chemical properties in common 
which have been adopted by Nature for oxygen 
transport. The two pigments bemoglobin and 
hemocyanin, the respiratory pigment of the arthropods 
and molluscs, contain iron and copper respectively. 
Both form an oxygen, a carbon monoxide and 
nitric oxide compound with the reduced metal, and 
an oxygen compound with the metal at its higher 
valency,”! so that functionally they are very alike. 
They seem to differ sharply, however, in the chemical 
nature of the group with which the metal is combined. 
In hemocyanin this appears to be a sulphur compound 
with a peptide,71 and the narrow distribution of 
hemocyanin may be due to the limitations of these 
essential prosthetic groups. In hæmoglobin on 
the contrary the iron is combined with a pyrrole 
derivative—porpherin—so that the problem of oxygen 
transport has been solved in two quite different ways, 
and we have the two metals serving the same function 
in virtue of the fact that they possess different 
prosthetic groups. 

Now in addition to their share in oxygen transport 
porpherins seem to be of almost universal distribution, 
and, whereas iron is the metal commonly attached 
to them, copper porpherins are also found in nature. 
The best known of these have no respiratory function 
and form the colouring matter in the feathers of 
the South African bird turaco. On the other hand 
the iron porpherins are the great respiratory catalysts 
of the organic world, so that here we have the two 
metals combined with the same prosthetic group 
and serving different functions. 


These iron porpherins seem to be present in every 
active aerobic animal and vegetable cell.45 It is 
this iron complex in yeast with which cyanide 
combines.?!9 

Iron is known to have many other functions. Yeast, 
which can only respire in the presence of organic 
hematin iron, can only ferment in the presence of 
inorganic, probably ferrous, iron.!!® Inorganic iron, 
and to a less extent hematin iron, activate catalysts 
like glutathione ?? and enzymes, and this metal has no 
doubt many functions of which we have not as yet got 
any conception. Why, for example, should the epithe- 
lial cells of the higher animals double their iron content 
quite rapidly at the close of the growth period, and 
thereafter maintain it at the higher level1°®°%? We 
do know, however, that two forms of iron are present 
in every cell which depends upgix oxygen for its 
respiration, and therefore that“ our food contains 
these two forms of iron. Are bth equally valus-yle % 
This is a question which hasfreceived cuusider: ble 
attention in the last 10 or 15 ypars. 


The Availability of Orggnic (Hæmatin) Iron 
in Nufrition 


Whipple and RobscheitfRobbins?°* found that 
hemoglobin was well utilfsed by anamic cogs for 
blood regeneration wh’ it was fadm nistered 
parenterally, but that qmly some §-20 yer cent. 
of it was so used wherf it was taken by mouth. 
Lintzel tried the experipent of adding 50 ug. of iron 
on one day to the diet Jf a man in iron equilibrium, 
and found that some J5-18 mg. of the metal were 


retained when it was gfen as the sulphateor aoo 
ese 


can bo supportad on oun 
grounds, for all are familiar with the way 15a whic 


but none when it waf given as hemogobm. 
are observations whi 


\ 


A 
pg 


THE LANCET] ` 


very small but often recurring hemorrhages into 
the gut can bring about a profound anemia. Lintzel 4? 
has maintained rats for 4-6 weeks on an iron-free 
diet and to this diet added iron in various forms. 
Ferrous sulphate and the chloride were well retained 
and stored, but not so hemoglobin iron. The bodies 
of the animals which had been given hemoglobin 
contained no more iron in their bodies than the 
controls. Elvehjem, Hart and Sherman 2! compared 
the rate of hemoglobin regeneration caused by various 
foods with the amount of inorganic iron they contained, 
and found there was a close parallel We may 
conclude therefore that iron in the organic tetra- 
pyrrole form is a poor source of iron for the body, 
and it is most satisfactory and interesting that 
copper in this form should also have been shown 
to be quite unavailable.*? I think this unavailability 
must be due to the fact that mammals have never 
evolved a digestive ferment capable of setting free 
iron from these porpherin compounds. Lintzel, 
for example,®® and others have shown that only 
some 5-10 per cent. of hæmoglobin iron can be set 
free by prolonged peptic and tryptic digestion in 
vitro, and that some of the iron in plants may also 
be most resistant to such treatment. Many attempts, 
mostly biological,’> 76 77 have been made to determine 
the available iron in food. These tests are not easy 
to carry out, and yet it is clearly important to know 
the proportions of porpherin and ionisable iron in 
our daily diets. 

L. R. B. Shackleton and I! have accordingly made 
a chemical survey of all the common foodstuffs 
eaten in this country and a synopsis of the results 
is given in Table II. 

TABLE II 


Available Iron in Foods 
Expressed as a percentage of the total iron 


Beef muscle es 8— 28 Cereals aa .. 80-100 
€ ver .. i 80—100 Cabbage, lettuce, &e. 50- 75 
Chicken muscle 25- 35 Legumes .. .. 70- 95 
Fish (white) 95-100 Tomatoes .. 50— 80 
», (herring) 55- 75 Plums . ..- 50—- 70 
Eggs, ben .. ‘8 100 Apples and pears .. 80-100 
Roe, herring ere 98 Grapes, raisins, &c. 86— 96 
Nuts eo ee 60—- 95 


You will notice that little of the iron in meat but 
nearly all the iron in liver, eggs, white fish and cereals 
is available. Most vegetables and many fruits fall 
into an intermediate category, but some fruits and 
nuts contain a very high percentage of their iron 
in available form. It follows at once from these 
figures that meat, for all the iron it contains, may 
be a poor source of the metal, and foods like eggs and 
brown bread are really as good although they do 
not contain so much total iron. Miss Widdowson 
Nene I have found that a person on a mixed diet, but 

‘eating over half a pound of meat per day, was taking 
n 22-1 mg. of iron per day of which only 9-3 mg. 
were available. A second person, who ate practically 
_ no meat, was only taking in 9-3 mg. of iron per day 
from the food, but 8-6mg. of it was available. I 
think that in future we shall probably assess iron 
requirements on the basis of available rather than 
total iron. . 


Total and Available Iron in English Dietaries 


I think I am right in saying that all surveys of 
British diets have been made by the “family ”’ 
method, and that there are no records of the weighed 
food intakes of individual normal men and women. 
We know that the calorie requirements of women are 
very much less than those of men, but that the needs 
of the two sexes, expressed as calories per kilogramme 
of body-weight are more nearly the same. We 


DR. R. A. MOCANCE : MEDICAL PROBLEMS IN MINERAL METABOLISM [marom 21, 1936 645 


have no right to assume that these relative require- 

ments of the two sexes apply to iron and other 

inorganic salts. We have every reason in fact to - 
suppose that they do not. One has only to consider 

the drain of menstruation, pregnancy and lactation 

on women’s stores of iron and calcium to realise that - 
their needs for these minerals must be greater than 

men’s. 

Miss Widdowson and [1° have carried out a 
survey by the individual method. We persuaded 
63 men and 63 women of the middle classes to weigh 
all their food for a week, and from this data and our 
own food analyses we have worked out each 
individual’s protein, fat, carbohydrate, calcium, 
iron and phosphorus intakes. We are only concerned 
for the moment with their iron intakes, which are 
summarised in Table III. Considering the total iron 


TABLE III 
Iron Intakes and Hemoglobin Levels of Middle-class Men 
and Women 
MEN WOMEN 


Mean! Max.! Min. ]Mean| Max.| Min. 
16°8 | 28:5 


Total iron mg./day 


7°8 911-4 | 173| 5:5 
Total iron mg./kg. body- 
weight/day ii .. | 024| .. oe 0:18 
Available iron mg./day .. |10°8 | 18°7| 5:3 | 7:9 | 12:4! 50 
Available iron mg./kg . 
body-weight/day 0°16 0°13) .. 
Heemoglobin percentage . | 102 | 114 | 86 93 102 | 87 


first you will observe that the average woman’s 
intake was far below the man’s, and the highest 
woman’s figure only just exceeded the man’s average. 
If you look at the intakes per kg. of body-weight you 
will see that even on this basis the women’s intakes 
are well below the men’s. This difference between 
the sexes is partly due to the higher consumption 
of meat by the men. The intakes of available iron 
per kg. of body-weight are more nearly the same, but 
there is still a balance in favour of the men which 
is simply explained by the greater amount of food 
eaten by them. This difference would not matter 
if all intakes were well up to or over the optimum, 
but this is not likely to be generally the case for 
many of these individual intakes are lower than the 
accepted American and English standards. At the 
same time there can be no serious iron deficiency 
among these people, for their average hemoglobin 
levels were normal and the male/female ratio also 
normal, 

When we began, however, to think over the so-called 
normal difference between the hemoglobin levels of 
the sexes and to consider it in the light of their iron 
intakes and iron requirements, we could not help 
feeling that the difference might not be physiological 
after all, but pathological. We therefore administered 
100 mg. of iron per day to a group of 31 normal men 
and women, mostly between 20 and 30 years of age. 
This treatment did not alter the hemoglobin level 
in the men’s blood but raised it without exception 
in the women’s. The average increase was over 
10 per cent., and the result of treatment was to leave 
the two sexes with almost the same average per- 
centages of hemoglobin. I think we must conclude 
that the hemoglobin levels of normal women in 
this country are being limited by their low iron 
intakes. They would probably be better and fitter 
on larger intakes and this could, I think, be settled 
if a sufficiently comprehensive investigation was 


646 THE LANCET] 


undertaken. It would appear that men get enough 
iron for their physiological requirements in this 
country, but I think it possible that their rate of 
acclimatisation to high altitudes, which depends 
partly upon new hemoglobin formation, may be 
controlled by their iron intakes,1°6 


Phosphorus 


I turn now to another element, phosphorus, which 
I believe is essential to all living matter. It is the 
shortage of this element in sea water which limits the 
development of the plankton, upon which practically 
all animal life in the sea depends. I only propose to 
touch upon one very small aspect of phosphorus 
metabolism, and my real excuse for doing so is that 
it has been occupying my attention for the last 
18 months. 

In the course of their evolution the seed plants have 
developed the property of forming and storing large 
amounts of a substance called phytin. This is the 
calcium magnesium salt of inositol hexa-phosphoric 
acid. Inositol has the empirical formula C,H;.0, 
and resembles the carbohydrates in having 6 -OH 
groups and a sweet taste, but differs from them in 
most other properties, particularly in possessing 
a cyclic structure. I suppose it is true to say that the 
efficiency of seeds depends to a large extent upon the 
fact that they contain the maximum amount of 
nourishment for the embryo combined with the 
minimum amount of moisture, and from this point 
of view phytin must be regarded as an almost ideal 
product, for it offers a means of storing carbon, 
hydrogen, phosphorus, calcium and magnesium in 
an inert and quite insoluble form. 

In that the seeds of plants may form a very 
important part of man’s diet, we have to consider 
the question of phytin in human nutrition. Many 
have assumed that the phosphorus calcium and 
magnesium are freely available, but there is plenty 
of evidence which suggests that they may not be. 
In the first place mammals have never evolved an 
intestinal enzyme capable of hydrolysing phytin 
and setting the phosphorus free in inorganic form,® 
and phytin itself is most unlikely to be absorbed 
without being hydrolysed. It is indeed easy to show 
that 25 to 65 per cent. of ingested phytin is excreted 
unchanged. I myself ate a pound of Hovis bread 
every day for 10 days which meant that I was having 
about 430mg. of phytin phosphorus per day (in 
addition to all the other wonderful things in brown 
bread !). I excreted just under 50 per cent. of this 
phytin phosphorus unchanged in my fæces and the 
remainder was probably destroyed by the bacteria 
in my large intestine.54 We must conclude that 
phytin phosphorus is largely unavailable. In the 
second place, if phytin is not digested it may hold 
large amounts of calcium in the gut as the insoluble 
salt and so prevent the latter’s absorption. In this 
way phytin, by being itself unavailable, may render 
calcium unavailable also. 

It has often been claimed that cereals tend to 
promote rickets. Bruce and Callow ® suggested that 
this might be due to the phytin in the cereals. The 
whole question is a very open one at present,?5 31 48 
but it seemed to me that we ought to know how much 
phytin there was in human food, so Miss Widdowson 
devised a method of estimating it and Table IV. 
shows some of our results. You will see what a 
high percentage of the phosphorus in whole wheat 
and oats is in the form of phytin. White bread 
contains much less phytin, but also much less total 
phosphorus. Nuts contain large amounts of phytin 


DR. R. A. MOCANCE: MEDICAL PROBLEMS IN MINERAL METABOLISM 


[manoH. 21, 1936 


TABLE IV 
Total and Phytin Phosphorus in Foods 
Edible portions only have been d. a a are 
expressed on the basis vt fresh or sa pe Lg weigh 


Total P. Phytin P. 


Mg./100 g. | Mg./100 g. Per cent, of 


Cereals— 
Wholemeal flour .. 355 168 46 
White ee see 102 15 15 
Hovis bread.. si 211 90 43 
Rolled oats .. ave 339 224 66 
Nuts— 
Brazilnuts .. ee 592 133 22 
Pea se a ae 365 210 58 
Vegetables— 
Potatoes ʻi <i 31 6 19 
Onions zs ate 30 0 0 
Swedes ie ss 19 0 0 
Carrots ae es 20 3 16 
Fruit— 
Apples ee ee 80 0 0 
Bananas s a 28 0 0 
Blackberries . ge 26 4 16 
Figs (dried) . «a 91 12 13 


phosphorus, but vegetables and fruits little or none. 
By applying these results to the dietary survey, to 
which I have already referred, we were able to find 
out how much total and phytin phosphorus people in 
this country were eating. The results are in Table V. 


TABLE V 
Total and Phytin P. Intake of Men and Women 
Men Women. 
(Mean of 63) (Mean of 63) 

Total P. (g./day) a ow 161 ee 1°13 
Phytin P. (g./day) : 004  .... 0:04 
Non-phytin—i. e., available P. 

(g. /da ay) 1°57 L E 1:09 
Available P. aa: "percentage of 

total P. 98 amas 97 


You will see that in English diets phytin phosphorus 
forms a very small percentage of the total phos- 
phorus. There are two reasons for this. Firstly, we 
derive a very large part of our phosphorus from 
meat, milk and other animal products which contain 
no phytin. Secondly, the majority in this country do 
not eat whole cereals but white bread, and, as you see 
in Table IV., this contains very little phytin. I 
think that in English diets phytin may almost be 
neglected. There is plenty of phosphorus in the 
food without it, and not enough of it to be a real 
danger to calcium absorption. It may be quite other- 
wise with native diets in which maize, millet, &c., 
form the bulk of the food. In them half the total 
phosphorus ingested may be unavailable, and possibly 
the calcium as well. 


The Alkali Metals, Sodium and Potassium 


‘I wish now to turn to other aspects of mineral 
metabolism and say something of the importance of 
sodium and potassium. All the common saltsof these 
metals are freely soluble. While this normally 
ensures complete absorption from the intestine it 
carries with it certain disadvantages, for there is no 
way in which the body can store reserves of these 
elements in an insoluble and inactive form. Although 
so much alike chemically and physically sodium and 
potassium fulfil quite different biological rôles, for 
animals and plants have universally adopted potas- 
slum as the main cellular base and sodium as the 


THE LANCET] 


extracellular ion. The cell membranes once formed 
seem to be almost impermeable to these soluble 
kations, so that cells bathed in a medium rich in 
sodium may contain none of this element. It has 
been shown experimentally that one of the marine 
diatoms, and possibly some of the seed plants, can 
substitute rubidium for potassium in cellular growth, °® 
so that potassium may not be essential for life in its 
general sense. Higher animals must have potassium, 
although rubidium is an element commonly found in 
traces in living cells.°* MZwaardemaker 11 showed 
that uranium could replace potassium in fluids used 
to maintain the ‘rog’s heart beat. I do not think 
that the possibilities of potassium substitution in 
animals or plants have been fully explored. 

Since sodium has been adopted as the main extra- 
cellular base, vertebrates and invertebrates with 
elaborate extracellular circulatory systems must 
contain considerable amounts of this element, and 
obtain it from their food. With no reserves to draw 
upon a constant supply is important, and although 
periods of deficiency can be survived if excretion can 
be cut down to a minimum, the moment the rate of 
excretion is forced up large amounts must be supplied 
or the most serious consequences will ensue. Plants, 
which have no such extracellular systems, may 
contain practically no sodium. Some insects also 7? 
appear to be able to thrive on minimal amounts of 
this element. Drosophila for example can flourish 
when 95 per cent. of the sodium in its body has been 
removed, and possibly may be able to do without 
any at alk. The discovery that such a highly organised 
creature as drosophila can do without sodium is an 
extraordinarily interesting one. It is fully as signi- 
ficant theoretically, although not perhaps so important 
economically, as for example the discovery that sheep 
require cobalt. ®® 


TABLE VI 
Sodium Content of Some Common Foods 
Mg./100 g. Mg./100 g. 

Meat 65- 8 Cereals ae 5-30 
Milk 43 Potatoes . 3- 4 
Eggs 185 Ve etables— 
organs: reen és 3-15 

ney, &c 110—160 Fruit ci 0- 3 
Fish 120—190 Nuts 2-10 


‘Average human intake/day : 3000-6000 mg. 


Table VI. shows the amount of sodium in a number 
of common food materials. You will notice how 
little some of them contain, and appreciate that 
additional salt may be an absolute necessity when I 
tell you that I would have to eat more than twice my 
own weight of potatoes every day to get my physio- 
logical intake of sodium. Men were mining for salt 
4500 years ago at Igidir.2° It is in hot climates where 
sweating is more or less continuous that salt becomes 
such a very important article of diet. A man may 
lose 3000-4000 mg. of sodium in a day by sweating, 
and a study of Table VI. will show that cereals without 
added salt would be a most inadequate diet.5? 


Water Regulation 
THE FUNCTION OF THE GLOMERULI AND TUBULES 


The water regulation of the body is undoubtedly 
one of the key problems of comparative physiology, 
and it is intimately linked with the metabolism of 
sodium and potassium and the evolution and function 
of the kidney. 

I cannot discuss water regulation or the meta- 
bolism of sodium without some reference to the 
function of the kidney, and the methods which have 


DR. R. A. MCCANCH : MEDICAL PROBLEMS IN MINERAL METABOLISM [Manon 21, 1936 647 


been developed in recent years for studying it. 
These consist essentially in methods of differentiating 
the function of the glomeruli and tubules. There 
have been several interesting developments. It has 
been found possible in frogs and snakes to insert a 
cannula into a single intact glomerulus and withdraw 
the glomerular fluid for analysis. In this way it has 
been shown that in the frog, necturus, and 
snake 5®74 the fluid filtered off in the glomeruli 
resembles plasma closely in composition except 
that it contains no protein. It does contain 
sugar, urea, chlorides and phosphates in the 
concentration in which they occur in plasma. 
Since the normal urine of these animals contains no 
sugar, reabsorption of this substance and water 
must take place in the tubules. Owing to the double 
blood-supply of the frog’s kidney it is also possible 
to perfuse the tubules through the renal portal vein 
without perfusing the glomeruli. In this way it has 
been shown that the tubules of the frog’s kidney do 
not excrete soluble sugars such as xylose, which | 
readily pass into the urine of the intact animal.®® 
The inference is that these sugars are filtered off in 
the glomeruli of the intact animal. This conception 
of the function of the tubules and glomeruli is very: 
much supported by the study of the secretion of 
urine in glomerular and aglomerular fish.5® 57 58 
The glomerular fish excrete xylose readily and other 
soluble foreign substances such as thio-urea and 
inulin. Glucose appears in their urine if they are 
given phloridzin. The aglomerular fish do not 
excrete xylose, sucrose or inulin °° and do not get 
glycosuria after phloridzin. This evidence all strongly 
suggests that the function of the glomeruli is to 
filter off all the soluble constituents of plasma, and 
that water and some soluble substances—e.g., glucose 
—are reabsorbed by the tubules. The aglomerular 
fish, however, can excrete creatinine, so that the 
tubules of these animals have also an excretory 
function. 

If we knew of some substance which was freely 
filtered off in the glomeruli so that its concentration 
in the glomerular fluid was equal to that of the 
plasma, and if we knew that this substance was not 
reabsorbed or excreted by the tubules, we could use 
it as a measure of glomerular filtration. Then, by 
comparing its rate of excretion with that of other 
substances, we could find out how the latter were 
being dealt with by the kidney. This method is 
applicable to mammals and man, and much of the 
work of the last ten years on the secretion of urine 
has been devoted to the search for such a substance. 
Rehberg, I think, first suggested that creatinine 
might be used for this purpose in man. He took 
creatinine by mouth to raise the plasma concentra- 
tion and estimated the plasma and urine concentrations 
and the volume of urine secreted in unit time. Now 
the volume of fluid filtered off in the glomeruli per 
minute 


_ percentage of creatinine in urine 
blood 


x vol. of 
urine per min. 


a» 99 LRA 


You will at once recognise that this formula is the 
same as that giving what is otherwise termed the 
creatinine clearance. Creatinine has been accepted 
by a number of continental workers, often without 
question, as a true measure of glomerular filtra- 
tion.® 6 7 8 11 19 22 23 2730 39 41 47 64 65 108 

Some have produced experimental evidence in its 
favour in the following way. Phloridzin has been 
known for a long time to lead to glycosuria, and, 
taking all the evidence together, phloridzin may be 
assumed to abolish the reabsorption of glucose in 


648 THE LANCET] 


DR. R. A, MCCANCE : MEDICAL PROBLEMS IN MINERAL METABOLISM 


[maron 21, 1936 


the tubules. Govaerts and . Cambier 2229 and 
Poulsson §* therefore compared the clearances 
of glucose and creatinine in fully phloridzinised 
animals and found them to be the same. These 
experiments were done on dogs, and the results were 
assumed to apply to man. More recent work has 
shown that this is probably not the case (vide infra). 

Nevertheless there is a great deal to be said 
against the indiscriminate use of creatinine as a 
measure of glomerular filtration.1® In the first place 
it is excreted by the aglomerular fish, so that some- 
where in the scale of evolution creatinine was actively 
excreted by the tubules. In the second place the 
rate of excretion of creatinine may be,!5 but apparently 
is not invariably, directly proportional to the plasma 
concentration, which is a sine qua non of any substance 
used to measure glomerular filtration.®5 84 85 86 

In connexion with some work on the absorption 
of sugars from the intestine, McCance and Madders 53 
suggested in 1930 that the pentose sugars might be 
used as measures of glomerular filtration. These 
non-metabolised sugars were later independently 
suggested and investigated in the United States. 
At first the American investigators accepted these 
sugars as true measures of glomerular filtra- 
tion.12 14 42 43 62 88 89 They found, as has Cope,!® 
that their clearances were below that of creatinine, and 
they therefore considered that the latter was to 
some extent excreted by the tubules. They also 
found that after phloridzin the clearances of glucose 
and the non-metabolised sugars were the same. 
Hober, however, reported that xylose was reabsorbed 
to a small extent by the frog’s tubules, and if this 
is true of other animals these sugars cannot give a 
true measure of glomerular. filtration. 


The latest compound to be used to measure 
glomerular filtration rate is inulin. This is a poly- 
saccharide with a molecular weight of 1000-4000, 
and therefore most unlikely to diffuse readily out 
of the tubules or to be reabsorbed. It is freely 
soluble in water and filtered off in the glome- 
ruli. This substance has been used by Shannon 
and his collaborators, ®4 88 9% who now admit that the 
pentose sugars and cane sugar are all reabsorbed 
to some extent and do not give an absolute measure 
of glomerular filtration. Inulin apparently is per- 
fectly satisfactory. Glucose and other sugars may 
only be used if reabsorption has been blocked by 
phloridzin. Creatinine may be used in the 
dog 75 8687195 byt not in the fish, in which it is 
actively excreted by the tubules, nor in man, in whose 
tubules some active excretion also appears to take 
place.85 

All methods of measuring glomerular filtration 
suggest that large amounts of fluid must be filtered 
off there—between 100 and 150 c.cm./min. in a 
normal man. Since the normal rate of urine secretion 
is only about 1 c.cm./min., 99 per cent. of the water 
in the glomerular filtrates must be reabsorbed. 


THE WATER REGULATION OF MARINE ANIMALS 


As already stated, cell membranes, except those 
of the glomeruli and capillaries, are not ordinarily 
permeable to cations. They are, however, freely 
permeable to water so that cells are subject to the 
laws of osmotic pressure. These statements are 
as true of the complicated multicellular organism 
as they are of its individual constituent cells. We 
know, for example, that fish have a more or less 
constant mineral composition, and yet experiments 
with heavy water have shown that equilibrium 
between the water inside and outside of a small 


living fish is attained in an hour.?* Now all 
vertebrates at the present time have an osmotic 
pressure very much greater than that of fresh water, 
but very much less than that of the sea. It is now 
thought that they were evolved in fresh water.’ 96 
However that may be, all the water swallowed by 
a fish living in fresh water tends to dilute the plasma, 
and water must also be absorbed through the gills. 
Their glomerulo-tubular kidneys deal effectively 
with this. The high rate of glomerular filtra- 


tion offers a ready means of separating water 
from the blood. The tubules reabsorb glucose, 
the necessary salts, and some water. The 


excess, which is excreted, results in the passage of a 
very dilute (hypotonic) urine. As the seas became 
more salt or as the free swimming vertebrates made 
their way into more saline waters, the whole situation 
changed. The environment became more con- 
centrated than the tissue fluids. Thus instead of 
water passing into the fish there was a tendency for 
the water to pass outward through the gills, and for 
the animal to become desiccated. This could have 
been corrected by the production of a sufficiently 
concentrated urine, but the marine fish have never 
evolved the power to secrete a urine more con- 
centrated than their plasma, and solved the problem 
of their water regulation in other ways ° 96 (see 
later). Mammals can secrete a hypertonic urine, and 
this ability seems to be associated with the introduc- 
tion of the so-called loop of Henle into their kidneys 
and the elaboration of a hormone in their posterior 
pituitary.1° Different species of mammals possess 
the power to secrete a hypertonic urine to very 
different degrees. Thus man can undoubtedly 
produce a urine much more concentrated than his 
plasma but not sufficiently concentrated to allow 
him to use sea water as his natural beverage. 


“ Water, water, everywhere 
Ne any drop to drink.” 


We may say I think with confidence that if 
mermaids really did live in the sea they certainly 
did not have a pair of human kidneys. There are 
nevertheless marine mammals, and they must drink 
sea water and yet retain control of their water 
metabolism. I am not aware of any study having 
been made of the kidney function of these animals, 
but I imagine it would be relatively easy and be well 
repaid. 

The marine fish, which you will remember live in 
a hypertonic medium but are unable to secrete a 
urine more concentrated than their blood, have solved 
the problem of their water regulation in two quite 
different ways.®> ®°® The bony fish drink sea water, 
which is absorbed, and excrete through their gills 4° 
a solution of sodium chloride more concentrated even 
than the sea. The result of this is to leave enough 
free water in the tissue fluids to enable the animal 
to elaborate the hypotonic and almost chloride-free * 
urine. Owing to the extrarenal excretion of salt 
and water the secretion of water by the kidneys of the 
marine teleosts is very small. Glomerular filtration 
is really unnecessary, and hence some of the more 
highly developed forms have lost all their glomeruli. 
The elasmobranchs, on the other hand, have perfected 
quite another mechanism, and it is to this which I 
wish particularly to draw your attention. These 
animals have gills which are impermeable to urea. 
Their glomerular function is quite normal. Soluble 
salts are readily excreted, and also xylose and inulin, 
which are not excreted by the aglomerular fish, 
but the urine contains only traces of urea in spite of 
concentrations of 1 per cent. and more in the plasma. 


THE LANOET] 


It has been shown +4 that this is due to the active re- 
absorption of urea by the tubule cells so that ultimately 
the animal becomes hypertonic to sea water by 
virtue of the urea which it contains. Water therefore 
is absorbed from the sea by osmosis through the gills 
and possibly other parts, and this enables a hypotonic 
urine to be secreted. Here then we have an example 
of the active reabsorption of an end-product of 
nitrogen metabolism, and interest lies in the process 
because it can be shown by any of the methods of 
measuring glomerular filtration that something of 
the same sort goes on in many other animals, including 
man. It may seem strange to you, but I think we 
must accept it, that a large part of the urea filtered 
off in our glomeruli either diffuses back into the blood 
stream or is more probably actively reabsorbed. 
i shall have more to say on this subject in a subsequent 
ecture. 


WATER REGULATION IN MAN 


Clothes moths and snakes can exist for long periods 
of time on their own water of metabolism,?8 but most 
animals and man must have a regular supply of 
water. In its absence urea accumulates in the blood 
but the nitrogen balances become negative so that a 
generalised tissue disintegration must set in. Death 
soon follows. The urine volumes are well maintained 
until the end, partly no doubt by the water set free 
from the cell breakdown, but the cause is not at all 
clear.55 98 

Too much water is just as fatal as too little.®’ 
Animals may readily be killed by pushing the adminis- 
tration of water. At first a diuresis develops, but 
later and most unexpectedly the animals get an 
oliguria, and finally an anuria. Towards the end 
they get convulsions from cerebral cdema.!? Patients 
have been killed in the same way.* 

Everyone recognises that if water is taken by 
mouth the usual consequence is the passage of addi- 
tional dilute urine and the restoration of the status 
quo.1 This apparently simple function is in reality 
a complicated one.? 60100 The water absorbed lowers 
the osmotic pressure of the plasma, but the diuresis 
does not coincide in point of time * so that one cannot 
postulate a simple renal mechanism regulating the 
osmotic pressure of the plasma. Moreover, if the 
plasma osmotic pressure be reduced in other ways, 
no diuresis is produced, and water then brings about 
less diuresis than before.’ 

The regulation of water metabolism in man is a 
difficult study because of many,® but in particular 
I think because of two, complicating factors. In the 
first place the excretion of water has in the course 
of evolution come under the control of a hormone 
from the posterior pituitary,!® and the simple and 
well-known relationship between drinking and 
diuresis only holds so long as the supply of hormone 
to the circulation is normal.!°® In the second place, 
owing to the constancy with which mammals main- 
tain their osmotic pressure, water metabolism and 
salt metabolism are intimately connected. Move- 
ment of water about the body is.almost invariably 
accompanied. by simultaneous movement of salts. 
The converse is also true. Thus the excretion of 
sodium salts brings about a reduction of the extra- 
cellular fluid volume, and a loss or gain of cell sub- 
stance a corresponding change in potassium.?® One 
of the most interesting recent developments in 
mineral metabolism is the discovery that the renal 
threshold for sodium seems to be controlled by the 
suprarenal cortex. At all events, in its absence and 
in Addison’s disease forced excretion of sodium 
takes place with consequent changes in the water 


DR. R. A. MCCANCE: MEDICAL PROBLEMS IN MINERAL METABOLISM 


[MARCH 21, 1936 649 


balance of the body. I hope to discuss this more 
fully in my later lectures. 

Let me close meantime by drawing your attention 
to an aspect of mineral metabolism and comparative 
physiology which I am sure will repay investigation. 
I refer to the control of so many aspects of mineral 
metabolism by- the ductless glands, or by vitamins. 
The parathyroids, the thyroid, the suprarenal cortex, 
the posterior pituitary and vitamin D are all directly 
concerned with the water or mineral metabolism of 
the higher animals. Some would include vitamin A, 
but I prefer to regard the concretions produced by 
its absence ?? as being secondary to the changes in 
the urinary epithelium or pH. 

When were these factors controlling calcium, 
phosphorus, water and sodium metabolism evolved ? 
And what of potassium, magnesium, and iron ? 
So far no controlling hormone for these elements has 


‘been: discovered, but this is no proof that such a 


hormone does not exist. 


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DR. G. M. FINDLAY & OTHERS: LYMPHOCYTIC MENINGITIS 


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69. Ramage, H., "and Sheldon, J. H.: Quart. Jour. Med., 
1935, n.s.iv., 121. 
70. Ramage, H., Sheldon, J, H., and Sheldon, W.: 
y. Soc. B., 1933, cxiii., 308. 
Ti; Redfield, A A.C.: Biol. Rev., 1934, ix., 175. 
72. Rehberg, P. B.: Biochem. *Jour., 1926, XX., 1447. 
73. Richards, A. N., Westfall, B. B., and Bott, "Pp. A.: Proc. 
Soc. Exp. Biol. Med., 1934, xxxii. a lB: 
74. Richards, A. N. Bordes. J. Walker, A. M., Hendrix, J. P., 
and Reisinger, J. A.: Jour. Biol. Chem., 1933, ci., 
179, 193, 223, 239, 255. 
. 5., and Kung, L.: Ibid., 1932, xeviii., 417. 
. S., and Vabiteich, E. M.: Ibid., 1932, xcvi., 
77. Rose, M. S., Vahlteich, E. M., and MacLeod, G.: Ibid., 
1933, civ., 217. 
78. Rountree, L. G.: Physiol. Rev., 1922, ii., 116. 
79. Rubinstein, D. L., Lwowa, W., and Burlakowa, B.: 


Biochem. Zeits., 1935, cclxxviii., 418. 

80. Schmidt, C. L. A., and Greenberg, D. M.: 
1935, xv., 297. 

81. Schmitz, H. W., Rohdenberg, E. L., and Myers, V. C.: 
Arch. Internal Med., 1926, xxxvii., 233. 

82. Schultze, M. O., Elvehjem, C. A., and Hart, E. B. 
Biol. Chem., 1934, cevi., 735. 

83. Shackleton, L. R B. . and McCance, R. A.: Biochem. 

Jour. Cell. and Comp. Physiol., 1934, v., 301.. 


Jour., 1936 (in press). 
84. Shannon, J. À.: 
85. s ; : Jour. Clin. Invest., 1935, xiv., 403 
: Amer. Jour. Physiol., 1935, exii., 405. 
: Ibid., 1935-360, cxiv., ’362 


86. >> 9 
88. Shannon, J. A., Jollitie, N., and Smith, H. W.: 
534. 


“3 1932, ci., 625. 
89. Same authors: Ibid., 1932, cii., 
90. Shannon, J. A., and Smith, H. W.: 
1935, xiv., 393. 
91. Sheldon, J. H.: Brit. Med. Jour., 1934,i., 47. 
92. 55 » : THE LANCET, 1934,ii., 1031. 
93. ii í Hwmochromatosis, London, 1935. 
94. Sheldon, J. H., and Ramage, H.: Biochem. Jour., 1931, 


Physiol. Rev., 


Jour. 


lbid., 


Jour. Clin. Invest. 


XXv., 1608. 
95. Smith, H. pyc Copeia, 1931, No. 4, 147. 
96. s5 : Quart. Rev. Biol., 1932, vii., 1. 
97. Smyth, F? S., Deamer, W. C., and Phatak, N. M.: Jour. 


Clin. Invest., 1933, xii., 55. 
98. Spicgler, A.: Zeits. f. Biol., 1901, xli. (n.s. xxiii.), 239. 
99. Stanbury, F. A.: Jour. ar Biol. Assoc. U.K., 1934, 


xix., 931. 
. Verney, E. B.: THE LANCET, 1929, i., 539, 645, 751. 
. Watchorn, E., and McCance, R. A.: Biochem. Jour., 1932, 


xxvi., 54 


102. Same authors: Proc. Roy. Soc. Med., 1934, xxvii., 1483 
gnp. i scct., p. 101). , 
103. Wells, H. G.: Chemical Pathology, Philadelphia, 1925, 


5th ed., p. 488. 

104, Whipple, G. H. . and Robscheit-Robbins, F. S.: 
Jour. Physiol., 1927—28, lxxxiii., 60 

105. White, H. L., and  Miouuctan, B. lbid., 1933, cvi., 16. 

106. Widdowson, E. M., ane MeCance, R. À.: Jour. of Hyg., 
1936, xxxvi., No. 


Amer. 


107. Witts, L. J.: THE bee 1932, i., 495, 549, 601, 653. 

108. Wy eee Oca V. D.: Zeits. re ges. cxp. Med., 1931, 
XXV., 7% 

109. Zondek, S. ae , and Karp, J.: Biochem. Jour., 1934, 
xxviii. 7 

110. Factor eanal, F., and Messiner- Klebermass, L.: Biochem. 


Zoits., 1933, celsi., 55. 


111. Zwaardemaker, H. Jour. of Physiol., 1921, lv., 33. 


NEw JIOSPITAL IN PONTEFRACT.—By the will of 
Mr. W. H. Hydes either a maternity or a children’s 
hospital is to be erected in the poor part of Ponte- 
fract. It is to be known as the Hydcs Hospital and 
will be administered by the governing body of the 
General Infirmary. The sum bequeathed by Mr. Hydes 
is said to be about £65,000. 


‘THE VIRUS ATIOLOGY OF ONE FORM 


OF LYMPHOCYTIC MENINGITIS 
By G. M. Finptay, C.B.E., M.D., D.Sc. Edin, 


OF THE WELLCOME BUREAU OF SCIENTIFIC RESEARCH 


N. S. Atcock, M.B. Edin. 


RESIDENT MEDICAL OFFICER, THE NATIONAL HOSPITAL, QUEEN- 
SQUARE; AND 


RuBY O. STERN, M.D. Lond. 


PATHOLOGIST TO ST. ANDREW’S HOSPITAL, NORTHAMPTON 


FRoM time to time cases of meningitis of unknown 
etiology have been described under a variety of 
names as serous meningitis, acute aseptic meningitis, 
or acute benign lymphocytic meningitis. The essen- 
tial characteristics of the disease, first clearly described 
by Wallgren (1925), have been recognised in this 
country, on the continent of Europe, and in America; 
despite the view of workers such as Eckstein, 
Hottinger, and Schleussing (1932) who believe that 
lymphocytic choriomeningitis is an abortive form of 
either poliomyelitis or epidemic encephalitis there is 
general agreement that it is undoubtedly a disease 
sul generis. 

Evidence as to the cause of the disease was first 
obtained by Armstrong and Lillie (1934) in America 
when, during the transmission in monkeys of infec- 
tious material from an individual who had died at 
St. Louis during the 1933 epidemic of encephalitis, 
they encountered a previously unidentified virus 
which in rhesus monkeys caused round-celled infil- 
tration of the meninges and choroid plexus. ‘The 
pathological condition was, therefore, desiguated 
lymphocytic choriomeningitis, the virus being quite 
distinct from that isolated by Muckenfuss, Armstrong, 
and McCordock (1933) and Webster and Fite (1933) 


and shown to be the undoubted cause of St. Louis 


encephalitis. Later Armstrong and Wooley (1935) 
isolated two other strains of a virus, pathologically, 
immunologically, and clinically identical with the 
first: one of these strains was obtained from a female 
who died in Maine, the other from a monkey that 
died after inoculation with the virus of poliomyelitis 
(monkey strain), These three strains were found to 
be pathogenic not only for rhesus monkeys but also 
for mice, though not infrequently individual mice 
were found to resist inoculation. In those mice that 
succumbed to the infection there was found, as in 
monkeys, infiltration of the meninges and choroid 
plexus with lymphocytes. Armstrong and Wooley 
(1935) and Armstrong and Dickens (1935) also showed 
that the sera of persons who had suffered from 
“aseptic meningitis” in districts as far apart as 
California, Maryland, District of Columbia, Illinois, 
Ohio, and Virginia contained immune bodies to the 
virus of lymphocytic choriomeningitis. At the same 
time Rivers and Scott (1935) isolated an identical 
virus from the cerebro-spinal fluid of two laboratory 
workers, while Traub (1935) isolated the same virus 
from a strain of apparently normal mice used in 
laboratory work at Princeton, New Jersey. 

There is thus evidence that the virus of ‘iympho- 
cytic choriomeningitis is widely distributed in the 
United States of America. | 

The probability that the same or a very closely 
allied virus was present in this country first arose 
in the autumn of 1934 when, through the kindness 
of Dr. J. A. Murray, F.R.S., at the time director of 
the Imperial Cancer Research Laboratories, one of 
us (G. M. F.) received a mouse that had exhibited 


THE LANOET] | 


mervous phenomena. This mouse, which had been 
the bearer of an engrafted tumour, had been exposed 
to radium. It was thought that either the radium, 


. by damaging the central nervous system, was itself 


responsible for the symptoms, or as the result of a 
local injury some infectious agent had gained access 
to the brain. The latter view proved to be correct, 
for mice inoculated intracerebrally with brain emul- 
sion from the first mouse died in 6-8 days with 
definite nervous symptoms. Cultures made from the 
brains of these mice were bacteriologically sterile, 
‘but filtrates obtained after passage through Berkefeld 
V candles proved to be pathogenic for mice. Seven 
passages were made in mouse brains with this virus 
(M strain) which was found to be pathogenic not 
only for mice but for rhesus monkeys, rats, and 
guinea-pigs. It thus seemed probable that the virus 
isolated by Armstrong and Lillie (1934) was also 
present in this country. In order that this point 
might be investigated, Dr. Charles Armstrong of the 
United States Public Health Service, to whom our 
thanks are due, very kindly supplied us with a strain 
of his virus. 

Before further investigations were made, however, 
it appeared to be essential to make certain that the 
virus was not already present in a latent form either 
in mice or monkeys in use in the laboratory. With 
this end in view, the sera of 22 rhesus monkeys were 
‘tested for immune bodies to the Armstrong strain 
of lymphocytic choriomeningitis virus [the A strain]. 
In none were immune bodies found. 


“ISOLATION OF LYMPHOCYTIC CHORIOMENINGITIS VIRUS 
FROM MICE 


Three strains of laboratory mice were tested for 
their reaction to the A strain of the virus. Twelve 
mice were selected from each strain. Six of these 
mice were inoculated intracerebrally with 0°03 c.cm. 
of a 2 per cent. suspension of starch in physiological 
saline, the other six were inoculated intracerebrally 
with 0:03 c.cm. of a 10 per cent. suspension in saline 
of mouse brain infected with the A strain. All 
three strains of laboratory mice were found to be 
free from infection, for of the mice infected with 
the A strain all died with typical symptoms, while 
all those inoculated with starch remained in good 
health for the four weeks during which they were 
kept under observation. 


At the same time it appeared to be of TN to 
determine whether other breeders’ mice were infected 
with lymphocytic choriomeningitis virus. Mice 
from fifteen breeders were therefore tested as before. 
All proved non-resistant except one strain. Here, of 
12 mice inoculated intracerebrally with the A strain 
of the virus 5 were completely resistant, while of 
12 injected intracerebrally with starch 4 developed 
symptoms in 6-11 days. Brain emulsions from 
these mice were inoculated intracerebrally into fresh 
mice which all died in 6-8 days. Eleven passages have 
been made with this virus of mouse origin (N strain). 
- The symptoms produced in mice by the A, M, and 
N strains are identical. The mice after intracerebral 
inoculation with a 20 per cent. suspension in saline 
of infected brain invariably die in 6-8 days. Shortly 
before death they develop a staring coat and tend 
-to sit quietly in a corner of their cage; sometimes 
-a slight tremor develops; if touched or stimulated 
in any way at this period they exhibit a form of 
convulsion, becoming quite rigid with the hind legs 
extended ; in a few seconds breathing stops and the 
mice are dead, though the limbs still remain stiffly 
extended after death, 


DR. G. M. FINDLAY & OTHERS: LYMPHOCYTIC MENINGITIS 


[maron 21, 1936 651 


When inoculated intracerebrally the minimum 
lethal dose is usually 0:03 c.cm. of a mouse brain 
suspension diluted 10% or 10%. At death virus is 
present not only in the brain but in the blood, kidneys, 
liver, spleen, adrenal, and lungs. It is also present 
in the urine, as noted by Traub (1935). When the 
virus is inoculated intraperitoneally the mice as a 
rule show no symptoms, though occasionally after 
a large injection—0-3 c.cm. of a 20 per cent. suspension 
of mouse brain—death has occurred with the usual 
cerebral symptoms. After intraperitoneal inoculation 
virus has been recovered from the spleen and occa- 
sionally from the kidney 24 months later. Virus 
applied to the lightly scarified skin of the mouse’s 
abdomen.may later be obtained from the kidneys 
and spleen. Virus was also obtained from the same 
organs of 2 out of 10 mice that had been fed on 
infected mouse brain ten days previously. Although 
virus may have been absorbed through the lining 


_of the alimentary canal the possibility in these cases 


of entry through small wounds on the limbs or about 
the mouth cannot be excluded. Instillation of the 
virus into the nostrils of mice under light ether 
anesthesia is followed by the development of cerebral 
symptoms and death. 


Mice dying from the disease rarely show any naked- 
eye pathological lesions. On a few occasions broncho- 
pneumonic patches were present in the lungs; more 
commonly the liver was pale yellow and fatty or 
old rose instead of purplish-red in colour. 


ISOLATION OF VIRUS FROM HUMAN CASES OF LYMPHO- 
CYTIC MENINGITIS" 


Preliminary experiment having shown that the 
stock animals to be used in the investigations were 
free from infection with the virus of lymphocytic 
choriomeningitis, an attempt was made to isolate 
the virus from the cerebro-spinal fluid of patients 
suffering from meningitis of unknown etiology. 
Up to the present it has been possible to isolate the 
virus from two individuals A. W. and B. C. The 
clinical histories of these patients are as follows. 


THE CASE OF A. W. 


This patient, a man aged 46, was admitted to the 
National Hospital on Oct. 17th, 1935, under the care of 
Dr. J. Purdon Martin. His family history was negative, 
and there was nothing of note in his personal history 
except that some days before the onset of his illness he 
had cleared out a shed which was heavily overrun with 
mice, 

About five weeks before admission he developed a 
headache, pain in the back, and a temperature of 102° F., 
which he attributed to “influenza.” These symptoms 
persisted, and as no cause could be found for the pyrexia 
he was admitted to the North Western Fever Hospital 
as a typhoid suspect. No evidence of enteric fever was 
obtained however during the nineteen days he remained 
in this hospital. Whilst there he ran an intermittent 
temperature which rose nightly to 101°F., though it 
gradually settled towards the end of his stay. On Oct. 5th 
he became rather confused and slightly hallucinated, and 
a day or two later pain and tenderness developed over 
the legs and lower abdomen. On Oct. llth he found 
difficulty in drawing up the left leg, and on the following 
day both legs became completely paralysed. At this 
time he lost all sensation in his bladder. 

Clinical and laboratory findings.—When admitted to 
the National Hospital on Oct. 17th the patient was 
obviously confused, though correctly orientated, could not 
give a connected history, and occasionally used wrong 
words. The cranial nerves were normal apart from early 
bilateral papilledema. The movements of the arms were 
normal. He was not able to sit up and the only move- 
ments possible in the legs were contraction of.the right 


652 THE LANCET] 


quadriceps and weak movements of the right ankle and 


toes. Reflexes: arms-jorks, + a— ; knee- and ankle-jerks, 
+a— ; abdominal reflexes absent; plantars extensor. 
Sensation : from the umbilicus down to the level of the 
fourth lumbar segment there was a marked hyperalgesia 
with overreaction. Below this level all forms of sensation 
were impaired. The calf muscles were very tender to 
pressure. There was complete retention of urine. 

The cerebro-spinal fluid, examined on Oct. 18th, was 
clear and colourless; the pressure was 195 mm. Cells: 
138 per c.mm., 98 per cent. lymphocytes, 2 per cent. large 
mononuclears. Protein : 0:28 per cent. Nonne-Apelt and 
Pandy reactions positive +. Lange0112232222. 
Wassermann reaction negative in blood and cerebro-spinal 
fluid. The changes in the C.S.F. are set out in the 
accompanying Table. 


Table showing Changes in O.S.F. 


Oct. Nov. 


| i 
18th|19th; 21st!23rdj25th| 31st| 7th | 16th 


T a | | d aaa 


Pressure (mm.) 195 |120 | — | — | — | — 1 — | — 

Cella (per c.mm.) -> 138 | 182 | 330 |272 | 168| 34) 30 9 
Lymphocytes (per 

cent.) . | 98/100) 97) 96] — | 100! 100 |100 
Large mononuclears ; 

(per cen 0| — 0i — i 0: 0| 0 
Polymorphs. (per | | ! 

cent.) .. ) Of O, —]| 4)—— o) o0 


| | 


0| 
Protein (per cent.) . o: -28| 0- 15 0- 15 0- 12,0. 09, 0: sale 08| 0°10 


A blood count on Nov. 27th showed 37,200 white blood- 
cells per c.mm. (polymorphonuclears, 76-5 per cent. ; 
lymphocytes, 23-5 per cent.). 

Progress,—Power gradually returned to the legs and 
he can now just lift his right ankle off the bed but cannot 
move the left leg. Tone has increased and ankle-clonus 
can be elicited on both sides. The plantar responses are 
extensor. He is unable to sit up without support and he 
cannot stand. Sensation: the overreaction gradually 
passed off and by Nov. 26th had disappeared. The 
analgesia grew steadily less and the only abnormality 
of sensation now present is some loss of deep sensibility 
and of bladder sensation. He began to pass urine naturally 
on Nov. 22nd.* 


CASE OF B. C. 


Aged 36, this patient was admitted to the National 
Hospital on Nov. 6th, 1935, under the care of Dr. Gordon 
Holmes. His personal history and his family history 
were negative. 

Twenty days before admission he developed a slight 
cold in the head accompanied by sneezing and malaise. 
Two days later his voice almost disappeared and he had 
two or three rigors. The following day he felt better 
and he remained well for four days. On Oct. 24th he felt 
ill again and complained of an aching pain in the back 
and insomnia. This pain gradually became more severe 
and spread up to between the shoulder-blades. A week 
before admission it decreased in severity but he noticed 
a tingling in his finger-tips and weakness in his grip. He 
also found he could not taste normally and his teeth 
“felt too big.” In addition he had slight difficulty in 
passing urine. By the next day numbness and tingling 
of the feet developed and his legs became weak. This 
weakness increased rapidly until he was unable to walk 
without support. The day before admission there was 
weakness of the facial muscles on the right side and 
momentary diplopia occurred. 

On admission his temperature was 100° F. He com- 
plained of retention of urine. Cranial nerves: There 
was a slight ptosis on the left side and a facial palsy of 
lower motor neurone type on the right side. Otherwise 
the cranial nerves were normal. The movements of both 
arms were weak, especially at the shoulders. He was 
unable to sit up in bed. The movements of both legs were 
so weak that he was unable to stand. Reflexes: All 


* Since this was written progress has continued and he is 
now able to walk. 


N 


DR. G. M. FINDLAY & OTHERS: 


LYMPHOCYTIC MENINGITIS [MABCH 21, 1936 


tendon-jerks were absent. Abdominal reflexes, upper 
present, lower only faintly present. Plantar responses, 
both extensor. Sensation : There was a loss of all forms 
of sensation peripherally in the arms; some impairment 
below the level of the third dorsal segment, but greater 
peripherally in the legs. The soles of the feet were tender. 
Cerebro-spinal fluid (Nov. 6th): pressure, 140 mm.; 
slightly yellow; ‘fine coagulum formed on standing. 
Cells: 63 per c.mm., 12 per cent. large mononuclears, 
Protein: 0:275 per cent. Nonne-Apelt positive+; 
Pandy positive ++. Lange 0000111122. Wasser. 
mann reaction negative in C.S.F. and blood. Blood 
count (Nov. 6th): white blood-cells, 8200 per c.mm. 
Nov. 27th: white blood-cells, 11,400 per c.mm. (poly- 
morphonuclears 71 per cent., lymphocytes 29 per cent.). 

Progress.—Catheterisation was necessary for three or 
four days. On Nov. llth he developed a complete left 
facial paralysis. Motor power gradually returned and 
by the 29th he was able to walk, the arms being then 
almost normal, though the right facial palsy was still 
present. Sensation had also returned by this time, though 
the tendon-jerks were still absent and the plantar responses 
remained extensor. On discharge he had regained practi- 
cally full use of his limbs, but still had an almost complete 
paralysis of his right facial muscles, which gave a complete 
reaction of degeneration. 


Cerebro-spinal fluid was removed from A. W. on 
the 37th day of illness. A rhesus monkey was inocu- 
lated intracerebrally with 1 c.cm. while 12 mice 
were each inoculated intracerebrally with 0-03 c.cm. 
Of these mice four died 7, 10, 10, and 16 days later ; 
histological examination of their brains revealed 
round-celled infiltration of the choroid plexus and 
meninges. The monkey remained normal for 8 days 
after inoculation ; its temperature then rose to 104° F. 
and continued between 104° and 106° F. till it was 
killed on the 13th day after inoculation. During 
the whole of this time it exhibited no definite nervous 
symptoms but lost weight and was abnormally 
quiet. No naked-eye lesions were found at the post- 
mortem and no bacteriological growth was obtained 
in aerobic and anaerobic cultures made from the blood 
and brain. Blood-serum, brain, and liver tissue were 
inoculated intracerebrally into mice which died in 
6-8 days with symptoms typical of lymphocytic 
choriomeningitis, while characteristic lesions were 
found in the central nervous system. 

Virus obtained from the blood-serum of this 
monkey has been carried on for 18 passages in the 
brains of mice and has shown no diminution in 
virulence during these passages, the mice invariably 
dying 6-8 days after inoculation. Two rhesus 
monkeys were each inoculated intracerebrally with 
l c.cm. of a 20 per cent. suspension in saline of the 
brain of Monkey 1. Five and nine days later their 
temperatures rose above 104° F. Monkey 2 gradually 
lost weight and continued with a febrile temperature 
till the 10th day after inoculation. Its temperature 
then fell and it became weak in the hind legs, slight 
ptosis developed in both eyelids, and the “monkey 
was kiled moribund 14 days after inoculation. 
Monkey 3 ran a similar course and was killed 18 
days after inoculation. 1 c.cm. of blood-serum from 
Monkey 1 was inoculated intracerebrally into 
Monkev 4. This animal showed a rise of temperature 
to 105°F. 4 days after inoculation and was 
killed 10 days after inoculation with symptoms 
identical with those of Monkeys 2 and 3. At death 
in all cases there were no characteristic appearances, 
though in Monkey 2 the liver was rather pale. 
Bacteriological cultures from the blood and brain 
were again sterile, but mice inoculated intracerebrally 
with liver, blood, brain, and adrenal all died in 
6-8 days. 

ene symptoms produced by this (W) virus and its 


a 


No Ney 


THE LANCET] 


distribution in these monkeys are identical with 
those obtained with the American strain of the virus 
of lymphocytic choriomeningitis. | 

Cerebro-spinal fluid obtained from A.W. on the 
44th day of his illness, seven days after the first 
withdrawal, was also inoculated intracerebrally into 
mice and into a rhesus monkey but the results were 
entirely negative. 

Cerebro-spinal fluid was obtained from B.C. on 
the 15th day of his illness. Twelve mice were inocu- 
lated intracerebrally with 0-03 c.cm. but only two 
died during the night 14 days later. The brains of 
these mice however showed histological changes 
typical of lymphocytic choriomeningitis. 

A rhesus monkey (No. 5) inoculated intracerebrally 
with 1 c.cm. of cerebro-spinal fluid showed no symp- 
toms till 14 days after inoculation when its tempera- 
ture rose to 104° F. Till the 23rd day after inocula- 
tion a febrile reaction continued, then the fever 
gradually abated and the animal recovered. Blood- 
serum from the monkey inoculated intracerebrally 
into mice on the 17th and 25th days after inoculation 
contained virus, since the mice died in 6-8 days. 
The blood of the monkey was bacteriologically sterile. 
Blood-serum obtained from the same monkey 37 days 
after inoculation and inoculated intracerebrally into 
mice did not contain virus. 

The virus obtained from the blood of this monkey 
has been carried on in the brains of mice for 13 pas- 
sages. Both the W and C strains of virus were 
found to be pathogenic for guinea-pigs and rats. 
Guinea-pigs inoculated intracerebrally died in 9-22 
days. The only symptoms due to the virus were 
gradual loss of weight, emaciation, and great muscular 
weakness.. Rats died in 8-11 days with similar 
symptoms. Identical symptoms were produced in 
these species by intracerebral inoculation of the 
American strain of the lymphocytic choriomeningitis 
virus. 

In addition to the rhesus monkey the crab-eating 
macaque Macaca irus has been found to be highly 
susceptible to intracerebral inoculation with both the 
English and American strains of the choriomeningitis 
virus. The following species do not exhibit any 
clinical symptoms following intracerebral injection 
of the virus: dog, ferret, hedgehog, field vole ( Microtus 
agrestis), bank vole (Zvotomys glareolus), rabbit, hen, 
canary, and parakeet. Wild mice are also susceptible 
to intracerebral inoculation; sufficient experiments 
have not yet been made 'to determine whether they 
may harbour the virus under natural conditions. 
Immune bodies may develop after inoculation, and 
the rabbit has been used for the production of immune 
sera. The virus may persist in the brain of the 
rabbit for at least 7 days. 

' HISTOLOGICAL LESIONS 

The essential histological lesion in the nervous 
system was that of an acute leptomeningitis, parti- 
cularly incident upon, though not confined to, the 
basal meninges, which produced an intense cellular 
exudation throughout the entire ventricular system. 
The lesions were similar in all the animals examined ; 
they differed only in severity. Separate descriptions 
of the appearances seen in the various species would 
be redundant. The following description of the 
lesions in the nervous system of a guinea-pig inocu- 
lated intracerebrally with the English strain of 
virus (W) will suffice as an example :— 

The meninges at the base of the brain were heavily 
infiltrated with cells. The infiltration extended over the 
cerebellum and for some distance over the posterior 
surface of the spinal cord, but did not extend over the 
vertex of the brain. The predominating type of cell 


DR. G. M. FINDLAY & OTHERS: LYMPHOCYTIC MENINGITIS 


[mancH 21, 1936 653 


present was the small lymphocyte, though many poly- 
morphonuclears and plasma cells were also seen. In some 
areas in the fourth ventricle’a perivascular arrangement 
of cells was noted, and in that part of the medulla adjacent 
to the Hoor of the fourth ventricle there was engorgement 
of the smaller blood-vessels and slight perivascular infiltra- 
tion. In sections of the brain which contained portions 
of choroid plexus there was an intense exudation of cells 
in between the choroidal cells, though these did not appear 
to be damaged by the infiltration. In general it may be 
said that the cells of the choroidal plexus were somewhat 
hypertrophied. 

The iter of Sylvius contained many cells, whilst the 
cavities of the lateral ventricles were almost obliterated . 
by cellular masses. 

The brain tissue was little affected by these meningeal 
lesions. The only reaction of note was a proliferation of 
the marginal neuroglia in the tissue adjacent to the walls 
of the lateral ventricles. There was no microglial reaction ; 
no changes in the neurones could be detected and there 
was no evidence of demyelination. 


As regards the severity of the lesions in the different 
animals, these were most intense in mice and guinea- 
pigs inoculated intracerebrally with either the Ameri- 
can or W strain of virus. In monkeys the lesions 
were much less striking. In Monkey 2, inoculated 
with W strain, the basal meninges only were affected, 
and these not to any great extent, but in the brain 
of a mouse inoculated with blood from this monkey 
the ventricular lesions were especially severe, the 
cells of the choroid plexus in the lateral ventricles 
being stuck together by masses of infiltrating cells, 
whilst there was much cellular infiltration of the 
meninges over the posterior aspect of the spinal cord. 

No lesions could be found in the brain of a ferret 
inoculated with the W strain of virus. In rabbits 
there were a very small number of infiltrating cells 
in the meninges and choroid. 

In only three mice have intranuclear inclusions 
been found resembling those described by Traub 
(1935) in guinea-pigs. These inclusions were found 
more especially in the cells of the choroid plexus 
and resembled in many respects those produced by 
the guinea-pig salivary virus. It seems extremely 
doubtful whether they are caused by the virus of 
benign lymphocytic choriomeningitis, since on rare 
occasions they have been found in the brains of 
apparently normal mice. The true significance of 
these acidophilic inclusions has recently been demon- 
stratel by Thompson (1936). They are due to a 
virus found in the salivary glands of mice. On the 
other hand, as will be mentioned later, small granules 
are found in the cytoplasm of many mononuclear 
cells in the exudate. 

In mice lesions are as a rule restricted to the central 
nervous system, though occasionally in the lungs 
there is evidence of a virus pneumonia while in the 
liver the Kupffer cells are swollen and prominent. 
In guinea-pigs and monkeys, more especially Macaca 
irus, the liver often exhibits fatty degeneration with 
areas of focal necrosis, accompanied by round-celled 
infiltration. Focal areas of round-celled infiltration 
are also seen in the suprarenals of monkeys, parti- 
cularly in the cortex. In the kidneys the glomerular 
tufts are swollen as a result not so much of infiltra- 
tion with round cells as of undue prominence of the 
endothelial cells ; occasionally a few infiltrating cells 
are found between the convoluted tubules. 


IMMUNOLOGICAL REACTIONS 
Sera from A. W. and B.C. were found to contain 
virucidal antibodies not only against the homologous 
strains but against each other, the American strain 
and the N strain derived from English mice. Anti- 
sera were prepared in the rabbit against the American 
m3 


654 THE LANCET] 


and N strains. These sera were found to neutralise 
from 100 to 1000 M.L.D. (minimum lethal doses) of 
virus, whether of the homologous or heterologous 
strains. The monkey which recovered after inocu- 
lation with the cerebro-spinal fluid of B. C. was sub- 
sequently resistant to intracerebral inoculation with 
the American strain. The human strains isolated 
in this country are thus either identical or at any 
rate very closely related both to the American human 
strain and to the English mouse strain. A number 
of other human sera have also been examined during 
the course of these experiments. The results will 
be given in a further publication but a few details 
may not be without interest. The brother of A. W., 
for instance, who lived with him gave no protection, 
but his partner in the garage where he worked had 
immune bodies in his serum, although without a 
history of illness affecting the nervous system. 
The serum of a patient from Ireland whose history 
has recently been detailed by Collis (1935) protected 
both against American and English strains. This 
patient lived in an eighteenth century house over- 
run with rats and mice. Our thanks are due to Dr. 
W. R. F. Collis of Dublin for supplying this serum. 

Serum from one of us (G. M. F.), who has carried 
out the animal experiments here described, fails to 
protect. 

THE VIRUS 

Filtration experiments with both the American 
and English strains show that the virus suspended 
in Hartley’s broth passes through Berkefeld V filters, 
Chamberland L, and L, candles, and with difficulty 
through Seitz E or K discs or Berkefeld N filters. 
This finding would indicate that the virus is of 
comparatively large size. This is also borne out by 
the fact that by centrifugation for 3 hours at 10,000 
revs. per min. it is possible to concentrate a con- 
siderable part of the virus in the deposit. Finally 
in experiments carried out in conjunction with Dr. 
R. D. Mackenzie it has been possible to demonstrate, 
in the cytoplasm of mononuclear cells from the brains 
of mice, rats, and monkeys infected with all strains 
of the virus, minute granules which stain purplish 
red with Giemsa, and are approximately of the 
same dimensions as the virus of herpes. These 
granules may be the actual virus. Agglutination 
and other experiments are at present being under- 
taken to investigate this question. The virus kept 
at 4°C. retains its activity for-at least 10 days and 
at 22°C. for at least 6 days, although by this time a 
considerable part of the virus is destroyed. 


DISCUSSION 


The experiments here described show that from 
apparently healthy mice it is possible to obtain a 
virus which on intracerebral inoculation into monkeys, 
mice, guinea-pigs, and rats gives rise to a fatal 
infection associated with infiltration of the meninges 
and choroid plexus. The involvement of the central 
nervous system appears however to be only part 
of a more generalised infection, since the virus circu- 
lates freely in the blood stream. From the cerebro- 
spinal fluids of two patients with somewhat vague 
nervous symptoms following febrile reactions it has 
been possible to obtain a virus which in experi- 
mental animals behaves in the same way as that 
obtained from English mice. The three English 
strains also behave in the same way as a strain isolated 
by Armstrong from a case of benign lymphocytic 
meningitis in America. Serum from a patient in 
Ireland recovered from the same disease contains 
immune bodies to both the American and English 
strains of the virus. There is thus evidence that 


DR. G. M. FINDLAY & OTHERS: LYMPHOCYTIC MENINGITIS 


[maron 21, 1936 


this virus infection is widely spread on both sides 
of the Atlantic. The virus is excreted in the urine 
of mice and can pass with ease through the scarified 
skin, which may thus constitute the chief portal of 
entry in human cases though the virus may possibly 
enter also through the nasopharynx. The evidence 
here brought forward shows that a virus infection 
is present in mice and possibly also in rats and that 
this virus can be communicated to man. The exact 
portal of entry in human cases has not yet been 
determined but judging from analogies with infection 
by Leptospira icterohemorrhagie it is likely to be the 
skin or mucous membranes. 


SUMMARY 


1. A virus has been isolated from the cerebro- 
spinal fluid of two patients suffering from obscure 
nervous symptoms associated with an increase of 
lymphocytes in the cerebro-spinal fluid. 

2. The virus inoculated intracerebrally into monkeys, 
mice, rats, and guinea-pigs causes a fatal infection : post 
mortem there is intense infiltration of the meninges, 
choroid plexus, and ventricles with round cells. 

3. When inoculated intraperitoneally into mice 
the virus causes no symptoms but remains for some 
weeks in the spleen and kidneys. It is excreted in 
the urine of mice and can pass through the lightly 
scarified skin. 

4, A similar virus has been isolated from apparently 
healthy mice. 

5. The human and mouse strains isolated in this 
country behave in animals in the same way as the 
American virus described by Armstrong. 

6. Sera from human cases in this country contain 
immune bodies to the American virus and to the 
English mouse strain virus. 

7. Certain of the properties of the virus are 
described and the mode of infection discussed. 


Our thanks are due to Dr. Charles Armstrong, of the 
United States Public Health Service, for his kindness in 
supplying us with a strain of the virus isolated by him. 
We also desire to thank Dr. Purdon Martin and Dr. 
Gordon Holmes for permission to investigate and to 
publish details of the patients under their care, and Dr. 
D. F. Rambaut for allowing the investigation of patho- 
logical material to be carried out in the laboratory of 
St. Andrew’s Hospital, Northampton. 


REFERENCES 


Armstrong, C., and Dickens, F.: Benign Lymphocytic Chorio- 
meningitis (Acute Aseptic Meningitis), U.S. Pub. Health 
Rep., 1935. 1., 831. 

Armstrong, and Lillie, R. D.: Experimental Lymphocytic 
Choriomeningitis of Monkeys and Mice Produced by a 
Virus Encountered in Studies of the 1933 St. Louis 
Encephalitis Epidemic, Ibid., 1934, xlix., 1019. 

Armstrong, and Wooley, J. G. : Studies on the Origin of a Newly 
Discovered Virus which Causes Lymphocytic Chorio- 
meningitis in Experimental Animals, Ibid., 1935, l., 537. 

Collis, W. R. F.: Acute Benign Lymphocytic Meningitis, 
Brit. Med. Jour., 1935, ii., 1148. 

Eckstein, A., Hottinger, À., and Schleussing, H.: Über die 
Beziehungen der meningitis serosa epidemica zur Polio- 
mvelitis bzw. Encephalitis epidemica, Zeitz. f. intern. Med., 
1932, cxviii., 97. 

Muckenfuss, R. S., Armstrong, and McCordock, A.: Studies on 
the Experimental Transmission of Encephalitis, U.S. Pub. 
Health Rep., 1933, xlviii., 1341. oe 

Rivers, T. M., and McNair Scott, T. F.: Meningitis in Man 
Caused by a Filterable Virus, Science, 1935, lxxxi., 439. 

Thompson, J.: Salivary Gland Disease of Mice, Jour. Infect. 
Dis., 1936, lviii., 59. ; 

Traub, E.: A Filterable Virus from White Mice, Jour. Immunol., 
1935, xxix., 69; and Science, 1935, 1xxxi., 298. ; 
Wallgren, A.: Une nouvelle maladie infectieuse du système 

nerveux central, Acta Paediat., 1924-25, iv., 158. 


—_ 


NORWICH HOSPITALS CONTRIBUTORS’ ASSOCIATION. 
The receipts of this association reached a new record 
in 1935, with a total of £48,403, which was an increase 
of £1581 over 1934. The total number of contributors 
is 121,000. 


THE LANCET] 


MR. R. T. PAYNE: IDIOPATHIC DILATATION OF STENSON’S DUCT 


[maron 21, 1936 655 


IDIOPATHIC DILATATION OF 
STENSON’S DUCT 


By REGINALD T. PAYNE, M.D., M.S. Lond., 
F.R.C.S. Eng. 


CASUALTY SURGEON, ST. BARTHOLOMEW’S HOSPITAL 
CURATOR OF MUSEUM, ST. BARTHOLOMEW’S 
HOSPITAL MEDICAL COLLEGE 


DILATATION of Stenson’s duct in the absence of 
obstruction or infection is an unusual condition. In 
the former group of cases the obstruction is invariably 
due to a calculus, and in the latter the dilatation is 
associated with recurrent pyogenic parotitis. The 
case now reported differs from both of the foregoing 
types in being associated with neither obstruction 
nor infection ; and in the absence of exact knowledge 
as to the underlying pathology it can only be regarded 
as possibly due to achalasia of the duct orifice. 


CASE RECORD 


The patient, a surgeon aged 51, first came under my 
care in May, 1934, on account of recurrent swelling and 
dilatation of the masseteric and buccal portions of the 
right parotid duct. These symptoms had started some 
two years previously and on the first occasion developed 
while the patient was operating. Since then he had 
never been free from the trouble. The swelling of the duct 
often occurred in the earlier part of the day, at times 
developing whilst the patient was drinking a cup of tea. 
On the whole the symptoms were particularly prone to 
develop during work demanding concentrated effort such 
as operating or putting up a fracture. The attacks had 
at times been induced by pipe-smoking and occasionally 
by emotional stress. When the swelling developed it 
could be felt as a small oval tumour in the line of the 
right parotid duct, and it was accompanied by discomfort 
rather than actual pain. The patient had learnt to relieve 
his symptoms by pressure over the swelling which imme- 
diately led to its disappearance and was followed by a 
gush of saliva into the mouth. On operating days this 
Manceuvre was carried out between operations in order 
to keep free from discomfort. At no time had there been 
any swelling of the parotid gland itself and there were 
no symptoms referable to the other salivary glands. 


Past history.—The patient had had an hemoptysis at 
the age of 21, and on this account went to live abroad. 
Shortly after this he had a mild attack of uncomplicated 
typhoid fever. He had never suffered from mumps or 
any other disease of the salivary glands. There was no 
history of hay-fever, asthma, eczema, or other allergic 
manifestation. In 193] he had new dental plates which 
never fitted very accurately, and the swelling of the right 
parotid duct started a year after this. His general health 
had been good but he was very highly strung and for 
some years had persistently overworked. 


PHYSICAL SIGNS 


The patient was a healthy, active man of sparse build. 
On examination of the right cheek when the swelling had 
developed a diffuse fullness could be seen in the line of 
the parotid duct in its masseteric and buccal portions. 
On palpation the parotid gland was not enlarged or tender 
but the distended duct could be felt as an ovoid tumour 
14 in. long and 4 in. wide at its widest part, reaching 
from the hilum of the gland to the duct orifice. The 
distended duct was slightly tender and pressure over it 
gave rise to a gush of saliva into the mouth. There was 
no abnormality to be made out after the duct had been 
emptied in this way. The orifice of the duct in the mouth 
was natural, there was no evidence of any local scarring, 
and the surrounding mucosa was normal. Its appearance 
was in every way identical with the orifice of the left 
parotid duct. The other salivary glands, their ducts, and 
the duct orifices all appeared natural. The patient was 
edentulous and the condition of the buccal mucosa was 
healthy. 


Saliva.—A catheter specimen of saliva from the right 
parotid duct was profuse, clear, and free from mucus, and 
its diastatic content was 20,000 units. A Gram film showed 
an occasional epithelial cell of pavement type in some of 
the fields but no organisms were present and cultures 
were sterile. 

Skiagrams and sialograms.—Skiagrams showed no 
evidence of a parotid calculus. Sialography was carried 
out and the resulting pictures are shown in Figs. 1 and 2. 


= m e 
5 = 
: Ma TD) | 
PATS 
“TA 
one = 
Pa 


Me ; : 
, A te 
» RE ue ee 


FIG. 1.—Right sialogram showing a marked degree of dilatation 
of the buccal portion of the parotid duct. 


Fig. 1 shows much dilatation of the buccal portion of the 
duct and Fig. 2 shows this condition together with dilata- 
tion and segmentation of the masseteric portion of the 
duct. Several attempts were made to get the lipiodol to 
pass into the intraglandular ducts, but without success. 
This was presumably due to some valve action in the 
interior, the mechanism of which was also responsible for 
the absence clinically of involvement of the intraglandular 
ducts in the swelling. 
OPERATION 

Under general anesthesia the terminal } in. of the 
duct was excised together with ł in. of its inner wall. 
The resulting cavity was packed with gauze. Irrigation 
followed by dilatation with small sinus forceps was carried 
out twice daily after operation and the wound kept 
lightly packed with gauze. The patient’s jaw was ban- 
daged and the diet was restricted to fluids. Healing of 
the mucosa was completed in about eight days, after 
which dilatation was carried out with canaliculus probes, 
daily at first and then at increasing intervals for a period 
of six weeks. No swelling of the parotid gland occurred 
after operation and the patient has remained free from 
symptoms since then. 

COMMENT 


Recurrent swellings of the parotid gland may be 
due to a variety of causes, including calculi, infec- 
tions, drugs, &c. Recently Pearson! has investi- 
gated these conditions in children and in the light 
of some of the evidence has suggested that there is 
a relationship between certain types and allergic 
manifestations such as eczema and hay-fever. The 
sudden appearance and disappearance of the parotid 
swellings in some cases and the occasional history 
of a familial tendency have led other workers to 
arrive at similar conclusions. 

The case now recorded differs from those referred 
to above in that the parotid gland itself was never 
involved, the swelling being entirely confined to the 
duct. The condition was not associated with any 
known allergic phenomena, but tended especially 
to occur during concentrated effort or as the result 
of some emotional stress. Clinical investigation 
demonstrated the absence of infection of the saliva 


656 THE LANCET] 


DR. R. BINNING : INTRAHEPATIC CARCINOMA OF BILE-DUCTS 


[maRcH 21, 1936 


and also showed the degree of dilatation of the duct. 
Jemtel 2 records a very similar case occurring in a 
boxer of 25. This patient developed a swelling of 
the parotid duct whenever he ate anything. Investi- 
gation showed a condition identical with that in the 
case now recorded, and a similar operation was per- 
formed with equally satisfactory results., A some- 
what similar case in a man of 70 is recorded by 


FIG. 2.—Right sialogram, after further injection of lipiodol, 
showing much dilatation of the buccal portion of the duct, 
together with dilatation and segmentation of the masseteric 
portion of the duct. f 


Bársony.’ In this case the swelling appeared during 
every meal and disappeared after massage, but the 
duct orifice was enlarged and the dilatation of the 
duct involved some of the intraglandular ducts. 

The clinical evidence in the case now reported 
suggests that the pathological dilatation of the 
parotid duct was secondary to the failure of relaxation 
of the duct orifice. The conditions under which the 
swelling occurred suggest that some neuromuscular 
incoérdination in a gland under the control of the 
parasympathetic system was a causal factor. If 
this is the case the condition bears some resemblance 
to achalasia of the cardia. In the present case 
recovery followed the operation described. 


REFERENCES 
1. Poarion T S. B.: Arch. Dis. Childhood, October, 1935, 
3 


° we 
2. Jemtel, M. le: Arch. franco-belees de chir., 1932, xxxiii., 781. 
3. Bársony, T.: Klin. Woch., 1925, li., 2500. 


PRIMARY INTRAHEPATIC CARCINOMA 
OF THE BILE-DUCTS 


By Rex Biynina, M.R.C.S. Eng. 


HOUSE PHYSICIAN AT ST. GEORGE’S HOSPITAL, LONDON 


AN unmarried woman, aged 46, a cook, was 
admitted to St. George’s Hospital complaining of 
abdominal pain and vomiting of three weeks’ duration. 


She had had slight indigestion and vomiting for the 
previous three months. The pain was severe, constant, 
and was not relieved by taking food, but it was somewhat 
eased by flexing the trunk. One week before admission 
she had a slight hwmatemesis. She was constipated 
and sometimes passed bright red blood on defecation. 
There were no abnormal urinary symptoms. She said 
that she had vomited bile occasionally and had had attacks 
of jaundice, which lasted only 24 hours. In two months 
she had lost a stone in weight. There was nothing of 


importance in her past history or in her family history. 
She had travelled extensively in Egypt and Syria, but had 
contracted no diseases while abroad. 

On admission to hospital on Nov. 23rd, 1935, the 
temperature was 97-5° F., pulse 105, and respirations 23 
per min, She was pale and weak in appearance, but not 
wasted. The abdomen was distended, particularly in the 
upper half. She was very tender in the right hypo- 
chondrium, The liver extended downwards 3 in. below 
the costal margin and was tender; the gall-bladder was 
palpable below the liver. There were some recently 
inflamed external piles and the rectum contained soft 
feces. The bases of the lungs were slightly dull to 
percussion; the heart was normal. A blood count 
showed: red cells, 5,160,000 ; hemoglobin, 74 per cent. ; 
leucocytes, 9920; colour-index, 0-64; polymorphs, 
74 per cent.; lymphocytes, 20 per cent.; mononuclears, 
8 per cent.; eosinophils, 5 per cent.; basophils, 1 per 
cent. The sedimentation-rate by Westergren’s method 
was 24 units in the first hour. The-Wassermann reaction 
was not quite negative. The diastase index of the urine 
was 200 units, or about 10 times the normal. Skiagrams 
taken on Nov. 26th showed a group of abnormal shadows 
in the gall-bladder region, possibly due to gall-stones. 
There was nothing abnormal shown in the lungs. An 
opaque meal was given on Nov. 28th, and skiagrams showed 
the yvall-stone opacities and gastritis, but no other organic 
lesion; the gastric emptving time was normal and no 
lesion was detected in the large intestine. A further 
skiagram of the chest on Dec. 4th showed that the right 
diaphragm was much raised and there was a small right 
pleural effusion. 

The patient became worse and progressive enlargement 
of the liver was observed. She was in constant pain. 
She died on Jan. 5th, 1936. 

Autopsy showed that the abdomen contained 14 pints 
of fluid. The liver was greatly enlarged and weighed 
15 lb. and the diaphragm was pushed up on the right to 
the level of the third rib. There was a diffuse carcino- 
matosis of the liver, especially of the right lobe, with 
enlarged glands at the hilum and in the gastro-hepatic 
omentum. The gall-bladder contained one large stone 
and many small ones. There were no pathological changes 
of importance in the rest of the body, and no evidence of 
metastasis or other growth was found. Sections were cut 
of the liver and the glands taken from the gastro-hepatic 
omentum. The sections of the liver showed extensive 
infiltration of adenocarcinoma. The cells resembled those 
of the bile-ducts and were cylindrical in shape, tending 
to become ellipsoid in some parts of the sections; there 
was no evidence of cirrhosis. The sections of the glands 
showed infiltration with similar cells. 


Multiple carcinoma of the intrahepatic bile-ducts 
is uncommon. Itis estimated that primary carcinoma 
of the liver accounts for only 0-5 per cent. of all 
cancers, and different authorities consider that 
14-32 per cent. of primary carcinomata of the liver 
arise from the bile-ducts.1 Bile-duct carcinoma is 
associated with cirrhosis of the liver in 50 per cent. 
of the cases,? and is more common in women.? There 
is jaundice in 60 per cent. and ascites in 58 per cent. 

This patient, therefore, presented certain uncommon 
features. There was no evidence at autopsy of 
cirrhosis of the liver, though there were several 
clinical signs suggestive of it. While she was in 
hospital jaundice was absent but there was a history 
of very slight attacks some months previously. 
She was considerably younger than is usual in this 
disease. 


I should like to express my thanks to Dr. A. Feiling 
for permission to publish this case, to Dr. John Taylor for 
the report of the autopsy, and to members of the radio- 
logical, bacteriological, and biochemical departments 
of St. George’s Hospital for carrying out the various 
investigations in the case. 


REFERENCES 


1. Ewing, J.: Neoplastic Diseases, third edition, London, p.733. 
2. Cabot Case Records, New Eng. Jour. Med., 1934, ccx., 36. 
3. Cabot Case Records, Ibid., 1934, cox., 1226. 


THE LANCET] 


FISTULA-IN-ANO * 
By J. P. LockHart-Mummery, F.R.C.S. Eng. 


EMERITUS SURGEON TO ST. MARK’S HOSPITAL FOR DISEASES 
OF THE BOWEL, LONDON 


THE treatment of fistula-in-ano has a very ancient 
history. Reference to it can be found in all the 
earliest medical MSS. and what is probably the very 
first medical treatise on a special subject is a treatise 
on “ Fistula-in-Ano,’” by John Arderne, which was 
found in a fifteenth century manuscript. Louis 
XIV., le Roi Soleil, was operated on for a fistula 
in. 1687, and it was recorded his surgeon received the 
magnificent fee of £6000 for making a success of the 
operation. 

THE CAUSES OF FISTULA 


Foreign bodies.—It has been generally supposed 
until quite recently that most fistule arise as the 
result of injury from foreign bodies which have been 
swallowed. Undoubtedly a small percentage of fistula 


. are so formed and there is a collection in the museum 


of St. Mark’s Hospital of foreign bodies which have 
been removed from fistula, They consist mostly of 
haddock spines, rabbit bones, pieces of wood and 
metal, and seeds. But I think it is very doubtful 
whether more than a very small proper” of fistula 
are so caused. 

Fissures and ulcers of all kinds in the anal region 
may result in fistule and abscess. A small neglected 
fissure is liable at any time to penetrate the muscular 
wall of the rectum, when a small direct fistula will 
generally result in an internal opening at the base 
of the fissure. 

Suppuration of the anal glands is probably the 
most common cause of all fistule. These anal 
glands, until quite recently, appear to have been over- 
looked by anatomists. They occur near the lower 
part of the anal canal as tubular, branching structures, 
lined with transitional epithelium. They pass into, 
or through, the muscular coat of the bowel and end 
in the connective tissue. In some cases they can be 
seen to pass through the circular muscle coat of the 
internal sphincter and terminate in the ischiorectal 
fossa. Very careful microscopic sections, cut in 
series, of the anal region generally demonstrate the 
presence of several such glands. Their composition 
and numbers are erratic, and they seem to serve no 
particular purpose. They correspond to the odori- 
ferous glands in animals which act as a sex attraction 
to the male, They are very well marked in the rabbit, 
pig, and chicken. The ducts of these glands open 
into the bases of the crypts of Morgagni. Connecting 
as they do with the bowel lumen, these vestigial 
glands act as a path for infective organisms to reach 
the connective tissue and set up an abscess. 

Dr. C. E. Dukes was able to actually demonstrate 
in 1931 that a case of fistula in St. Mark’s Hospital 
was due to suppuration in one of these glands. Care- 
ful dissection of the fistula revealed that the track 
was lined with the transitional type of epithelium 
of which the glands are composed. This case was 
published by Sir Charles Gordon-Watson.! These 
findings have since been confirmed by other observers, 
notably by Dr. Tucker and Dr. Hellwig.’ 

Just as appendicitis is due to inflammation occurring 
in a vestigial organ, the appendix vermiformis, so 
fistula-in-ano is caused by a suppuration occurring 
in these vestigial sex glands. 


è A post-graduate lecture delivered at St. Mark’s Hospital 
on Feb” Gth, 1936. 


MR. J. P. LOCKHART-MUMMERY : FISTULA-IN-ANO 


[maRoH 21, 1936 657 


Congenital cysts, as a cause of fistule, are much 
commoner than is generally supposed, and at 
St. Mark’s Hospital quite a number of them are seen 
in the course of a year; even as many as two cases 
have been operated upon in one week. These cysts 
are an exaggeration of the post-anal dimple, which is 
found in some 20 per cent. of human beings. Patients 
are, of course, born with these cysts, but they seldom 
give trouble until adult life, when, possibly as the 
result of their rapid growth or of injury, they start 
to suppurate and an abscess forms. They may be 
detected easily, as they always occur in exactly the 
same place, just over the tip of the coccyx in the 
middleline, A very careful examination will generally 
reveal hairs projecting from the opening of the sinus, 
and when these hairs are seen it is quite conclusive, 

These cysts have had a bad reputation in the past 
because their true nature has not been recognised 
and they will not heal up until they are completely 
cut out. As the tracks are lined with epithelium 
the cysts will reform unless every part of the cyst 


‘wall is removed. When completely cut out they, 


of course, give no further trouble. Sir John Bland- 
Sutton was the first person to recognise their true 
significance. They are due to faulty coalescence 
of the skin during early embryonic life and are true 
sequestration dermoids. They have no connexion 
whatever with the rectum. ) 

Tubercle is the cause of fistula in about 20 per 
cent. of all cases. Tuberculous fistulæ can be fairly 
easily distinguished from ordinary fistule by their 
clinical appearances. There is very little induration 
of the tissues, the skin is undermined and of a blue 
or purplish colour, and the discharge is a thin serous 
one rather than ordinary pus. 

The vast majority of cases of tuberculous fistule 
are secondary to phthisis of the lung, and the infection 
has no doubt reached the rectum as the result of 
sputum being swallowed. In a few cases tuberculous 
fistula may be primary, and in such instances the 
infection has probably come from the gut, as we know 
that tubercle bacilli are not infrequently to be found 
present in the fæces of people who have not got any 
clinical signs of tuberculosis. It is quite useless 
to test the pus from a fistula for tubercle bacilli, as 
it is seldom found even in cases where there is no 
question about the diagnosis. 

There are two methods of proving the presence of 
tubercle in these fistula. One is to make a very 
careful microscopical examination of a piece of the 
wall of one of the tracks, the slides being stained 
by the Ziehl-Neelsen method and searched for tubercle 
bacilli; the other method is to inoculate guinea-pigs. 


A portion of the wall of the fistula is cut up in small 
pieces and treated with antiformin. This destroys all 
the other micro-organisms but leaves the tuberclo bacilli 
intact. After three hours the material is washed with a 
sterile salt solution. centrifuged, and the residue injected 
into the abdominal wall of the guinea-pig. At the end 
of six weeks the guinea-pig is killed and examined for 
caseous nodules. 


Injury and trauma.—Some of the most serious and 
most troublesome fistule that I have been called 
upon to treat have been due to the injection treatment 
of piles. It is only fair to say that in all these 
patients—and there have been quite a number— 
the treatment has been carried out badly, and in 
most of them urea-quinine hydrochloride has been 
used for the injection instead of carbolic. There 
has been no case of fistula in St. Mark’s Hospital 
as the result of the injection treatment of piles, to 
my knowledge, in spite of the fact that some 80 


658 THE LANCET] 


injections a week are given here. When the treat- 
ment is carried out inexpertly, however, an abscess 
may result, and this is likely to lead to a very bad 
type of fistula. I had a patient recently who had 
to have five operations and it took over a year before 
the condition was healed ; one track went up to the 
promontory of the sacrum. 

Another cause of traumatic fistula, of which I 
have seen several cases in the last few years, is the 
treatment of rectal carcinoma with radium. The 
insertion of radon seeds or radium needles in the 
neighbourhood of the rectum is very liable to set 
up an abscess, and a fistula results. These cases 
are particularly troublesome, as, owing to the action 
of the radium, there is very great difliculty in getting 
the parts to heal. No attempt can be made to do 
more than just provide adequate drainage to the 
infected tissues. 


TREATMENT 


In practically all cases the initial lesion is an 
abscess of which the fistula is a secondary develop- 
ment. If the initial abscess is opened at the earliest 
possible opportunity and free drainage established 
to the exterior, or into the bowel, about 70 per cent. 
of such abscesses will heal without resulting in a 
fistula, For this to occur it is necessary that the 
abscess should be opened before there is any large 
accumulation of pus and within at least 30 hours of 
its formation. Very free drainage, also, should 
be provided and the cavity should not be packed with 
gauze or any foreign body introduced. This method 
of draining abscesses was advocated by me in 1923 3; 
it has now been used in St. Mark’s for a number of 
years and is found to greatly reduce the incidence of 
fistula. It consists of cutting away the skin over the 
abscess cavity so as to leave a large opening and 
applying a wet compress to the outside. No packing 
is used, nor any drainage introduced, and there is 
no interference at all with the interior of the abscess. 
Too often what happens is that the abscess is left 
until it bursts through the skin, or into the bowel, 
or else an inadequate opening is made into it. Once 
a fistula has formed there is only one method of 
treatment that can be effective—namely, an opera- 
tion to lay open and drain all the tracks. 


A certain proportion of fistula can be cured by 
quite a simple operation, but I have no hesitation 
in saying that very many require considerable 
experience and much skill, if satisfactory healing is 
to be obtained, and that of all the cases which come 
into St. Mark’s Hospital for treatment the fistula 
cases are the most difficult, and I am not excluding 
excision of the rectum for cancer. Hardly two are 
alike and each requires special study. A fistula 
operation is not a major operation and should never 
endanger life, but it is very far from being a minor 
one. More surgeons’ reputations are damaged by 
unsuccessful operation for fistula than by laparotomies. 
The bad results of laparotomy are generally buried 
with flowers, while the fistula go about the world 
exhibiting the unsuccessful results of the treatment. 


While it is impossible to describe any one method 
of operating for fistula, since there is too much varia- 
tion in the conditions found, there are nevertheless 
certain broad principles involved in successful treat- 
ment which deserve our serious consideration. None 
of the many attempts that have been made to classify 
fistulæ is, in my own opinion, satisfactory, nor can 
they ever be, since fistula-in-ano do not lend them- 
selves to any satisfactory classification. There is 
an infinite variety, 


MR. J. P. LOCKHART MUMMERY: FISTULA-IN-ANO 


[MARCH 21, 1936 


PLANNING THE OPERATION 


Our object in operating upon any fistula is to obtain 
sound and permanent healing in the minimum time 
and with the least inconvenience to the patient. 
The first consideration, however, is to obtain good, 
sound healing, and although this can be occasionally 
secured when the patient is allowed to walk about 
this is seldom worth attempting, and I prefer to 
have the patient in bed during the whole period of 
convalescence, 

The first principle involved in curing a fistula is 
to provide free drainage to all the fistulous tracks. 
It is, however, not sufficient to provide drainage 
at the time of the operation, but so to plan the wound 
that free drainage can be maintained during the 
whole period of healing. In dealing with a fistula 
wound we are forced to make use of healing by 
granulation, since healing by first intention is not 


‘ possible, and a proper understanding of how to get 


sound healing by ‘third intention,’ as it is often 
called, is essential to success. All tracks must be 
freely opened up, but if the fistula is very extensive 
or goes very deep, it is often inadvisable to do this 
all at one sitting, as it may involve too extensive 
damage to the muscular structures, or lead to 
deformity of the parts. Hence, it is often better 
to plan the operation in several stages. 

When complete division of all the tracks will 
involve complete division of the external sphincter, 
the operation should always be performed in two 
stages, the division of the muscle being left to the 
second stage, when the remainder of the wound has 
to a large extent already healed. There is usually, 
one might almost say always, a track opening into 
the anal canal, what we call the internal opening, 
but in only a minority of patients does this open 
above the external sphincter, and its division, there- 
fore, involve division of this muscle. However 
many external openings there may be it is almost 
an invariable rule that there is only one internal 
opening, and it is well to bear that in mind. In 
most cases this internal opening is in the midline 
and usually posterior. 

When possible the wound should be so planned 
that the portion of it involving the skin is considerably 
wider and larger than the portion involving the 
mucous membrane and the bowel; this will often 
require what at first appears to be an unnecessarily 
larce wound. When operating at St. Mark’s I have 
often found that onlookers have been surprised at 
the amount of skin which I have cut away, no less 
than at the fact that the sphincter muscle has not 
been cut at all. The object of cutting away so large 
a proportion of skin is to provide a free opening to 
the fistulous track, which will remain a free opening 
until the track itself is healed. 

A very common mistake in operating for fistula 
is to miss one of the main tracks, and when this 
happens it invariably leads to failure. The track 
that is most commonly missed, in my experience, 
is that passing across from one ischiorectal fossa 
to the other, behind the anal canal. This is often 
present even in a fistula which appears at first to be 
confined to one ischiorectal fossa only; it may 
also occasionally be multiple. 

We have first to satisfy ourselves that we have 
laid open all the tracks, and for this purpose the 
eyes and fingers are the best guide. I have found 
that radiograms with Lipiodo] and the injection 
of the fistulous tracks with dyes are most misleading 
and do not help. When the parts are laid open 


THE LANCET] 


it is usually quite easy, if one has experience, to 
detect the openings of unsuspected tracks or to feel 
them with the fingers. 

The next thing is to decide whether we are going 
simply to leave the wound open to granulate, or if 
we should remove all the fibrous tracks. If the 
latter can be done successfully, healing will be sounder 
and much more rapid than if the dense fibrous tracks 
are left, since they are naturally composed of poor 
healing material. The decision will depend upon the 
knowledge and skill of the surgeon, but he must bear 
in mind that it is quite useless to remove only part 
of the tracks. When the tracks are very extensive 
and extend very deeply it is usually impracticable 
to remove them without the danger of damaging the 
muscular apparatus, or the rectum itself. When 
this is the case the wound should be simply left to 
granulate, being carefully, but very lightly, packed 
with wool or ribbon gauze. Wool is better as a rule, 
since being unwoven those fibres that become involved 
in granulation tissue can be left and the remainder 
washed out. While a woven material will all have 
to come away in one piece, and the granulating 
wall most certainly damaged, which is what we 
wish to avoid. To allow the granulation wall to 
form packing should be left undisturbed for at least 
three days and then soaked out in a bath, after which 
it should be changed twice a day, great care being 
taken to pack the wound lightly and not to damage 
the healing surfaces. 

If the surgeon decides that it is feasible to remove 
all the fibrous tracks, this should be done. The 
first finger of the left hand should be kept in the 
rectum to act as a guide and prevent accidental 
damage to the bowel'or the musculature. Every 
bit of fibrous track should be dissected out with the 
greatest care so as not to leave anything but healthy 
fat. Bleeding points should, if possible, be twisted 
rather than ligated, as healing will occur much 
better if foreign bodies in the form of catgut are not 
left in the tissues. If ligatures have to be used, they 
should consist of the finest catgut only and should 
be as few as possible. 

Having completed the operation the wounds 
should all be well swabbed out with strong Monsol 
or some other suitable antiseptic. A good area of 
skin should be removed in order to leave really free 
drainage, and a wet antiseptic compress applied 
outside. As a rule no packing at all should be 
inserted, as we want the whole wound to collapse 
and the fatty walls to adhere to each other. The 
wound must be carefully watched daily during the 
next few days to see that no pockets, or residual 
cavities, have formed in the deeper parts, but on 
no account should a probe be used. A finger can 
be passed into the rectum and the deeper part of the 
wound squeezed to see if any cavity is left. If a 
track, or a cavity is discovered, it must be lightly 
packed and treated in the ordinary way. If the 
treatment is successful it will be found that instead 
of a deep wound or wounds, there is only a large and 
quite superficial one, which heals up rapidly without 
much trouble. A very great saving of time can 
often be obtained by this method of operating, as 
even if only the deeper parts heal by first intention 
the resulting wound will be smaller and heal more 
easily than if treated in the more orthodox manner. 

The after-treatment of a case of fistula is most 
important and personally I do not undertake to operate 
for a fistula unless I can supervise the after-treatment 
myself. Dressings should be changed twice daily 
at first, and the patient should soak himself in a hot 
bath before removal of the dressings. Antiseptics 


MR. J. P. LOCKHART-MUMMERY : FISTULA-IN-ANO 


[marcu 21, 1936 659 


should be discarded after the first three or four 
days and the wound should be lightly packed with 
gauze or wool soaked with castor oil. 


TREATMENT FOR SPECIAL KINDS OF FISTULA 


In a fistula where the internal opening is to one 
side and the division of the track will involve dividing 
the external sphincter, the operation should always 
be done in two stages. The track leading to the 
internal opening is not divided until the external 
wound has healed down to it. 

Submucous tracks running up the bowel should be 
divided into the rectum and the edges trimmed 
away to give good and sufficient drainage. This 
is not difficult, but there may be some trouble in 
controlling the bleeding if the track passes high 
up the bowel. These tracks can be divided with 
a cautery, or the bleeding controlled by a large tube 
in the rectum, and by packing. In a few cases it 
may be necessary to make use of the elastic ligature 
to divide such tracks owing to the impossibility 
of controlling the bleeding if they are divided with 
a knife. 

Very high tracks which pass outside the muscular 
coat are fortunately very unusual. When they do 
occur they are the cause of much anxiety as.they are 
very difficult and sometimes impossible to deal with 
adequately. They cannot be completely laid open 
into the bowel, as they would involve too much 
damage to the musculature. As free drainage as 
possible should be provided for and the deep parts 
of the wound drained with tubes suitably disposed. 
They may sometimes be healed by injecting the 
deep tracks with’ acriflavine in anhydrous glycerin, 
or of silver nitrate grs. 20 to the ounce. 

Tuberculous fistule. —The treatment of these 
patients should be on conservative lines. It is 
useless to expect healing of a tuberculous fistula 
in a patient who is losing weight and suffering from 
active tubercle in the lungs or elsewhere. If there 
is not satisfactory drainage of the tracks this should 
be established by the simplest method and the 
patient at once sent to a sanatorium or put under 
proper conditions of fresh air and sunshine, the local 
treatment being entirely subordinate to the general 
treatment for tubercle. When the patient's general 
condition has improved, and he is putting on ‘weight 
and is in a good state of resistance, the fistula can 
be treated in the usual way. As there is always 
a risk of spreading the tuberculous infection into 
healthy tissue or to other parts of the body by the 
lymphatics, it is better to use a diathermy knife 
or an actual cautery rather than a scalpel. 

Sacrococcygeal fistule——The only thing necessary 
to get satisfactory healing is to excise all the tracks 
completely right down to the fascia overlying the 
bone. The wound should be left open to granulate. 

When the fistula wound shows signs of not healing, 
the first thing to do is to examine it very carefully 
to make sure that there is no fresh track or one that 
has been missed, and to make sure that there is free 
drainage. A properly healing fistula wound should 
show no obvious pus after the first week and the 
presence of pus generally indicates a deep and 
unnoticed track or bridging in some part of the 
wound. Poor or insufficient drainage is usually 
the cause of the trouble and should be remedied by 
laying the wound open again. Too tight packing is 
sometimes the cause; all packing should be as loose 
as possible. 

At a special hospital like St. Mark’s we not 
unnaturally get some very bad cases of fistula. 
The cases which have been unsuccessfully treated 


660 THE LANCET] 


DRS, K. COSTELLO & TYLOR FOX: ASTHMA AND .EPILEPSY 


[MARCH 21, 1936 


elsewhere are frequently .sent here and such cases 
come from all over the world. Many of them are 
real problems and require most careful treatment, 
but I am thankful to say that we are almost invariably 
able to send them home cured in the end. 


REFERENCES 
s Gordon watson, SiO Proc. Hoy. Soc. Med., 1932, xxv., 1019. 


- Tucker, a C., & d Helfwig, C >» A.: Arch. of Surg., 1935, 
XXxxi, 
3. a J. P.: Proc. Roy. Soc. Med., 1923, 
xvi., 65. 


A CASE SHOWING AN 
UNUSUAL RELATIONSHIP BETWEEN 
ASTHMA AND EPILEPSY 


By KATHLEEN COSTELLO, B.A. Sydney, M.R.C.S. Eng. 


ASSISTANT MEDICAL OFFICER, LINGFIELD EPILEPTIO 
COLONY ; AND 


J. Tytor Fox, M.D. Camb., D.P.M. 


MEDICAL SUPERINTENDENT OF THE COLONY 


X. Y. was born in January, 1921. There is no 
record of cither epilepsy or asthma in the family 
history. At the age of 10 she began to suffer from 
asthma,.accompanied by bronchitis, and also from 
epilepsy. From the first, according to the father’s 
statement, the fits always occurred at the end of 
the asthmatic attack. X ray examination at Guy’s 
Hospital was negative, and there was no evidence 
of tuberculosis. The patient spent several months 
at the Downs Hospital. 


She was admitted to the Lingfield Epileptic Colony i in 
November, 1933. At that time it was stated that the 


dyspneic attacks were increasing in frequency, and the 
more severe ones were terminated by a major epileptic 
fit. At the time of admission the general condition of the 
patient was poor. No abnormality in the central nervous 
system was found. The chest wall was thin and there 
was a depressed sternal sulcus. Posteriorly 


there was 
relative dullness at the right apex and left base, with 
tubular breathing at the left apex. A few scattered 


crepitations were heard, especially in the left axilla. 

For the first few months after admission there was 
persistent cough with fairly frequent attacks of definite 
dyspnea at night. Six of these attacks, which were more 
severe than the rest, ended up, when the patient was very 
cyanosed, with typical epileptic fits. In the summer of 
1934 the bronchitis cleared up and the asthma ceased. 
The signs in the chest, which had varied a good deal from 
time to time, disappeared. The patient began to gain 
weight rapidly and is now fat and healthy. There hes 
been no recurrence of the epileptic attacks. From the 
first treatment was directed to the alleviation of the chest 
condition, and no medicine was given to control the fits. 


A good deal has been written about the connexion 
between epilepsy and asthma, and it has often been 
suggested that they are both allergic manifestations. 
In some cases where they coexist it seems that the 
two types of attack may replace each other. In one 
case at present at Lingfield it certainly seems that 
when the fits are frequent the asthmatic attacks 
are fewer, and vice versa. 

But so far as we know a case of this kind, when 
the epileptic fits only occur at the culmination of 
severe attacks of asthma, when there is considerable 
cyanosis, has not been reported before. With cyanosis, 
no doubt, the cerebral cells have insufficient oxygen, 
but other clinical conditions which cause cyanosis 
do not also cause epileptic fits. 


MEDICAL SOCIETIES 


ROYAL SOCIETY OF MEDICINE 


SECTION OF OTOLOGY 


AT a meeting of this section on March 6th, under 
the presidency of Mr. HARoLD Kiscu, a discussion on 


Disturbances of Function of the Ear Following 
Injury 


was opened by Dr. G. KELEMEN (Budapest) who 
divided injuries into (a) those in which the petrous 
bone shared in general damage to other parts of the 
skull, (b) those in which the injury was limited to 
a disturbance of the sense of hoaring or that of 
equilibrium. During the late war, he said, the former 
group was frequent ; in peace time the latter were the 
more prevalent. In recent years disturbances of 
hearing and equilibrium had been studied in factories 
where both faculties were endangered. The con- 
sequences were divisible into (1) those in which 
secondary inflammation was the important factor, 
(2) those in which the injury of the terminal nerve 
organ was not complicated by inflammation, or at 
least where the associated suppuration was not the 
most important factor. For insurance or forensic 
purposes injuries of the ear were classified according 
to their symptoms; for diagnosis and treatment 
according to their localisation. The commonest 
fractures were longitudinal in front of or behind the 
pyramid ; they might cross the labyrinth and, out 
of sight of the otoscope, involve important parts 
of the sense organs. Fractures might also present 
a route for intracranial complications via the internal 
auditory meatus. 


In most cases the line of fracture was independent 
of the direction of the blow and of the site of the 
injury. It descended from the squama to pass round 
the capsule of the labyrinth. The eighth nerve 
might be injured (1) at its commencement in the 
narrow interosseous channels, (2) later where it 
ran, more loosely, in the internal auditory meatus, 
(3) in a funnel- shaped cavity, sometimes with a spur 
of bone narrowing the opening. It was at this 
narrowed spot that the nerve itself was apt to suffer 
damage; in other parts of its course the injury 
might be perineural. Inflammatory disease of the 
ear was of many varieties, from the simple otitis of 
the new-born infant to the formation of cholesteatoma. 
Bleeding between the layers of the tympanic membrane 
might detach the inner layer from the handle of the 
malleus; it did not necessarily lead to perforation. 
Injury might cause cysts, secondary inflammation 
in which led to development of the cholesteatomatous 
sac. 

A splinter of bone under the intact skin of the 
meatus might be taken for a simple swelling of soft 
parts, when it really implied a fracture. A skiagram 
was apt to mislead unless taken from various angles. 
The tegmen tympani lay so close to the facial nerve 
and its geniculate ganglion that a fracture in this 
region might easily involve that nerve. Hæmor- 
rhages in the cochlea might result in disturbance of 
hearing like tinnitus, or. in deficient perception of 
certain notes. Defective hearing was frequently 
observed in association with injuries to the head, 
as Kisch pointed out, even when visible signs of 
fracture of the skull were lacking. Fracture of the 
tegmen might involve the dura and endocranium. 
Patients might die of meningitis months after 


THE LANCET] 
apparent recovery from fracture of the base of the 
skull. More radical measures were required for 
traumatic than for non-traumatic suppurative cases. 
Lesions due to trauma were serious in proportion 
to the degree of secondary inflammation ; treatment 
should be on general principles. | 

Mr. E. D. D. Davis said that in compensation 
cases following motoring accidents disturbances of 
the function of the ear were frequently seen. He 
confined his remarks to internal ear or nerve deafness. 
The difficult cases were those of alleged concussion 
deafness, in which it was assumed there was an 
internal ear, labyrinthine, or nerve deafness arising 
from the concussion associated with head injury. 
In civil life nerve deafness as a result of injury was 
in his experience rare. Lannois and Chavanne 
reported that in 262 cases of simple labyrinthitis 
only 5 per cent. had almost total and apparently 
incurable deafness. The drum mechanism acted 
as a protection against the effect of explosions on 
the internal ear. 
injuries were common, cases of nerve deafness were 
divided into three groups: (1) with structural and 
permanent damage to the internal ear, (2) psychical 
or functional deafness, (3) temporary deafness. 
Cases in group (1) showed evidence of severe injury, 
such, as bleeding from the ear, escape of cerebro- 
spinal fluid, prolonged loss of consciousness, paralysis 
of cranial nerves, particularly the facial, and other 
brain injuries. There was tinnitus and vertigo, and 
obvious trauma of the ear. The deafness was 
permanent with loss of perception of high notes. 
X ray photography might show a fracture involving 
the labyrinth. Group (2) included patients who 
feigned deafness and even loss of voice; there were 
unexplained nervous phenomena, contradictory results 
from hearing tests, and no keen desire for recovery. 
There might be definite opposition to examination, 
and the structure of the ear showed no sign of injury. 
Group (3) consisted of cases of temporary deafness 
regarded as due to concussion, shock, or explosion. 
After a few weeks’ rest these cases usually recovered. 
If genuine deafness remained after six months it was 
usually permanent. Many cases of shell concussion 
recovered rapidly. Well-marked cases of concussion 
deafness showed exaggerated reflexes, tremors, vaso- 
motor disturbances, vertigo, and headache. Absence 
of signs of trauma to the ear and a normal caloric 
reaction in the labyrinth indicated the temporary 
nature of the deafness. A forgotten inflammatory 
or other ear disease, especially otosclerosis, might 
be revealed by scarring and opacities of the drum. 
In compensation cases Mr. Davis urged that medical 
witnesses on both sides should meet and try to agree 
as to the nature of the case. A ruptured drum 
required rest in bed, without local treatment; the 
meatus was cleaned and the ear left alone. 

Mr. HERBERT TILLEY referred to the case of a man, 
aged 69, who was standing on a railway platform when 
an engine near emitted a shrill shrick; he put his 
hands to his ears and said it felt as if a knife had been 
stuck into each ear. There was tinnitus for a short 
time, but no vertigo. The deafness following had 
been extreme, and he felt it greatly as he was very 
musical. He found difficulty in carrying out the 
duties of his post. The insurance company denied 
that it was an accident and disclaimed responsibility. 

Sir JAMES DuNDaAS-GRANT said that cases of 
concussion often were benefited by small doses of 
perchloride of mercury. 

Mr. SYDNEY Scott, referring to a statement that 
not more than 5 per cent. of cases of fracture of the 


ROYAL SOCIETY OF MEDICINE: OTOLOGY 


During the late war, when ear’ 


[maron 21, 19386 661 


base had nerve deafness, said the probable reason of 
that small proportion was that many cases of fracture 
of the petrous bone were fatal. One such patient 
of his, however, survived for 20 years. He was a 
railway guard who was flung from one end of 
his van to another and was concussed. There was 
deafness with absolute loss of labyrinthine reactions, 
and bilateral rupture of the auditory nerve was 
diagnosed. 


Mr. E. Dracon said that in a series of 230 cases 
of fracture of the skull 33 survived, and of the latter 
11 had an acute suppurative condition of the ear. 
On 5 of them he performed the operation for acute 
mastoid disease. There was no tinnitus and no 
vertigo. 


OTOSCLEROSIS ASSOCIATED WITH BLUE SCLEROTICS 
- AND FRAGILITAS OSSIUM 


Mr. T. RITCHIE RODGER referred to a case shown 
by Mr. Cleminson in 1926. Ten years before that 
van de Hoeve and de Kleijn had pointed out the 
frequent association of otosclerosis with blue sclerotics 
and imperfect osteogenesis. Julia Bell found that 
60 per cent. of adults with blue sclerotics were deaf 
and the same proportion had fragile bones, while 
44 per cent. had both. Inheritance was usually 
dominant, but there were exceptions. There was no 
such sex preference as was found in otosclerosis, but 
affected females had a slightly higher percentage 
of affected offspring than a corresponding number 
of affected males. Otosclerosis did not develop 
until the third decade, and transmission was generally 
direct ; in one of his families two generations were 
skipped. Cockayne believed that both mesodermic 
and ectodermic defects were determined by a single 
dominant gene. The sella turcica seemed to be 
contracted, as if the pituitary body had not developed 
properly. There were often deformities apart from 
fractures. The deafness and the changes in the 
petrous bone were typical of otosclerosis. Mr. Rodger 
wondered whether the inheritance factor might not 
lead to some secondary metabolic difficulty which 
could be circumvented in time to prevent the onset 
of deafness. 


Prof. NAGER (Zürich) said the bone process in 
otosclerosis was similar to that in fragilitas ossium, 
where there was also a defect of the osteoblasts. In 
otosclerosis there must be an endocrine factor, because 
the condition usually started at puberty and the 
symptoms arose only at the moment that the joint 
was attacked. The process might be present in the 
capsular part without showing symptoms. Treat- 
ment with thyroxine often reduced the tinnitus. 
Hyperparathyroidism, which bore many similarities to 
otosclerosis, had been produced by intoxication with 
certain vitamins. 


Mr. F. J. CLEMINSON remarked on the wide distribu- 
tion in some cases of the otosclerotic changes. The 
late Dr. Albert Gray had stated that otosclerosis 
invariably began in, and was for long confined to, 
the region of the fenestra ovalis. 


NEWARK Hospitat.—Last year workpeople sub- 
scribed the record sum of over £2000 to this insti- 
tution, but the authorities would like to see the 
subscription list equal the voluntary levy. The average 
cost per bed here has been reduced from £101 to 
£97 12s. 7d., and the length of stay of in-patients 
from 22 to 20 days. 


662 THE LANCET] 


HUNTERIAN SOCIETY 


INTRODUCING a discussion on March 16th at 
a meeting of this society (Dr. W. BRANDER, the 
president, being in the chair) on the subject of 


Fatigue 


Dr. ADOLPHE ABRAHAMS said that among the presenting 
symptoms for which practitioners were most commonly 
consulted were tiredness, or one of its equivalents, 
lack of energy, premature exhaustion, undue fatigue, 
lassitude. Certain serious pathological states—myas- 
thenia gravis, Addison’s disease, malignant disease, 
Addisonian anzmia, diabetes, tuberculosis, post- 
influenzal debility—-were accompanied by asthenia. 
But the majority of patients who complained of 
chronic fatigue were not suffering from any serious 
or indeed any disease at all, nor as they alleged from 
over-work ; they were simply bored. Yet it was a 
matter of common experience that the amount of 
congenial work which even an average person could 
undertake was colossal. Dr. Abrahams here related 
a personal experience. 

“ When I was a house surgeon at St. Bartholomew’s,”’ 
he said, ‘‘ the practice—whether or no it obtains to-day— 
was to go on full duty every week-end in five, when from 
midday Friday until midday Tuesday you were responsible, 
in addition to your routine duties, for every surgical 
emergency. I recall one such full duty when through 
continuous pressure I never completely undressed during 
the four days and nights. It happened moreover that 
for most of that week-end there was a dense fog, and as 
a consequence I lost all distinction between day and 
night, all conception of time. I experienced a sense 
not of fatigue but of supreme happiness, the memory 
of which persists to this day. I recall a similar experience 
during the war; but it is superfluous to elaborate what 
everyone here has also encountered: periods of con- 
tinuous intense work congenial and satisfactory to be 
contrasted with the sense of exhaustion only too inevitable 
when the work, though far less exacting, is of a nature 
which is for one reason or another uninteresting and 
unprofitable.” 

We were all agreed, Dr. Abrahams continued, 
that work as such never caused a breakdown ; some 
mental conflict must be present. Of course when 
patients came with the story of recent gross reduction 
in their ability to undertake exertion, physical or 
mental, it was natural to try to identify some 
responsible toxin, acting as a brake upon the machinery 
of activity. We admitted the influence of certain 
accepted toxins—tuberculosis, malignancy, influenza 
—but what were we to say of the more elusive toxins 
in focal sepsis? Once determined to incriminate 
some such abnormality and having excluded the 
accessible teeth, tonsils, sinuses, prostate, gall- 
bladder, appendix, and pelvic organs, there remained 
the almost unlimited field provided by the alimentary 
canal. Contemporary advertisements discovered here 
the invariable cause of tiredness and sought its cure 
in suitable pabulum or the eradication of intestinal 
poisons. But both the scientifically minded physician 
with his toxins and the more matter-of-fact practi- 
tioner who accepts the idea of boredom must not 
forget the psychologist who finds in fatigue a defence 
against anxiety or the undertaking of responsibility 
or even Nature’s protection against over-exertion. 

Dr. Abrahams then turned to the problem of fatigue 
as an accepted physical consequence of muscular 
exercise. Fatigue is due to exhaustion of the 
substances required for the supply of energy or more 
exactly to the accumulation of sarco-lactic acid, 
the excess which the blood stream is unable to wash 
out. If exercise is of such severity that the lactic 


HUNTERIAN SOCIETY 


[marcu 21, 1936 


acid produced is no more than can be removed 
simultaneously by oxidation—accepting as the 
maximum intake of oxygen four litres a minute— 
fatigue will not occur until other factors of exhaustion 
enter into the problem. But with really violent 
exercise the generation of lactic acid is far too 
considerable for its elimination—e.g., in the case of 
a sprinter, 1 gramme of lactic acid accumulates for 
every stride taken, i.e., 40 grammes in the hundred 
yards. Athletic training to some extent consists 
in perfecting the circulation for the removal of lactic 
acid, but it also embodies the education of the muscles 
to neutralise fatigue products or perhaps to tolerate 
their presence. The great athlete, Dr. Abrahams 
thinks, has muscles constitutionally superior in this 


respect. Perhaps the maximum accumulation of 
lactic acid possible to the most highly trained 
individual is 120 grammes. Furthermore the capacity 


to resist fatigue is bound up with the willingness to 
push oneself to the last degree; the seat of fatigue 
is in the nervous system and the available reserve 
is immeasurable. In long-continued exercise of 
submaximal severity, fatigue may be due to shortage 
of fuel. American experiments upon marathon 
runners had shown an exact correlation between 
exhaustion and hypoglycemia which Dr. Abrahams 
had been unable to confirm. But exhaustion during 
a substantial athletic effort was a disturbed mechanism 
concerned with several widely different factors ; 
for in addition to the shortage of fuel, to the accumula- 
tion of lactic acid, to the element of monotony, 
there was the prevention of loss of heat and of moisture 
under certain unfavourable conditions. The lassitude 
often experienced on the day or days following a 
severe eifort had been attributed to myocardial 
weakness and the same explanation had been applied 
to the incapacity for effort after bacterial illness, 
especially influenza. “I am unable,” he said, 
“to agree that any direct cardiac association need 
be invoked. After all, the muscular metabolites 
must have an effect upon the central nervous sytem 
and to this I attribute protracted and delayed fatigue, 
and, I may add, the symptoms which are on insufficient 
evidence accepted as ‘ heart-strain °.” 


MENTAL FATIGUE 

Dr. C. S. Myers, F.R.S., said that fatigue is 
usually defined as “that state of lessened activity 
of an organ which results from its previous activity.”’ 
But so varied are the effects of prolonged mental 
work, so complex and so widespread is the “organ ”’ 
of mind, and so ignorant are we of the nature of 
mental activity that a correspondingly succinct 
definition of mental fatigue would fail to serve any 
useful purpose. On grounds of physiological analogy, 
we might at first be disposed to attribute mental 
fatigue to the exhaustion of locally available mental 
‘‘energy.” But the only apparent evidence that we 
had of such a cause of mental fatigue related to 
structures outside the central nervous system— 
namely, in the effects on consciousness produced by 
stimulating the ‘‘ protopathic’’ or “spot” system 
of sensibility. These effects were easily observable 
in the skin; where, if any one heat spot or cold 
spot is re-excited immediately after its previous 
stimulation, it would fail to elicit a second sensation. 
Its previous response, comparable perhaps to an 
explosion, had apparently resulted in complete 
exhaustion: rest is needed for its recovery. But 
there were other sensations, if not too intense, which 
seemed virtually indefatigable. We can listen almost 
eternally to the gentle ticking of a clock or endure, 
likewise without apparent sensory fatigue, the 


THE LANCET] 


continuous daylight of a northern summer. There 
are other prolonged but more intense sensations— 
e.g., the hearing of a continuous loud tone, which, 
while not suffering appreciable change themselves, 
nevertheless—owing, it is believed, to central inhi- 
bition—result in a rise of the threshold of hearing 
for tones of the same and of neighbouring 
pitch. So far as cerebral fatigue is concerned, 
it might be wondered whether any impairment of 
mental activity would be expected either through 
the exhaustion of locally available energy or through 
the accumulation of toxic influences due to its exer- 
cise. Conscious processes however seemed to involve 
the activity of extensive areas of the brain functioning 
as a whole; the notion of “centres of conscious- 
ness ” was fast becoming obsolete. 

Uninterrupted concentration at any task, Dr. 
Myers said, is unnatural; it is our nature to take 
repeated brief rests during any long period of mental 
work. But whereas the uninterrupted maintenance 
of mental activity in one particular field of attention 
cannot endure for long, the freer play of phantasy 
in day-dreaming and in sleep seemed untiring. 
Feelings of mental weariness are not invariably 
a faithful index of mental impairment; lessened 
output of mental work may indicate that we are 
mentally fatigued without our necessarily feeling so, 
or we may feel mentally fatigued without necessarily 
showing it in poorer work. Measurement of the 
output of work was at present our most trustworthy 
index of mental fatigue, for unfortunately we have 
no sufficiently reliable objective tests of mental 
fatigue. Purely physiological tests have proved of 
little use. Periodically interpolated mental tests 
are.at the mercy of the will and of the feelings of the 
subject; they are also subject to the effects of 
practice and of consequent automatism; and they 
differ, owing to their necessary simplicity, from the 
more complex directive, aim-seeking characters of 
higher mental work. There can however be no 
doubt that, in general, the efficiency of performing 
certain interpolated mental (e.g., arithmetical) tests 
is lowered by continuous mental work. Both the 
feeling of mental fatigue and fatiguability showed 
vast individual differences. The obsessional type of 
psychoneurotic might be kept by his abnormally 
strong perseveration incessantly at work when the 
normal worker would be unable to resist from taking 
protective rests. Especially he, but also even the 
best balanced and most vigorous person, under 
sufficiently prolonged or intense mental activity 
would ultimately suffer, sometimes quite suddenly, 
from pathological fatigue or so-called mental break- 
down. Extreme muscular fatigue had never been 
shown to cause mental breakdown. 

Some light was thrown on the pathology of mental 
breakdown by considering the effects of prolonged 
activity at the lowest levels of the central nervous 
system. As the spinal flexion reflex tires under con- 
tinuous excitation or frequent excitation, it becomes 
weaker and more tremulous, and may finally even 
cease altogether. But during this fading there occur 
brief periods of intermission and even of replacement 
by the antagonistic response of extension; inhi- 
bited movements are more ready to break through. 
The same occurs when we are at work in some parti- 
cular field of mental activity. Antagonistic and 
irrelevant fields of attention are successfully inhi- 
bited, at first without voluntary effort owing to the 
incentive of interest, but later, as interest wanes and 
boredom enters, through the exercise of volition. 
Finally as this directive activity of the will fails 
through fatigue, we can no longer, despite the utmost 


HUNTERIAN SOCIETY 


[maRcH 2], 1936 663 


effort, attend to the work on which concentration 
is required. Thus local boredom gives place to general 
fatigue. Continued cortical stimulation of the 
flexor area results in a facilitated increasing response, 
then to a rise in sensitivity of the antagonistic extensor 
area, and finally to a quasi-epileptiform wave of 
movement spreading to neighbouring motor areas. 
These changes were in some aspects analogous to 
the collapse of the higher codérdinating centres and 
to the wasteful dissipation and ‘short-circuiting of 
energy, characteristic of mental breakdown through 
overwork. 


It seems, Dr. Myers concluded, that mental fatigue 
is most evident and serious when the work is of a 
kind that demands concentration of attention, and 
that then its most prominent feature is a collapse 
of “directive activity ° which manifests itself in 
impairment and distraction of attention, loss of 
skill and deficient effort, in irritability and other 
symptoms of loss of self-control, and finally in more 
serious disorders of volition, cognition, and emotion. 
But in addition to such fatigue of volitional direction, 
there is likewise a fatigue of the mental processes 
which are subject to such direction. 

But, he added, we do not know what occurs when 
fatigue sets in. We may conjecture that synaptic 
resistances are increased, or that adverse chemical 
bodies are formed, like acetylcholine, neurogenic and 
humoral in nature, or resembling in their action the 
toxins generated by excessive muscular activity. 
It may also be that antitoxins can be formed, resistant 
to such fatigue. But we are as ignorant of these as 
we are ignorant of the supposed toxins and anti- 
toxins responsible for, or defensive against, sleep. 
We are also ignorant of the differences which are 
likely between the fatigue caused by intensive or 
prolonged mental work and the fatigue caused by 
deprivation of sleep. 


FATIGUE IN INDUSTRY 


Dr. J. C. BRIDGE said that in his visits to centres 
of industry he had been impressed by the ability of 
workers to continue at heavy tasks for eight or more 
hours every day of the working week; he felt sure 
that part of the explanation lay in the fact that the 
work was not actually continuous, but the men had 
“ breathers,’ intervals of rest between the tasks. 
Mechanisation too in recent years had done much to 
reduce the muscular energy necessary at many of 
the heavier kinds of work. He assumed there was 
a physiological fatigue which was good and healthy, 
but he knew of no means of determining subjectively 
where this ended and pathological fatigue began. 
A recent move was to substitute for three eight- 
hourly shifts four six-hourly ones; one result of 
that change had been to increase the output. Repe- 
titive work in attending to machines of uncanny 
complexity must produce in the worker a sense of 
boredom or fatigue. In making clothing the com- 
ponent articles were sent along on a continuous 
band; workers along its path had a set piece of 
work to finish before the garment was passed on to 
the next. That kind of monotony was well calcu- 
lated to produce fatigue. When intervals of rest 
were allowed, many of the women occupied them- 
selves with knitting! He could only presume that 
no more than a small part of the human anatomy 
became fatigued by the work. Fatigue in industry 
had been for some time diminishing, and was still 
being reduced, but its form varied owing to the 
changing forms of employment. Study of these 
was important. l 


664 THE LANCET] 


LIVERPOOL MEDICAL INSTITUTION 


. —wancH 21, 1936 


DISCUSSION 

Dr. Guy P. CrowpEn found it impossible to 
regard fatigue as a single entity ; he found himself 
unable to isolate it from what appeared to be the 
daily cycle of every active person. The problem 
to be faced was: is the phase of recovery a real 
and full compensation for the expenditure of energy ? 
At the end of a day, and at the end of the week, 
fatigue had overtaken recovery and—speaking from 
the physiological standpoint—there was some leeway 
to be made up. Did the routine of life permit the 
day-to-day equilibration of that cycle? One could 
not assume a dominating influence preventing 
equilibration apart from many factors known to 
influence fatigue and recovery. In the case of the 
worker distinction must be made between dynamic 
fatigue as a result of movement efforts, and static 
in which there was fixed attention with possible 
strain. There was too the factor of environment. 
Some work was done in comfort; ventilation, 
humidity, air movement, and radiant heat were 
important, as well as distractions due to noise or 
vibration, not forgetting air pressure (caisson work). 
In all this it was impossible to ignore the personal 
factor; much depended on whether the person 
concerned was educated and able to appreciate the 
significance of changes in routine, the regulation of 
light, and even the wearing of protective garments. 
Some single and apparently trivial factor might 
turn out to be the chief cause. A person engaged at 
a desk might be at work which involved postural 
strain, and he might suffer considerable fatigue in 
local muscle groups. Fatigue meant a diminution 
of capacity as assessed by the previous optimum of 
physical fitness. A further factor of real importance 
was that of appropriate and sufficient food, linked 
up with congenial home conditions. 

Dr. R. K. Howat argued that the process of 
recovery from fatigue was never complete. It was 
true that after a period of rest one might feel as 
fresh as ever, but that did not mean complete recovery. 
Every living creature entered on life with a definite 
reserve of energy, and even with sufficient food and 
periods of rest there was a danger of being on the 
wrong side in the matter of equilibration. Fatigue 
might be a protective agency against complete 
exhaustion. 

Dr. Stewart WEBB regarded fatigue as largely 
individual ; many were content to perform the most 
monotonous tasks so long as they were not called 
on to bear any responsibility. 

Dr. If. L.'ATTWATER spoke of the delicate and 
exacting work involved in making filament lamps, 
the suspension of the filament occupying about ten 
seconds each. Monotony was countered by the 
offer of bonuses to those who dealt with the largest 
number of lamps cach week, and there were no 
complaints of fatigue. On the other hand, those 
who had to produce dies for very fine work only put 
in short hours and did suffer from fatigue. 

Mr. ILOPE CARLTON agreed that fatigue was largely 
central, and the question of shock was important. 
A boxer who had been knocked out was suffering 
from fatigue, and that was a central lesion. Dis- 
cipline also had much to say. During the late war 
the endurance of a trained battalion as compared 
with that of new recruits was largely a question of 
superior discipline. Recent work at Down Farm 
on fatigue in smooth muscle had disposed of old 
ideas on the subject; there was no deficiency of 
blood chlorides, even up to the point of death. 
Fatigue was not due to histamine bodies ; the death- 
dealing substance lay in the cell. 


Dr. LETITIA FAIRFIELD insisted on the importance 
of rhythm, which became evident on watching the 
methods which workers chose for themselves. 
Children’s favourite method of doing things was to 
attack them in bursts of energy, alternated with 
periods of rest, and if allowed to carry on as they 
pleased they were quite fresh at the end of a long 
day; whereas if a certain procedure was imposed 
on them they soon tired of the task. When a person’s 
whole desire and interest was concentrated on his 
work, this had the effect of postponing and diminish- 
ing the amount of fatigue. Men working at exacting 
occupations for long hours during the late war would 
not confess to fatigue although their muscles were 
twitching and they were evidently spent. Absence 
of mental conflict was very important. 


Dr. ABRAHAMS in replying said it’ was usually 
the fussy person who was particular about the 
athlete’s diet; the great athletes did not bother 
about it. Also, the record-breaker was not usually 
the educated person; if he were he would commence 
to reason while at his running, and the first question 
he would ask would be, “ Why am I doing it ? Isit 
worth while ? ”’ 


LIVERPOOL MEDICAL INSTITUTION 


A MEETING of this institution on Feb. 27th, with 
Mr. G. C. E. SIMPSON, the president, in the chair, 
was devoted to short papers on problems in general 
practice. 

Treatment of Psoriasis 


Dr. R. M. B. MacKenna said that certain definite 
precautions should be taken by persons prone to 
psoriasis ; they should not wear tight clothing, they 
should avoid alcohol, foods containing spices, and 
fatty foods, and as a rule they should expose them- 
selves to sunlight as much as possible. With a severe 
attack in the stage of efflorescence, an expectant 
line of treatment should be adopted ; rest in bed was 
a measure which was usually omitted but often did 
more good than any other. 

In the discussion which followed, Dr. F. GLYN- 
IuGuES, in reference to Dr. MacKenna’s mention 
of German work supporting the idea of faulty fat 
metabolism in psoriasis, said that until two months 
ago it had been his practice in Belmont-road Skin 
Hospital to put all his psoriasis patients on a fat- 
free diet. Ie was satisfied that this had decreased 
the time required to clear the skin. Lately he had 
gone further and put these patients on a milk diet 
only, and had been very pleased with the result, 
particularly in very chronic cases. The method had 
the advantage that it could be carried out at home. 
Speaking of the use of intramuscular injections of 
mercury, he said he would like to be sure that their 
good results were due to the action of the drug on 
the disease proper, and not to its action on syphilis, 
which could produce lesions closely resembling 
those of psoriasis. The Wassermann reaction in 
these cases was not always reliable. 

Dr. G. S. Swan said that psoriasis was one of the 
bugbears of a general practitioner’s life. His main 
object was a form of treatment to enable the patient 
to continue his employment. Baths twice daily, 
followed by complete inunction, were almost impos- 
sible of achievement outside hospital. 


Phlyctenular Conjunctivitis 


Mr. A. McKie REID, in a paper on the xtiology 
and treatment of phlyctenular conjunctivitis, began 


THE LANCET] 


by pointing out its association with cervical adenitis, 
pathological tonsils and adenoids, occasional bone 
and joint disease, and with hilar and abdominal 
tubercle. The lesion showed neither tubercle bacilli, 
true giant-cells, nor caseation, and the evidence in 
favour of its being tuberculous was chiefly clinical 
and experimental. The occurrence of phlyctenules 
when sacs of tubercle bacilli were tied in the body 
of non-tuberculous animals, when external irritants 
(e.g., staphylococcal toxin) were introduced into the 
- conjunctival sac of tuberculous animals, as a focal 
reaction after a skin-test and as a local reaction after 
a conjunctival test for tuberculosis, were quoted in 
support of the theory that the disease is a focal 
manifestation of systemic disease—a tuberculo- 
toxic manifestation in the allergised ocular epithe- 
lium. Treatment included local application of ung. 
hydrarg. oxid. flav. and treatment of the accom- 
panying catarrhal conjunctivitis with saline lavage 
and 2 per cent. mercurochrome drops (zinc and silver 
salts were contra-indicated). Improved hygiene, 
administration of vitamins, hyperalimentation, arti- 
ficial sunlight, and, where systemic tuberculosis was 
present, institutional treatment were useful. The 
disease was much commoner in communities where 
economic and industrial conditions were bad, and 
Mr. Reid maintained that its prevention was essen- 
tially a sociological problem. 


Dangers of Nose-blowing 


Mr. Joun ROBERTS said that the act of nose- 
blowing, although accepted as a necessary civilised 
convention, was not physiological, because normally 
the nasal secretions (with their entangled bacteria 
and dust) pass backwards into the pharynx and are 
swallowed. It seemed probable that the body, in 
this singular way, kept vaccinating itself against 
prevalent micro-organisms through the agency of 
the stomach and intestinal canal. By a considera- 
tion of the aerodynamics of the middle-ear cul-de-sac 
it could be clearly shown that the forecd passage of 
air through a constricted nasal passage could easily 
impel some secretion (on its way past the orifice of 
the Eustachian tube) into the tympanic cavity— 
particularly if the tympanic membrane was absent 
or perforated. Clinical experience had conclusively 
shown the liability to acute otitis media following 
injudicious and forcible nose-blowing in such condi- 
tions as the common cold, measles, and scarlet fever, 
and also in swimmers and divers. 

In the discussion, Mr. McKie REID said that 
vigorous nose-blowing immediately after excision 
of the lacrymal sac was sometimes followed by an 
alarming swelling of the eyelids suggesting cellulitis. 
This was surgical emphysema due to the tissue planes 
in the eyelids, laid open by the incision, being brought 
into direct communication with the intranasal 
cavity. The condition resolved quickly on the 
application of pressure-pads and abstention, (for 
a day or two, from nose-blowing. 

Dr. W. B. BENNETT said that he considered the 
safest method was to “ blow” each side of the nose 
separately, somewhat after the practice of the manual 
labourer, who closed one nostril with his finger, 
while he cleared the other, which remained open. 
A handkerchief could, of course, be held near the nose. 

Dr. R. J. MARTIN said that blowing the nose was 
an expiratory movement resulting from irritation of 
the nasal mucous membrane. While normal ciliary 
action propelled debris downwards, to be disposed 
of by the acid gastric juice, this mechanism often 
needed assistance during modern conditions of town 
life. This assistance was provided by the acts of 


ROYAL ACADEMY OF MEDICINE IN IRELAND 


[marcy 21, 1936 665 


sneezing, coughing, and blowing the nose. The danger 
of forcible nose-blowing arose when infected mucus 
lay at the entrance to the Eustachian tube, and 
infection of the middle-ear cleft was particularly 
likely to occur in those cases in which a dry per- 
foration already existed in the tympanic membrane. 


Mr. H. V. FORSTER read a paper on Tonsil Function 
and the Attitude to Tonsillectomy, and Mr. H.C. W. 
NUTTALL one on Septic Fingers. 


ROYAL ACADEMY OF MEDICINE IN 
IRELAND 


A MEETING of the section of obstetrics and gynzco- 
logy was held on Feb. 14th with Dr. J. F. CUNNINGHAM, 
the president, in the chair. 


Sudden Death During Labour 


The PRESIDENT showed a specimen from a patient 
in whom a cardiac lesion caused death during labour. 

The patient, a primipara aged 33, appeared to be quite 
normal when she came into hospital. Her lungs and 
heart were examined and nothing abnormal was found. 
There was no albumin in the urine. After she had been 
in labour for 12 hours it was thought that she was in 
the second stage. No vaginal examination was made. 
After she had been 15 hours in labour the head appeared 
on the vulva. The patient said that she could not see 
at all, her eyelids got very swollen and she became 
cyanosed. She was given chloroform and had a very 
easy low forceps delivery. She was given chloroform 
for only seven minutes. She died suddenly, and the 
baby was stillborn. Forceps were used because the 
patient was in great distress owing to the cyanosis. At 
post-mortem examination the abdominal organs and the 
brain were found to be normal. The lungs showed 
adhesions and evidence of old-standing pleurisy. There 
was moderate fatty infiltration of the heart, but the 
valves were normal. There was no evidence of endo- 
carditis. The right ventricle was dilated, and the wall 
was extremely thin. There was an antemortem clot in 
the left ventricle. 

Dr. Cunningham said he had previously seen two 
cases in which a clot had appeared, but it was in 
the right auricle or ventricle. This was the first time 
he had seen a clot in the left ventricle. 

Dr. BETHEL SOLOMONS said that sudden death in 
labour had been attributed to various causes. ‘* Labour 
shock ”? as a diagnosis usually meant ignorance of 
cause of death. Lmbolus, postpartum hxmorrhage, 
acute cardiac dilatation, and many other factors 
were blamed. In this case it was impossible to 
exclude chloroform as the cause. le still believed 
that chloroform was dangerous in hospital practice, 
whereas it was apparently safe in the hands of an 
experienced practitioner. The post-mortem specimen 
which had been shown did not solve the puzzle. 

Dr. G. C. DockerRay said that the specimen 
reminded him of one in the College of Surgeons in 
which a large ball thrombus in one of the chambers 
of the heart had caused death. It was a good deal 
larger than the clot in this case, but presumably 
the mechanism was the same in both. Most chloro- 
form fatalities seemed to occur in patients with 
perfectly normal hearts ; so selection of patients for 
chloroform would probably make little difference. 
Many cases of so-called acute dilatation of the heart 
were really cases of tachycardia with, in addition, 
fibrillation. 

Dr. F. DoYLe said that this was a case which would 
fill many people with alarm. There was nothing 
which could clinically suggest death, and it was very 
remarkable that death should have been so sudden. 


666 THE LANCET] 
Death might have been due to the anesthetic, but 
apparently this was not so. Nitrous oxide and 
oxygen was in his opinion the proper anesthetic 
for these cases. It would be interesting to know 
whether in this case the chloroform had really had 
any effect on the heart or not. 

Dr. KERRY REDDIN said that in the last two months 
he had known of three patients with congenital heart 
disease who had been sent out of maternity hospitals 
undiagnosed. He thought there was great slackness 
in examining the hearts of the women and the babies 
in the maternity hospitals, and said that neither 
heart cases nor tuberculous cases were properly 
examined there. 


The PRESIDENT, in replying, said that the absence 
of any clinical symptoms when the patient came into 
hospital first could be explained by the pathological 
report which said that she had no valvular lesion 
of the heart at all. When she became distressed and 
blue during labour it was very difficult to know the 
reason. He did not think that the anesthetic had 
had anything at all to do with the death of the woman, 
and believed the cause of death must have been 
that the heart went through a great strain during 
labour; this strain increased towards the end of 
labour, and it was then that the anesthetic was given. 
This death had not altered their routine in the hospital 
of giving chloroform. Every case on admission 
was examined to see if there was any heart lesion, 
and if there was, this was taken into consideration 
when an anesthetic was being given. 


Ovarian and Endometrial Graft 


Dr. BETHEL SOLOMONS reported a case in which 
an ovary and a piece of functioning endometrium 
from the uterus were grafted from one woman to 
another. He knew of no similar recorded case. The 
patient had previously had years of amenorrhea 
and much hormonic treatment had failed; but 
menstruation followed the operation. 

The PRESIDENT said that this was probably the 
first time that an operation such as was described 
by Dr. Solomons had ever been performed. It 
was extremely interesting to hear of a graft of ovary 
and of endometrium being made at the same time. 
He thought it was common to find that a graft of 
an ovary into the rectus muscle failed. The ovary 
did not live very long. The graft often gave rise 
to pain, and later a cystic swelling sometimes appeared 
in the rectus muscle. It was noteworthy that the 
endometrium had an effect on the ovary as well as 
the ovary on the endometrium. He thought that 
very likely the endometrium was a ductless gland, and 
would have this effect. He wondered if it was the 
patient’s own ovary which was now functioning, 
in which case the result would be likely to be more 
permanent. The patient’s own ovary might have 
been stimulated by the operation; this would have 
an effect on the endometrium ; and the endometrium 
in turn reacted on the ovary. It was fairly easy to 
graft endometrial tissue, but very difficult to graft 
ovarian tissue. 

Dr. T. M. IIEALY hoped that Dr. Solomons would 
report later on on the behaviour of the endometrium. 
It would be interesting to know the degree by which 
the uterus was covered with endometrium in six or 
eight months’ time, and whether it was behaving 
as normal endometrium did in the ordinary individual. 
Dr. A. W. SPAIN and Dr. Dockeray spoke of the 
relation of blood groups to success in grafting. 


Dr. Sotomons, in reply, said he thought a graft 
lasted for two or three years. He believed that the 


ROYAL ACADEMY OF MEDICINE IN IRELAND 


[MarcH 21, 1936 


menstruation, which had already occurred several 
times, was due to the presence of the grafted ovary 
and the endometrium. 


Juvenile Rheumatism 


Dr. C. J. McSwEENEY addressed the Section of 
State Medicine on this subject at a meeting held on 
Feb. 28th with Dr. J. A. HARBISON, the president, 
in the chair. He began by saying that he thought 
rheumatism responsible directly or indirectly for 
1500 deaths a year in the Irish Free State. His 
impression was that the disease was at least as 
common in Dublin as it was in the larger cities in 
England. It was essential to recognise that nowadays 
rheumatic manifestations in childhood were usually 
subacute, and even subclinical; hence the replace- 
ment of the term ‘acute’? by the more precise 
‘“‘ juvenile.” Subacute rheumatism was more likely 
to lead to cardiac involvement because it was more 
often neglected. Where no special provision’ was 
made for rheumatic children not less than 60 per 
cent. of them developed organic heart disease, and 
any scheme aiming at the prevention of heart disease 
must provide for the ascertainment of rheumatic 
children at an early stage. Probably not more than 
10 per cent. of cases under supervision would require 
hospitalisation at any one time, but supervision of 
all rheumatic children should be maintained at 
intervals of three months for the whole of school life. 
Control of the disease was largely a question of 
ensuring a correct régime of rest, sleep, diet, and 
clothing. In selecting suitable cases for hospital, 
and in assessing the activity of the rheumatic process, 
estimation of the sedimentation-rate of the red cells 
was of great value. Summarising the results obtained 
in the treatment of 598 cases in a special hospital in 
Cardiff between April, 1929, and June, 1934, Dr. 
McSweeney said that of 492 children admitted with 
early carditis 376 had normal hearts on discharge 
after an average of 10-12 weeks’ treatment. The 
relapse-rate was also less in children who had had 
hospital treatment. 


Dr. W. R. F. Corris said that the attitude of the 
average clinical teacher towards rheumatic fever was 
apt to be depressing, but Dr. McSweeney’s results 
with cases detected early were exceedingly promising. 
He deprecated incomplete removal of tonsils, which 
did more harm than good to rheumatic children.— 
Dr. KERRY REDDIN complained that little interest 
was evinced by the children’s hospitals in rheumatic 
children.—Dr. R. E. STEEN described juvenile 
rheumatism as a disease of malnutrition and faulty 
hygiene, and said that adequate rest was impossible 
in the patients own home.—Dr. DOROTHY PRICE 
held that rheumatic children could not be properly 
handled in an out-patient department.—Dr. T. T. 
O’ FARRELL thought the problem was one for parents, 
school teachers, and public health authorities rather 
than clinicians.—Dr. E. HARVEY emphasised the need 
for research into causation.—The PRESIDENT said the 
detection of 30 rheumatic cases a week in the course 
of school medical inspection in his area showed how 
serious was this problem in Dublin. Specific pro- 
vision was necessary for these cases. 


Dr. McSwEENEY, in reply, said that absolute rest 
in bed constituted 95 per cent. of the treatment of 
juvenile rheumatism. Severe cases of chorea become 
quickly quiescent with no other treatment than abso- 
lute immobilisation. A pulse-rate persistently over 90 
during sleep in a rheumatic child was suggestive of 
activity. Relapses sometimes occurred during hospital 
treatment, but were uncommon. 


THE LANCET] 


[marcu 21, 1936 667 


REVIEWS AND NOTICES OF BOOKS 


La tuberculose. ostéo-articulaire 


Hvolution—Diagnostic de début et Traitement. 
By Dr. Jacques Catv&é (de Berck), with the 
collaboration of M. GaAaLLtanp and M. MOZER. 
Paris: Masson et Cie. 1935. Pp. 208. Fr.50. 


TUBERCULOSIS in any partof the body generally 
calls for prolonged treatment and even more pro- 
longed observation of the patient after discharge 
from hospital; and this is particularly true when 
bones and joints are involved. It is therefore to be 
expected that the best teaching on the treatment 
of tuberculous joints should come from surgeons who 
have had many years’ experience in a hospital chiefly 
devoted to the treatment of these conditions. 
Dr. Jacques Calvé and his splendid hospital at Berck 
enjoy a reputation extending far beyond the 
borders of France; this work is therefore sure 
of an international welcome. It is written for 
those who are already familiar with the ordinary 
manifestations of tuberculous joint disease; the 
absence of text-book descriptions is a refreshing 
feature in a book which gives an informal presentation 
of the author’s views on the whole subject, with 
special reference to the three most common sites of 
infection—the spine, the hip, and the knee. The 
views of other workers are discussed with frankness 
and keen insight and in a generous spirit. 

The old-fashioned ‘‘surgical”? conception of @ 
tuberculous joint is shown to be wrong. It is not 
the case of a tuberculous joint occurring in an other- 
wise healthy individual, but of a tuberculous patient 
who happens to have a focus of disease in a joint. 
Adequate general treatment is the first essential. 
Under favourable conditions the lesion runs its 
course with a regularity not unlike that found in 
soarlet fever or pneumonia, the difference being that 
the process is very much slower. There is a stage 
of invasion; then a long battle between the local 
disease and the body’s defences, marked by attack 
and retreat on one side or the other; in the end the 
victory generally falls to the patient and repair 
begins. The profession in this country now recognises 
that so-called conservative measures are the most 
important feature in the successful treatment of 
tuberculous joints; yet there is still an impression 
that these measures have merely been tried empirically 
and found to be good. Calvé shows why conservative 
treatment is rational and therefore correct. In the 
absence of a specific remedy of proven value, the 
surgeon serves his patient best by placing him in 
a suitable environment and putting the damaged 
joint completely at rest until the lesion becomes 
quiescent. At this stage operative fixation is often 
of value in stabilising a joint that has been dis- 
organised by disease. There is also an indication for 
early operation—i.e., when an early tuberculous 
focus appears in the neighbourhood of a joint. Prompt 
eradication of the focus may save the joint from 
involvement. But, generally speaking, operative 
treatment is no more than an occasional accessory. 

On one major point we are inclined to disagree with 
Dr. Calvé. He does not advocate exploratory 
arthrotomy in early cases undertaken to settle the 
diagnosis. In the knee, at any rate, this simple and 
safe operation will often give the correct diagnosis 
when the test of function leaves the surgeon in doubt. 
Biopsy is not infallible but it is the most certain 
means of diagnosis at present known in doubtful 
cases of arthritis of the knee and ankle. 


The early arthrodesis of every tubereulous joint, 
as advocated by Hibbs, makes an immediate appeal 
to everyone familiar with the laborious technique 
and the constant attention to detail demanded 
by the conservative régime, and there is a tendency 
for some surgeons to accept Hibbs’s teaching without 
weighing the possible cons against the alluring pros. 
The older orthopedic surgeons in this country have 
learned their lesson, though little has been said by 
them in the literature. Junior men, impatient of 
conservatism, should read Calvé’s splendid discussion 
of this problem; it will cause them to make haste 
slowly. 

There are few things in this delightful book that 
call for adverse comment. The section on differential 
diagnosis is too short to be of much value and is 
probably ‘unnecessary ; and there is no excuse for 
printing X rays of the spine upside down—see pp. a 8 
(Fig. 24—right) and 81. 


Post Mortems and Morbid Anatomy 


Third edition. By THEODORE SHENNAN, M.D., 
F.R.C.S. Edin., Professor of Pathology in the 
University of Aberdeen. London: Edward 
Arnold and Co. 1935. Pp. 716. 30s. 


THis book has long been the standard work in 
English devoted solely to post-mortem technique 
and morbid appearances. It is essentially a practical 
work and gives the reader precise and helpful informa- 
tion obviously based on the author’s own extensive 
experience ; innumerable hints on minor points which 
may seem obvious to the morbid anatomist will 
be of considerable help to the student. For the 
most part the book is limited to pure morbid anatomy, 
but morbid histology and general pathology have 
been included where they are necessary for a proper 
appreciation or interpretation of the post-mortem 
findings. This is particularly true of the section on 
renal disease in which the author has not hesitated 
to include even the clinical picture. 

The new edition retains the general style and lay-out 
of its predecessors and is arranged as far as possible 
in the order in which the organs are examined accord- 
ing to the author’s technique. A number of sections 
have been rewritten, in particular those on endo- 
carditis, tubercle, and splenic and renal disease. There 
have also been several lesser alterations, and new 
illustrations have been added. The section on disease 
of the coronary arteries might well have been enlarged, 
particularly the part describing the appearances of 
old and recent thromboses. There is a minor 
printer’s error on p. 438. | 

The new edition, like its predecessors, will certainly 
prove useful if not indispensable to anyone called 
upon to perform post-mortems. 


Human Pathology 


Fourth edition. By Howard T. KARSNER, M.D., 
Professor of Pathology, Western Reserve University, 
Cleveland, Ohio. London: J. B. Lippincott 
Company. 1935. Pp. 1013. 45s. 


THE major alterations in this edition have been 
made in the chapters on tumours, the hemopoietic 
system, the endocrine diseases, and the central nervous 
system. Apart from these, a number of lesser changes 
appear in the text. and all the important advances 


668 THE LANCET] 


made since the last edition appeared in 1931 are 
noticed. The new material has been carefully sifted 
and nothing included which is not likely to find 
general acceptanée. The section on the anæmias 
is unduly brief and in discussing tubercle insuflicient 
stress is laid on the importance of primary infection. 
The lists of references also call for criticism in a 
text-book designed for students. They are very 
long and unusually complete, but no undergraduate 
could judge of the relative importance of the papers 
mentioned without some help. 

The book as a whole is remarkably complete without 
being unduly large and the teaching is sound. The 
photographs and drawings are well chosen and 
reproduced. 


Infant Behaviour, Genesis and Growth 


By ARNOLD GESELL, Ph.D., M.D., Sc.D., Director 
of the Clinic of Child Development and Professor 
of Child Hygiene in Yale University ; and HELEN 
THOMPSON, Ph.D., Research Associate in Biometry, 
the Yale Clinic of Child Development. London: 
McGraw Hill Publishing Company, Ltd. Pp. 343. 
18s. 


Dr. Gesell is known for his comprehensive objective 
studies of infant behaviour. The present volume is 
based upon his earlier work; it deals with genetic 
interpretations and methods of investigation, both 
by cinematographic observation and actual daily 
tests upon the growing infant. There is scarcely 
a muscular movement of the human infant from 
birth to the second year which has not been carefully 
_ studied from day to day in order to investigate growth 
in codrdination and the emergence of intelligent 
social behaviour. The book contains a series of 
graded estimates of the child’s ability to carry out 
simple operations. Each test situation has been 
studied with the energy of Hercules. 

No student of infancy can be without this important 
book. It should be of value to all those who are 
interested in the academic study of infant behaviour 
and also and particularly to those who find it so 
dificult to decide whether mental retardation has 
appeared in the early months of life. We must 
congratulate the authors in having produced in such 
an excellent form the results of their far-reaching 
researches, 


` An Index of Differential Diagnosis of Main 
Symptoms 


Fifth edition. By Various Writers. Edited by 
HERBERT FRENCH, C.V.O., C.B.E., M.D. Oxon., 
F.R.C.P. Lond., Consulting Physician to Guy’s 
Hospital; late Physician to H.M. Wousehold. 
Bristol: John Wright and Sons Ltd.; London: 
Simpkin Marshall Ltd. 1936. Pp. 1145. 63s. 


Tur new edition of this important book reflects 
great credit on Dr. French and his 18 collaborators. 
Two new authors, Dr. Bruce Perry and Mr. W. H. 
Ogilvie take the places of the late Dr. Carey Coombs 
and Mr. R. P. Rowlands. Dr. Perry has contributed 
articles on angina pectoris, cardiac bruits, and irregular 
pulse ; Mr. Ogilvie on club-foot, spinal curvature, and 
inguinal swellings. Descriptions of new diagnostic 
tests of proved reliability, such as the Aschheim- 
Zondek, have been introduced and this new edition 
attempts as before to cover the whole diagnostic 
field of general medicine, surgery, gynecology, 
dermatology, neurology, and ophthalmology. Certain 


KEVIEWS AND NOTICES OF BOOKS 


[mance 21, 1936 


diseases which have recently become less unfamiliar, 
such as botulism, abortus fever, Pink disease, and 
tularemia, receive attention. The statement, already 
inaccurate, that the organism of psittacosis is unknown, 
shows how difficult it is to keep a work of this size 
up to date. Dr. Hurst’s otherwise admirable article 
on constipation, which should be read alike by doctor 
and medically minded layman, offers certain points: 
in the differential diagnosis between acute constipation 
and acute intestinal obstruction, which may not be 
universally acceptable. He states that “visible 
and palpable peristalsis is never present except in 
obstruction,” whereas, in fact, it is often to be 
observed in healthy persons of lean habit. He says, 
moreover, that vomiting is never feculent in non- 
obstructive cases except “at a very late stage,” 
but is not this equally true of obstructive cases f 


No experienced clinician would wait for fecal vomiting . 


before diagnosing acute intestinal obstruction. On 
the other hand, Dr. Hurst wisely emphasises the 
importance of early diagnosis of absolute constipa- 
tion, if necessary, by giving two enemata at short 
intervals. 

Dr. French, not only the editor but also the most 
prolific writer of the book, has himself supplied 
nearly 150 articles on a great variety of subjects. 
There are many excellent photographs and coloured 
plates, those of the fundus oculi illustrating Mr. H. L. 
Eason’s notes on ophthalmoscopic appearances being 
worthy of special mention. 


From a Colonial Governor’s Notebook 


By Sir REGNAaLD St.-JoHnston, K.C.M.G. 
London: Hutchinson and Co. (Publishers), Ltd. 
1936. Pp. 285. 12s. 6d. 


Sir Reginald St.-Johnston, barrister, doctor, and 
administrator, has in this book recounted certain 
of the experiences undergone, and for the most part 
enjoyed, during 30 years in the Colonial Service. 
The book does not attempt to be a chronological 
record of the author’s life in the Colonies, but is, as 
he says himself, ‘“ a series of odds and ends taken from 
my notebooks during the time I was administrating 
the government of several colonies or dependencies.” 
After qualifying in medicine and being called to 
the Bar from the Middle Temple, Sir Reginald joined 
the Colonial Service, and for a period held various 
judicial and administrative appointments in Fiji. 
The war intervened, and he saw service abroad and 
subsequently was attached to the War Oflice for 
special duty. In 1920 he was appointed acting 
governor of the Falkland Islands and later, in 
succession, colonial secretary to the Leeward Islands, 
administrator of St. Kitt’s and Nevis, and governor 
of the Leeward Islands, from which post he recently 
retired. 

In describing the official and social duties and 
responsibilities which fell upon him in the various 
important posts, the author produces an eminently 
readable book. Previous works from his pen have 
led us to expect him to display an eye for coloured 
environment, dramatic instinct, and a faculty of 
fluent narrative; here the many entertaining stories 
which he tells show intimate acquaintance with all 
aspects of life in the West Indies, in high official 
circles, and in the lowliest native life. The book 
abounds with thumbnail sketches of well-known 
personalities and picturesque descriptions of places, 


“with notes on the natural history and the climatic 


conditions. 


THE LANCET] ON 


FEELING SECURE 


[marcH 21, 1936 669 


THE LANCET 


LONDON: SATURDAY, MARCH 21, 1936 


ON FEELING SECURE 


Tue issue of the crisis through which we have 
been passing this week will be mainly determined 
by the workings of the group mind. It may be 
well to consider how far the national and inter- 
national reactions of the moment which perplex 
the politician may resemble the individual reactions 
observed by the psychiatrist and becoming increas- 
ingly familiar to the medical profession as a whole. 
In times of crisis everyone is deeply concerned 
with the question of security, and seeks by all 
‘possible means to regain the state of calm. Calm, 
both in the individual and in society, is usually 
regarded as the normal state and crisis as a dis- 
turbance coming from without. A little reflection 
leads to a different conclusion, for most people 
and most communities are far less stable than they 
imagine themselves to be. When we are at peace, 
we dread more than anything the pain of examining 
our instability ; only in time of crisis do we feel 
impelled to “ get something done.” The tendency 
to avoid facing something that is dreaded is 
familiar to every member of the profession but is 
the special study of the clinical psychologists. 
They distinguish two types of fear, objective and 
subjective, according to whether the source of 
apprehension is known to the victim or not. A 
good instance of the latter is fear of the dark: a 
person attributes (“ projects” is the technical 
term) to his environment terrifying impulses 
which exist within his own mind without his 
being aware of them; he is afraid unless he can 
have the assurance of his senses that his surround- 
ings are not harmful. The same process of projec- 
tion is at work when a person (or a nation) suddenly 
selects a particular enemy and attributes his 
troubles to that enemy. A patient who feels that 
he is encircled by enemies is a difficult case to 
handle. By attributing aggression to others he 
can regard himself as an exceptionally pacific 
person, but his own aggressive attitude may 
rouse such fear in others that they adopt counter- 
measures—and then his delusion is, of course, 
turned into reality. This much is old knowledge ; 
more recent researches throw some light on the 
causes of another type of mentality. There are 
people who “revel in danger.” When others are 


with good grounds afraid, they feel calm and to 
their surprise are strangely at ease with them- 
selves ; prolonged peace (they call it “inaction ”’) 
leads to uneasiness, they suffer from “ peace- 
neurosis” which is “ cured” by war. Investiga- 
tion shows that danger is welcomed because, when 
the source of mental tension is external as 
in war, the mind is relieved of an internal 
strain—that of dealing with its own aggressive 
tendencies. 


The nucleus of the whole problem lies in the 
mode of dealing with aggressive impulses. If 
these are coupled with a pleasure in constructive 
activities, the result is productive work; an 
example of this may be seen in the gigantic under- 
takings in Russia to-day. If the individual cannot 
find satisfaction in constructive activity, for 
instance if he is unemployed or is put to an uncon- 
genial occupation, the necessary condition for the 
binding of the aggressive impulse to cultural ends 
is lacking, and there is risk of a breakdown of 
social relations. ‘The political analogy is revolu- 
tion, if the aggression is kept within the frontiers, 
or war if the aggression is projected outwards. 
This is the reason why in the case of an individual 
faced with an impending crisis it is so important 
that his energies should to the last moment be 
given a constructive outlet. Perhaps the same 
applies to nations. Recent investigations into the 
psychological problems of neurotic breakdown 
and of criminality have disclosed a surprising 
fact—viz., that the projection of aggression out- 
wards is not simply to preserve the illusion that 
the subject is a thoroughly peaceable person ; it 
also serves in the mind of the subject an uncon- 
scious purpose of preserving a loved object or 
ideal from hostile attack. This is a complicated 


concept, but it has the support of the clinical 


observation that the most effective way of main- 
taining contact with an aggressive or deluded 
patient is to show an understanding of his ideals 
and hidden aspirations and a realisation that 
behind the barrage of his attacks there is also a 
wish for good relations. An appreciation of his 
constructive contributions to society, however 
slight in fact these may be, goes some way to 
strengthen the forces of cohesion and pacification 


‘within the personality. But such measures may 


fail, and a resort to force may be necessary. Here 
clinical experience again helps us; the return to 
sanity is hastened if the patient is not treated as 
an outcast. The day when the insane were 
loaded with chains is over; nowadays contact 
is not lost even though the patient is forcibly 
restrained. 


In a world where unrest and danger abound it 
sounds a mockery to speak of feeling secure, but 
a step in that direction is taken when we can 
recognise our own aggressive impulses and not 
blindly project them on to others; we then sce 
our neighbours more clearly and do not confuse 
their intentions with our own, our own with 
theirs. Objectivity does not give security, but 
it enables the darkness to be faced without morbid 
dread. 


THE LANCET] 


670 


ACUTE ASEPTIC MENINGITIS 


< 


RECENT work suggests that the “acute aseptic 
meningitis” of WALLGREN and of GUNTHER is a 
true clinical entity, and that its cause is a virus 
isolated by ARMSTRONG. The disease has come into 
prominence during the last few years, partly because 
it is mildly epidemic and seems to be getting 
commoner, and partly because of its importance 
in the differential diagnosis of tuberculous menin- 
gitis. By the bedside it is often impossible to 
distinguish these two conditions ; yet in one the 
prognosis is excellent, in the other almost hopeless, 
Since the description of this new disease physicians 
have come to recognise that every patient with 
supposed “tuberculous meningitis ” has a possible 
chance of complete recovery, so long as the chloride 
content of the cerebro-spinal fluid remains above 
650 mg. per 100 c.cm., and tubercle bacilli have 
not been demonstrated. This chance is small, but 
it does nevertheless exist, and no wise practi- 
tioner would willingly conceal it from anxious 
relatives. 

The nomenclature of the whole subject is con- 
fusing. Many diseases of the nervous system show 
a lymphocytic meningeal reaction (e.g., tuber- 
culous and syphilitic meningitis, poliomyelitis, 
encephalitis lethargica, herpes zoster, and the 
encephalomyelitis of acute exanthemata) ; so that 
the recognition of lymphocytes in the cerebro- 
spina] fluid does not carry us very far. In making 
a diagnosis of acute aseptic meningitis the follow- 
ing points will be found of value. The patient 
may be a child or an adult, and the onset is acute, 
sometimes preceded by a sore-throat. Severe head- 
ache is usually the first symptom and this is soon 
followed by other evidence of meningeal irritation 
or of increased intracranial pressure : stiffness and 
pain in the neck, back, abdomen, or limbs; 
vomiting; photophobia ; restlessness and insomnia. 
Drowsiness, delirium, or stupor are rare; and 
convulsions uncommon except in infants. Pyrexia 
is usual; it is often mild, but may perhaps be 
high at the onset. Constipation or retention of 
urine may sometimes cause trouble. 
stages examination reveals little apart from the 
usual signs of meningeal irritation, the patient 
lying on one side complaining of severe headache 
and refusing to be disturbed. Children may 
appear very ill indeed, and when they are brought 
to hospital their parents often believe them to be 
dying. In infants the anterior fontanelle may 
bulge. Gross papilloedema, pupillary changes, and 
cranial nerve palsies do not often develop. Kernig’s 
and Brudzinski’s signs are usually positive. 
Early pyramidal signs in the arms, trunk, or legs 
may perhaps be found, but these are not con- 
spicuous. Lumbar puncture reveals a cerebro- 
spinal fluid under increased pressure, clear or 
slightly cloudy, rarely forming a thin clot on 
standing. Its cells are increased, usually numbering 
about 100-300, but sometimes as few as 50 and 
sometimes as many as 3000. At the onset these 


ACUTE ASEPTIC MENINGITIS.—ROYAL MEDICAL BENEVOLENT FUND 


In the carly, 


$ 
| 


[MARCH 21, 1936 


cells may be almost entirely polymorphonuclears ; 
in the course of a few days they are replaced by 
lymphocytes, and by the end of a week there 
may be lymphocytes alone. Cultures are sterile ; 
no organisms can be seen in stained films, and 
guinea-pig inoculations give no result. The 
prognosis is excellent. For a while pyrexia may 
be continuous or remittent, but between the 
fourth and fourteenth days the temperature usually 
falls by lysis. Recovery is then rapid and most 
patients are able to leave their beds in the third 
or fourth weck of the disease. 

In 1934 ARMSTRONG and LuLmw isolated a new 
filtrable virus, which caused a lymphocytic 
meningitis in monkeys and mice. They suggested 
that acute aseptic meningitis was the disease, 
in man, which most closely resembled that pro- 
duced experimentally in animals by their virus, 
and soon it was found that convalescent serum 
from patients who had had this particular disease 
protected monkeys and mice from the effects of 
the virus. In other laboratories similar strains of 
virus were isolated, both from patients and from 
mice, and ARMSTRONG was able to prove that these 
different types were pathologically and immuno- 
Jogically identical. All this work was done in 
America, but its continuation in this country is 
recorded in our present issue where Drs. FINDLAY, 
ALCOCK, and STERN report the isolation of viruses, 
resembling ARMSTRONG’s, from two cases of 
lymphocytic meningitis of obscure clinical type. 
The blood-serum of both patients contained 
antibodies which protected animals, not only 
against these two viruses, but also against the 
American strain and against one found in appar- 
ently healthy English mice. In brief, it seems 
justifiable from the evidence now before us to 
conclude that there is a virus living in some 
strains of healthy mice, on both sides of the 
Atlantic, which is capable of producing severe 
neurological disease in other mice, in monkeys, 
guinea-pigs, and rats; and that this virus can be 
isolated from the cerebro-spinal fluid of human 
patients suffering not only from the well-recognised 
clinical entity ‘‘acute aseptic meningitis,” but 
also from another, more obscure, pyrexial nervous 
disease, This relation of human illness to virus 
infection in mice will not escape notice and may 
prove important. At least we may be sure that the 
work so far done will be the basis of much 
further study of the nervous diseases of virus 
etiology. 


ROYAL MEDICAL BENEVOLENT FUND 


THE annual meeting of the Royal Medical 
Benevolent Fund, to be held on Tuesday next, is a 
centenary occasion, and its significance should not 
be lost on us. The Fund represents an organised 
attempt carried on through 100 years to minister 
to the needs of the less fortunate of the medical 
profession through the subscriptions and donations 
of members of their own calling who are better 
endowed with worldly possessions. That sounds 
fine, but as we have had occasion to remark almost 
annually, the circumstances are not such as to 


THE LANCET] 


afford reason for much complacency. For although 
the Fund has had a long life, and although the 
energy of the authorities of the Fund has been 
unremitting and excellently directed, the response 
of the medical profession has not been propor- 
tional; it does not point to a recognition of a 
general responsibility among us towards our more 
needy brethren, although the evidence of those 
needs is convincing and.tragic. 


Now, on a more cheerful note. There will 
have been observed by all who consider the well- 
being of the whole profession—which ought to 
mean every man and woman whose name is on 
the Medical Register—that the Fund has lately 
taken a greater hold on the attention of practi- 
tioners. For the last three years, when reviewing 
the annual report, we have been able to announce 
a stronger condition of the Fund and the report 
for the year ending Dec. 3lst, 1934, showed real 
progress in an increase of income, an increase 
in the number of annual subscribers, and an 
increase in small donations to the special Christmas 
Fund. Annual progress of this sort is highly 
satisfactory, and will have given great encourage- 
ment to the authorities of the Fund ; none the less 
if the progress were maintained at the same rate 
it would still take some 50 years before the 
aggregate benevolence of the medical profession 
towards its less fortunate members would reach the 
annual sum needed to deal with the sad cases 
which come before the Fund for assistance. The 
stories published by the committee of the Fund 
from time to time in the columns of the British 
Medical Journal and The Lancet show that there 
exist among us a number of practitioners who 
in their old age, through broken health or ill 
fortune, find themselves in the saddest of circum- 
stances with no one to whom they can appeal for 
help. The Fund also extends help to widows 
of medical men and daughters who in later years 
find themselves without means of support, and 
these cases are among the most poignant. Further 
the grants are not made on any surface aspect 
of the requests for help ; all cases are investigated 
carefully to ensure they represent genuine distress 
before a grant is made, and anxious care is taken 

that the necessary precautions against abuse should 

be conducted with sympathy and delicacy— 
not an easy task but one that is rendered easier 
because undertaken by persons with full knowledge. 
Annuities are given only in the circumstances where 
there is no possibility of affairs mending, and 
the highest annuity which can be given at present 
is £40 per annum, which often docs not meet the 
real scriousness of the position. But the deep 
gratitude expressed by the beneficiaries, not only 
for such substantial support but also for the slight 
augmentations received from the sharing up of the 
Christmas Fund and the material donations from the 
associated Guild, combine to prove the status of 
deep poverty on which many of our brethren are 
compelled to exist. 

The centenary occasion affords a poignant 
opportunity for the setting right of this position, 
and it is to be sincerely hoped that the whole 


TREATMENT BY PROLONGED NARCOSIS 


[maron 21, 1936 671 


profession may recognise this and rally to 
the support of the Fund. Next Tuesday comes 
the statutory annual meeting, but there will be 
in April a general appeal to the profession 
setting out the claims of the Fund to larger 
and more general response. The appeal will have 
behind it the long history of a charity greatly 
needed and admirably administered. None should 
fail to see its force, and, incidentally, no one 
need delay until April before giving support. 


TREATMENT BY PROLONGED NARCOSIS > 


THE psychiatric use of prolonged narcosis has 
lately had a wider vogue in this country because 
of the Cardiff work on insulin as a protective 
against poisoning by the narcotics employed. 
Dr. PARFITT’S paper in our issue of Feb. 22nd 
must be read, however, as a warning against too 
easy confidence in such precautions. His series 
of carefully treated patients showed alarming 
toxic symptoms, which were as common in those 
who received insulin as in those who had only 
glucose in addition to the narcotic somnifen, and 
3 of his 56 patients died. So risky a method of 
treatment is plainly unsuitable for general appli- 
cation, unless the advantages can be clearly 
demonstrated. 


The situation is in some respects parallel to 
that arising when malaria was introduced into 
the treatment of general paralysis. Widely dif- 
ferent in efficacy, the two methods have this in 
common, that there is no precaution, no routine 
procedure in their administration which can take 
the place of special experience in their use, or 
good clinical judgment in selecting cases and super- 
vising the course of the therapy. This may well 
be seen in the various publications from Burghdlzli, 
the clinic in which the method was first employed 
by Krarsı. In the first year, 1920, three patients 
died. From then till 1927, when OBERHOLSER 
published the experience of the clinic, there was 
not a single death among the large number of 
cases treated. Variations in the technique were 
tried, and in 1929 all oral ingestion was stopped 
during the 10-14 days of the treatment; fluids 
being given by the rectum instead. Dial, Luminal, 
and other narcotics were urged besides somnifen, 
and Lutz reported the rather satisfactory results. 
Then, in 1930 a mixture suggested by CLOETTA, 
who had been responsible for the original proposal 
to Karst in 1920, was introduced, and the out- 
come has been gratifying.’ The precautions taken 
by the very experienced physicians and nurses of 
the hospital have been exceptionally detailed ; 
to read of the many points to which they have 
learnt to direct their attention is to recognise the 
need for expert handling of the method if its 
risks are to be minimised and its best effects 
secured. Yet even in these accomplished hands 
there have been mishaps. Of 125 narcoses, carried 
out on 84 schizophrenic patients between 1930 
and 1934, two ended fatally, and others caused 
much concern. 


> Cloetta, M., and Maier, H. W.: Zeits. f. d. ges. Neurol. u. 
Psych., 1934, cl., 146. 


672 THE LANCET] 


In appraising these results, however, it must be 
borne in mind that the method was more thorough 
and drastic than that usually employed in England. 
In a mitigated form, continuous narcosis can in 
careful hands be employed extensively and safely. 
Dr. P. K. McCowan, who states that at Cardiff 
City Mental Hospital it is rarely found necessary 
to give more than 4'0 c.cm. in the 24 hours, reports 
in our issue of Feb. 29th (p. 508) that 154 cases 
have been treated without a single fatality, and 
in an English psychiatric clinic it has been much 
and profitably used for eight years, likewise with- 
out a death. The value of the method can best 
be estimated by noting the number of hours of 


THE PORTAL OF MEDICINE 


[maRcH 21, 1936 


sleep obtained with the drugs over a fixed period, 
and the outcome in adequate numbers of patients 
with particular varieties of mental illness and of 
well-investigated prognosis. The recent paper of 
MonntieR,? also from Burghélzli, is excellent in 
this regard, as also for the discussion of pre- 
cautions, mechanism of improvement, and course 
of the narcosis. It might with some reason be 
urged that no one should undertake this some- 
times dangerous method of treatment, with or 
without insulin, until he had familiarised himself 
with the exceptional knowledge of the physicians 
at Burghdlzli, available in their publications. 


3 Monnier, M.: Nervenarzt, November, 1935. 


ANNOTATIONS 


THE PORTAL OF MEDICINE 


TuE three volumes! sent us at this time of year 
by the Registrar of the General Medical Council 
always contain food for thought. Last year we 
remarked that the number of new qualifications 
had risen steadily since 1929 and was 40 per cent. 
above the entry which seemed to mect requirements 
in pre-war days. The figure was then 1664. It is 
now 1884; and since there is also an increase in the 
number of medical students registered—last year 
2350, this year 2603—on which turns the number of 
qualifications after a 5-6 year interval, evidently the 
engorgement of the medical profession is continuing 
and indeed increasing. In May last as we anticipated 
the position was considered by the General Medical 
Council, when Sir Norman Walker recited the figures 
and commented upon them. ‘I recall,’ he said, 
‘our past experience that, when trade is bad, entries 
of medical students go up, and vice versa. There are 
schools which are conscious of the fact that their 
equipment and staff are being severely strained, 
and that they must consider limitation of entry. 
But there is a general feeling of hope in the air to-day, 
and perhaps the severe limitations under considera- 
tion in some 


places may not be 3500 
necessary. There l 
will not, I feel 


sure, be any ten- 
dency to lower the 
standard of entry 
even if numbers 
do go down a 
little.” But if the 
analogy from past 
experience still 
held, there should 
have been a 
diminution in the 
number of stu- 
dents entering last 
year, at all events 
in the latter half, 
for by that time 
the trough of trade 


5,000 
2.500 


2,000 MEDICAL 


ae UOENTS | 
| 500} 


wl AN 


1.000 PRACTITIONERS 


1 The Medical Reg- 


ete SE 


depression was already a year or more in the past. 
It may be that the lag is longer than this and that 
the prospect of better commercial openings may only 
now be beginning to divert school-leavers away from 
medicine. It is clear enough that the suggested 
limitations of entry to medical schools cannot generally 
have been put into force, although everywhere 
the raised standard has been maintained. 

In one respect the entry is still abnormal. For 
several years past the number of medical students 
gaining access to the students’ register by virtue 
of study abroad has been well over a hundred, 
the influx being preponderatingly from German 
universities. In 1935 111 of the 122 names so 
registered implied German origin and, with slight 
exception, they are the names of men and women— 
for many of them are women—who began their 
medical study ten, twenty, or even more years ago, 
and may be presumed to have already practised 
medicine in the country of their origin. Very few 
continental refugees, if the students’ list can be taken 
as a guide, are studying medicine from the outset 
at English or Scottish schools. The influx of 
unfortunate refugee practitioners seeking registration 
here can hardly continue long. Many who resent 
or fear their com- 
petition in medical 
practice might 
have less reason 
to object to a 
foreign element in 
dental study 
where the number 


T of entries, though 


rising, is still quite 
insufficient to 
cover the death 
or retirement of 
the immense 
group of middle- 
aged dentists 
admitted under 
the Dentists Act 
of 1921. The 
increment of 14 
dental students in 
1935 is entirely 


ister for 1936 (21s.); DENTAL covered by the 24 
the Medicaland Denta `o $ who came from 
Students Register for 500 ; EN: -0 G T 
1935 (78. 6d.); the STUDENTS 0: 4 hoe „o? i À ermany. urn- 
Dentists Register for "o-0-0-070 0-0" o Be x 2070920 ne ing to the addi- 
lished onthe Ay pu osorno" oS : D : ` ee rs : tions to the 
ished ror e encra y , 

Medical Council ay PRACTITIONERS Medical Register 
rea ees re i900 1905 1910 1915 1920 1925 1930 1935 itself it may be 


THE LANCET] 


noted that there is an increase in every section ; 
the surplus of 220 over last year’s increase is 
made up of registrations in England 124, 
Scotland 38, Ireland 23, Colonial 23, Foreign 12. 
It is many years since as many as 19 names have been 
added in a*single year to the Foreign section of the 
Register ; they are all admitted on Italian qualifica- 
tions although in only 6 cases has the name an 
Italian sound. 


This and much more of the trend of medical polity 
can be gleaned from these three volumes which 
contain, as always, that recital of the Medical and 
Dentists Acts which should be studied as closely 
by those within the profession as they are by those 
without. The graphic picture has been again brought 
up to date and may spare a number of words in 
setting out the situation. 


PHYSICAL MANIFESTATIONS OF EMOTION 


THF changes in the body which accompany 
emotion have not- yet been fully explored. The 
cruder manifestations of anger and fear, which all 
may witness and experience, were illuminated by the 
researches of W. B. Cannon and the part played by 
the vegetative nervous system and the suprarenals 
in producing these familiar outward signs of emotion 
is now established. But it is doubtful whether in 
their daily practice doctors give sufficient regard to 
the physical phenomena that can be laid to the door 
of an emotional disturbance. It would be unjust 
to conclude that this neglect of the psychogenic is 
the outcome of faulty habits of thinking about 
disease or faulty teaching. It is in large measure 
due to the vagueness of these psychosomatic relations, 
the lack of precise information as to the more 
restricted changes which may occur within one or 
other bodily system, and the way in which “‘ emotion ” 
is talked of in the round, whereas it is particular 
emotions, with their specific psychic quality and 
causation, that have clinical significance. As long 
as it seemed that diarrhea, for example, might be a 
manifestation of fear, that constipation might also 
be attributable to this affect, and that either might 
be due to other affects as well, the adequacy of 
simple psychogenic explanations for such a dis- 
order as diarrhea remained suspect. Doubtless 
also the difficulty of distinguishing between the 
common, quasi-universal manifestations of affect 
and the personal individual ones has been a stumbling- 
block. The psychiatrist, however, is continually 
impressed by the frequency with which functional 
and even plain structural changes in the body can 
be traced back to emotional upsets, sometimes 
transient, sometimes lasting. In his concern for 
individual experiences, and psychological causes, 
he may sometimes, indeed, overlook the importance 
of the physiological happenings which are, more or 
‘less inevitably, set going by an affective happening 
to such effect that they become independent of their 
origin and proceed according to their own laws of 
succession. It is clearly profitable for all physicians, 
whether psychiatrists or not, to have at their disposal 
a comprehensive survey of what is known concerning 
the influence of emotions on the functions of the 
various organs of the body. A monograph has 
lately been written by Dr. Erich Wittkower,! which 
covers the literature of the subject and describes 
his own researches, carried on for several years in the 
medical clinic of the Charité in Berlin and latterly 
in the central pathological laboratory at the Maudsley 


1 Jour. of Ment. Sci., 1935, lxxxi., 533. 


PHYSICAL MANIFESTATIONS OF EMOTION 


' and usually terminal stage of the disease. 


[Marcu 21, 1936 673 


Hospital. So diligently has this author studied the 
work of others that his bibliography is gargantuan ; 
and his own investigations have covered a very wide 
field. The respiratory and circulatory systems, 
salivary and biliary secretion, the stomach, the blood, 
the urine, and the thyroid gland are reported 
on in detail, as is also the psychogalvanic reflex. 
Dr. Wittkower indicates the significance of the 
relationships discussed for any interpretation of 
the findings in internal medicine as well as in the 
neuroses ; though in his excursion into the latter field 
he is sometimes guilty of over-simplification of the 
problems. However, the monograph is not designed 
only for psychiatrists; it provides a detailed 
conspectus whereby physicians as a whole may make 
themselves acquainted with the large, though still 
inadequate, body of knowledge embedded in a polyglot 
multitude of publications. 


MYCOSIS FUNGOIDES 


VYING with pemphigus in its malignancy, and 
equally intractable and uncertain in its reactions to 
all forms of treatment, mycosis fungoides, in spite 
of the immense amount of work that has been lavished 
upon it, remains an unsolved problem. Fortunately 
like pemphigus it is an exceedingly rare disease, and 
even the large skin clinics do not see more than one 
or two cases in as many years. It owes its name to 
Alibert, who first described it in 1814, long before 
the term ‘‘ mycosis °” had assumed the significance 
it holds to-day. As far as we know the symptoms 
are not due to a mycotic or fungous infection, and 
the second appellation also is adjectival only, and 
descriptive of the fungating character of the third 
Of the 
published cases 75 per cent. have occurred in men in 
the fourth decade of life, and very few of these have 
survived the fifth. The first or premycotic stage 
may resemble an eczema or psoriasis so closely that 
the most experienced are commonly misled. It may 
last for years with intensely pruritic patches, which 
nothing but X ray treatment will relieve. This 
feature should tend to arouse our suspicions of the 
underlying cause of the symptoms, which may be 
further enlightened by microscopic examination of 
the sections. In the second, or stage of infiltration, 
there is a cushion-like soft elevation of the patches, 
which become rather more sharply outlined, and as 
they spread outwards in a circular or gyrate fashion 
tend to coalesce. In so doing they demarcate or 


-surround residual islets of healthy skin, which are 


thus roughly angular in outline and highly charac- 
teristic in the clinical picture. The third stage is 
that of ulceration of the extending patches of 
infiltration, which often reach the size and conforma- 
tion of tumours. These are always soft and the 
term ‘‘ tomato ”’ describes them with some accuracy. 
They are usually exceedingly sensitive to quite small 
doses of X rays (4-} S.B. dose). Only one or two 
should be treated at a sitting for fear of undesirable 
effects from too rapid absorption of toxic substances. 
Hitherto X rays have been the only reliable weapon 
in treatment, and even these fail eventually in the 
large majority of cases to do more than postpone 
the inevitable exhaustion from ulceration and 
secondary sepsis. As in several other dermatoses 
improvement has sometimes been observed to follow 
pyrexia both accidental and artificially induced, and 
Dr. H. MacCormac now reports a case? in which the 
method of malarial therapy, as for G.P.I., was twice 


! Proc. Roy. Soc. Med., vol. xxix., February, 1936, 
p. 23838. 


674 THE LANCET] 


successful after all other measures had failed. The 
author confidently asserts that “without this treat- 
ment he would have died.” The improvement was 
certainly sustained from May, 1934, when he was 
demonstrated to the dermatological section of the 
Royal Society of Medicine, to the present day. It 
is of course much too soon to claim a cure, but the 
method is accessible nowadays in any large hospital, 
by courtesy of the Ministry of Health, and is well 
worthy of further trial. It may not be out of place 
to remind our readers that most diagnosed cases of 
mycosis fungoides have already been subjected to 
prolonged or frequently repeated X ray treatment, 
as a result of which they may have developed anemia 
and leucopenia of variable degrees. Due considera- 


tion of the differential blood count should therefore 


always precede the malarial inoculation. 


THE TREND OF POPULATION 


In the course of three public lectures lately given 
in the statistical department of University College, 
London, Dr. R. Kuezynski, well known to students 
of vital statistics for his extensive work on popula- 
tion problems, spoke of the past and possible future 
trend of population growth in different parts of the 
world and the close bearing this trend has on the 
economic problems of the day. Over the past century 
and a half he finds that the white population of the 
world has increased at an average rate of nearly 
1 per cent. per annum. This increase has been due 
to the decline in mortality following on advance in 
the standard of living and in the art and science 
of medicine. Such factors have led to nearly a 


doubling of the expectation of life at birth in the. 


countries of western and northern Europe. This 
extension of the average duration of life is, however, 
as is generally recognised, due largely to the vast 
improvement during the twentieth century in the 
infant mortality-rate and in the ages of childhood 
and young adult life. At more advanced ages, 
60 years and over, there has been relatively little 
improvement, as is shown in the new English life 
table on p. 686, and it is possible that we are just as 
incapable of extending life at these ages as were our 
forefathers. Kuczynski takes the view, therefore, 
that future population trends will depend mainly 
upon fertility and not, as in the past, upon changing 
mortality. Whether fecundity—that is, reproductive 
power—has changed in the course of years is a con- 
troversial question. There is no evidence, except 
for France, that fertility in marriage was lower until 
the middle of the nineteenth century than in former 
centuries, and the decline of fertility in recent years 
is in Kuczynski’s opinion almost certainly due to 
the deliberate restriction of births. The best measure 
of the present rate of growth he takes to be the net 
reproduction-rate—the number of future mothers 
derived from present mothers. By that measure all 
countries of western and northern Europe, the 
United States, Australia, and New Zealand are failing 
to reproduce themselves. At present rates in western 
and northern Europe 100 women give birth to only 
76 future mothers. The population of England and 
Wales will probably increase for another seven years 
and then decline, with an increasing proportion of 
persons in the older age-groups. In 1881, persons 
of 60 years or more formed only 7 per cent. of the 
total population; in 1931 they comprised 11 per 
cent.; and by 1981, if the present trend continues, 
they will have risen to 22 per cent. Very little 
improvement in the reproduction-rate could be 
derived from an improvement of the mortality-rate 


THE TREND OF POPULATION 


[marca 21, 1936 


of women in the childbearing ages, or in a higher 
marriage-rate, or in an earlier age of marriage than 
at present. Increased fertility can only be brought 
about, Kuczynski believes, by less birth control. 
Better economic conditions would not necessarily 
achieve this, for fertility began to fall while the 
standard of living in this country was still rising, 
and the economic incentives applied in Italy appear 
to have been a complete failure. It is too early to 
say yet whether action in Germany is likely to be 
effective, but she is relying rather upon the inculca- 
tion of new ideas than upon economic advantages. 
A general desire for more children seems to be the 
only hope of increasing fertility, and it hardly appears 
likely, with the world in its present state of instability, 
that that desire is going to develop. In addition the 
general attitude on questions of population has 
radically changed. Twenty-five years ago the pros- 
pect of a decreasing population in this country would 
have been viewed with alarm ; now, with widespread 
unemployment, we are far more afraid of over- 
population. Whether those fears are justified 
Kuczynski is more than doubtful. Under-population, 
by limiting consumption and economic development, 
may possibly be as powerful a cause of unemploy- 
ment as over-population. It may well appear that 
Mr. Smith the builder is better off by having only 
one child, but he is only better off so long as other 
people have, say, three, and therefore create a demand 
for his services. 

There is no doubt, as Lord Dawson pointed out 
in introducing Dr. Kuczynski, that these problems 
of the growth of peoples are closely linked with all 
the social and economic questions of the day, and 
the lecturer gave his audience much to think about. 


TREATMENT OF PERIPHERAL ARTERIAL 
OBSTRUCTION 


Mrtnops for the passive exercising of blood- 
vessels in a limb which is the site of arterial obstruction, 
for example, contrast baths, have been in use for a 
long time. More recently an apparatus for alternately 
increasing and reducing the air pressure on the limb 
has been used with the same object and strong 
claims have been made in its favour. Some of these 
claims are critically reviewed by E. V. Allen and 
G. E. Brown? who are well known for their work 
on arterial disease. It is admitted that alternate 
pressure and suction (sometimes referred to as 
‘“pavex,’ signifying passive vascular exercise) is 


- able to increase the blood flow in a limb, both when 


normal and when the seat of some vascular obstruc- 
tion, since this procedure causes a definite increase 
in skin temperature, which may last up to 72 hours. 
However, though there is no evidence that the blood 
flow can be increased permanently by this means, 
a transient increase repeated frequently might be 
expected to relieve symptoms. Published reports 
indeed suggest that with this treatment indolent 
ulcers may heal, rest pain may be relieved for variable 
periods, intermittent claudication is usually benefited, 
while gangrene can be avoided in cases of sudden 
arterial occlusion if the treatment is begun early 
enough. Irom their experience of 60 cases the 
authors are able to confirm these results only in 
part; they found more benefit in the pain of ischzemic 
neuritis than in the pain accompanying trophic 
lesions, while in one case of sudden arterial occlusion 
gangrene developed in spite of treatment begun 
within a few hours; the pain was, however, relieved. 
In intermittent claudication no improvement was 


1 Jour. Amer. Med. Assoc., 1935, cv., 2029. 


ree £4 Ne 
ee 


THE LANCET] 


noted. The conclusion drawn from the total results 
is that though passive vascular exercise has its uses 
in arterial disease it has yet to be shown that its 
value, except perhaps in ischemic neuritis, is greater 
than that of other conservative measures. It may 
also be a suitable method in older patients for whom 
protein shock and sympathectomy might be considered 
inadvisable. 


CHANGES IN THE BREAST DURING THE 
MENSTRUAL CYCLE 


Dr. Howard C. Taylor,! of New York, has made a 
serious effort to determine how far the clinical changes 
in the breast associated with menstruation are related 
to histological changes. The views hitherto expressed 
are notoriously conflicting, some observers having 
reported what almost amounts to a complete recon- 
struction of the glandular elements of the breast 
with each menstrual period and their disappearance 
in the intervals, while others deny the evidence for 
epithelial proliferation and retrogression. It may be 
recalled that three years ago in our own columns 
Dr. Helen Ingleby? described cyclical histological 
changes as occurring, not only in normal breast 
tissue, but in tumours of the breast. Thus she 
regarded fibro-adenomata as owing their development 
to local interference with the normal process of inter- 
menstrual involution. Cystic mastitis was in her 
view the result of irregularity in the cyclical changes 
in the breast, while the variations in histological 
appearances of carcinoma depended on the degree 
to which the cells of the lobules had undergone a 
malignant change whereby they lost their power of 
postmenstrual involution. 

The difliculty of obtaining normal material is at 
once evident—particularly material from cases in 
which a reliable menstrual history is available. 
Taylor makes his observations on tissues from four 
sources: (l) apparently normal parts of breasts of 
41 patients operated on for disease processes in other 
parts; (2) breasts, or parts of breasts, removed 
because of pain at the periods; (3) a few hyper- 
trophied breasts which were available for histological 
study; and (4) gross sections and histological 
examinations made in a few cases of secretion from 
the nipple. Iis first conclusion is that ‘‘ normal” 
breast tissue shows much variability of the glandular 
elements without relation to the stages of the 
menstrual cycle, and that no epithelial proliferation 
typical of any stage can be recognised. In one 
patient portions were removed from identical parts 
of the two breasts, one section being made 14 days 
after the last period, and the other on the day that 
menstruation began; yet there was no detectable 
difference in the degree of acinar development, 
although the case was one in which a painful hyper- 
trophy of the breasts occurred ateach menstrual period. 
The most constant findings recorded are cyclical 
intracellular changes, leading to blurring of the cell 
outlines; and cedeina of the interlobular connective 
tissue, due to premenstrual hyperemia and leading 
to sharper definition of the lobules. Taylor believes 
that those observers who have described a definite 
epithelial proliferation in the premenstrual period 
have formed their opinion without sufficient regard 
for the normal variations, and in particular for the 
age variations, of the material examined. Painful 
breasts may or may not show diffuse areas of indura- 
tion. Even with a fairly well-marked nodularity, 
histological examination may show little to distinguish 


1Surg., Gn, and Obst., Feb. 1st, 1936, p. 129. 
THE LANCET, 1932, ii., 835. 


MORE BADIUM WANTED 


[maron 21, 1936 675 


the section from normal breast tissue. @Œdema or a 
slight localised hypertrophy must here account for 
the signs and symptoms. Increased density of the 
connective tissue does occur in some cases, and may 
be associated with an actual diminution in the size 
of the lobules. The findings in the painful hyper- 
trophies were much the same. Some showed a normal 
histology ; in others there was an increase in fibrous 
tissue. Signs of epithelial proliferation and of cystic 
formation were uncommon ; areas containing ‘“‘ dis- 
appearing lumps °? were found to differ little from 
the normal. The cases of discharge from the nipple 
did, however, show definite changes in the glandular 
elements. The ducts were widely dilated, and were 
filled with amorphous material; the acini were more 
numerous, and the duct epithelium might appear 
active, even filling the lumen in places, or forming 
papillomata. Evidence of catarrhal inflammation 
and fibrosis was sometimes found in these cases. 
Secretory activity seemed to bear no relation to 
the menstrual cycle. Non-puerperal lactation is, of 
course, distinct from the type of discharge associated 
with duct changes; but chances to study this 
condition histologically are uncommon. 


MORE RADIUM WANTED 


THE sixth annual report! of the National Radium 
Commission expresses a belief that at least another 
20 grammes of radium could be used to reinforce the 
routine work of existing centres throughout the 
country and to provide larger units for special work. 
The recommendation may come as a surprise to 
careful readers of earlier reports who will have 
noticed the guarded tone which the Commission has 
adopted towards the use to which the national supply 
of radium has been put at certain centres and par- 
ticularly towards the larger units of radium element. 
The long delay in the issue of this report can hardly 
be attributed solely to the eviction of the Com- 
mission from its pleasant offices in the Adelphi and 
may be associated with the need for unanimity felt 
by the Commission before issuing so important a 
recommendation. It is not long since many of those 
who know most about the properties of radium were 
still feeling that some of it might have been left 
more safely on the Belgian slag heaps than distributed 
where the knowledge and responsibility for its 
clinical use were still imperfectly developed. The 
delay will have enabled the five new members of the 
Commission—Dr. Thos. Carnwath, Dr. T. Ferguson, 
Dr. Robert Hallam, Prof. J. C. G. Ledingham, F.R.S., 
and Prof. James Young—to take their share in the 
decision. Reports from national radium centres this 
time contain much reason for contentment. Whole-time 
radiologists and physicists have been appointed, 
follow-up departments have been so active that 
almost every patient treated has been traced, 
reorganisations have been carried out, and generally 
the Commission’s policy of centralisation, coöperation, 
and documentation has been realised. In the words 
of the report, “the national centres provide evidence 
of a determined effort on the part of the authorities 
concerned to fall in with the Commission’s ideal of a 
national scheme,’ and although the number of 
recional centres has not been increased, four hospitals 
with radium departments have been recognised by 
the Commission. In fact just as the centres are 
actually becoming progressive, and just as the Com- 
mission is drawing upon the last available supplies, it 


2? Sixth Annual Report of the National Radium Trust and ’ 
Roui -piason 1934-1935. Cmd. 5112. H.M. Stationery 
ce. i 


t 


676 


THE LANCET] 


is being asked for larger and larger quantities of 
radium. Turning to the use of larger units the 
report states that the work of the three l-gramme 
units has proceeded without interruption, while the 
standing clinical committee has reported that this 
form of treatment is of definite value. There is only 
one 5-gramme unit known to be in use at the moment 
in Great Britain. The investigation of beam therapy 
is being followed by the Trust “with great interest.” 
So far it has been limited to carcinoma of the head 
and neck, but with results sufficiently promising to 
justify the continuance of the investigations. This is 
in brief the background set out in the report to 
justify the Commission’s desire for more radium. 
The public has never been backward in providing 
more when called upon to do so and no doubt it 
will be forthcoming. 


THE PRICE OF MILK FOR HOSPITALS 


In the House of Commons on Feb. 17th Mr. 
Thomas Johnston complained that the policy of the 
Government, by raising the price of milk supplied 
to hospitals, clinics, and poor-law institutions, was 
increasing their already serious difficulties. He asked 
the Minister of Agriculture to restore the price to 
that charged before the inauguration of the milk 
marketing schemes. In Glasgow the local authorities 
and voluntary hospitals have been agitating for two 
years for cheaper bulk supplies of milk from the 
Scottish Milk Marketing Board. They have shown 
that the city corporation is now paying £13,000 a 
year more than before the scheme come into force, 
while a voluntary hospital such as the Royal 
Infirmary is paying an extra £1500. Last week a 
committee of the corporation met to consider a letter 
received from Sir Godfrey Collins, Secretary of State 
for Scotland, who wrote that he would not be justified 
in asking the Milk Board to reduce the price to 
hospitals merely on the ground that this price had 
been raised by the elimination of price-cutting com- 
petition. The Board, however, would be prepared 
to agree to a 50 per cent. reduction in the price of 
any milk bought by hospitals in excess of last year’s 
supplies. The corporation’s committee expressed 
dissatisfaction with this reply, maintaining that the 
offer of a lower price conditional on increased purchases 
is of little value because the patients are already 
getting as much milk as they can consume. They 
decided to ask the Secretary for Scotland not to 
make a final decision until the report of the 
Reorganisation Commission on Milk Marketing has 
been issued. 


Lord Willingdon, the retiring Viceroy of India, has 
consented to be chairman of the St. George’s Hospital 
rebuilding fund. 


THE death is announced from Washington of Dr. 
William Holland Wilmer, the prominent American 
ophthalmologist, director of the Wilmer Ophthalmo- 
logical Institute. 


On Tuesday and Thursday, March 24th and 26th, 
at 5 P.M., Mr. Joseph Needham, Sc.D., will deliver 
the Oliver-Sharpey lectures to the Royal College of 
Physicians of London. He will speak on chemical 
aspects of morphogenetic determination. 


WE regret to announce the death of Sir Kedarnath 
Das, of Calcutta, principal of the Carmichael College 
` and author of ‘The Obstetric Forceps ”’ and other 
well-known works on midwifery and gynxcology. 


THE PRICE OF MILK FOR HOSPITALS 


\ 


[marncH 21, 1936 


THE SERVICES 


ROYAL NAVAL MEDICAL SERVICE 


Surgeon Rear-Admiral Bryan Pickering Pick, O.B.E., 
has been appointed Honorary Surgeon to the King from 
Jan. 16th, 1936. 

Surg. Comdrs. F. L. H. MacDowel to Excellent ; K. A.J. 
Mackenzie to Drake for R.N. Hosp., Plymouth; and 
J. C. Souter to Pembroke for R.N.B. 

Surg. Comdr. G. S. Harvey placed on the Retd. List 
at own request with rank of Surg. Capt. 

Surg. Lt.-Comdr. H. J. McCann to Pegasus. 

Entered as Surg. Lts. (D.) for Short Service: 
Ferguson, J. B. Morris, H. P. L. Rhodes, and 
Williamson. 


A. F 
D. N. 


ROYAL NAVAL VOLUNTEER RESERVE 


Surg. Lt. W. D. M. Millar promoted to Surg. Lt.-Comdr. 
Surg. Lt. R. Cormack to Royal Sovereign. 


ROYAL ARMY MEDICAL CORPS 
Maj. P. A. Stewart retires on ret. pay. 


ARMY DENTAL CORPS 
Capt. I. A. Barlow to be Maj. 


TERRITORIAL ARMY RESERVE OF OFFICERS 
Maj. H. H. Fowler, from Active List, to be Maj. 


ROYAL AIR FORCE 


Squadron Leaders H. W. Corner to R.A.F. Depôt, 
Uxbridge, and V. S. Ewing to No. 9 Flying Training 
School, Thornaby, for duty as medical officers. 

Flight Lt. G. S. Strachan is promoted to the rank of 
Squadron Leader. 

Flight Lts. W. G. S. Roberts to R.A.F. General Hospital, 
Hinaidi, Iraq, and J. A. Kersley to Princess Mary’s R.A.F. 
Hospital, Halton. ° 

Flying Offrs. D. S. M. MacArthur to No. 10 Flying 
Training School, Tern Hil; C. F. R. Briggs to Home 
Aircraft Depôt, Henlow ; L. M. Crooks to Princess Mary’s 
R.A.F. Hospital, Halton; D. J. Sheehan to Central 
Flying School, Upavon; H. D. Conway to No. 1 Flying 
Training School, Leuchars; W. J. Fowler to No. 2 Flying 
Training School, Digby; R. F. Wynroe to No. 5 Flying 
Training School, Sealand; E. B. Harvey to No. 7 Flying 
Training School, Peterborough; and I. K. Mackenzie to 
No. 9 Flying Training School, Thornaby. 

Dental Branche——F lying Ofirs. R. M. Brown to Head- 
quarters, R.A.F., Cranwell, and W. E. Nelson to Air 
Armament School, Eastchurch. 


INDIAN MEDICAL SERVICE 


Lt.-Col. W. E. R. Williams, O.B.E., to be Col. 

The promotion to the rank of Maj. of the under- 
mentioned officers is confirmed: M. S. Gupta, R. Linton, 
and H. W. Mulligan. 

Lt.-Col. J. Scott, D.S.O., O.B.E., I.M.S., has vacated the 
appt. of Surg. to H.E. the C.-in-C. 

The undermentioned appts. have been made :— 

Surg. to H.E. the C.-in-C.: Maj. E. P. N. Creagh, 
R.A.M.C. 

A.D.M.S.: Col. W. J. Powell, C.I.E., Col. S. G. S. 
Haughton, C.I.E., O.B.E., and Col. D. C. V. Fitzgerald, 
M.C. 

D.A.D.H.: Lt.-Col. J. C. Chukerbuti. 


In deference to the King’s wish that public 
functions connected with the sciences and the arts 
should not be cancelled, it has been decided that the 
biennial dinner of the Royal Society of Medicine 
shall be held at the May Fair Hotel on Wednesday, 
May 6th, at 7.30 for 8 p.m. Sir Kingsley Wood and 
Mr. Philip Guedalla will be among the guests. 


THE LANCET] 


[waRoH 21, 1936 677 


PROGNOSIS 


A Series of Signed Articles contributed by invitation 


XCITI.—_ PROGNOSIS IN MEASLES 


MEASLES is the biennial ‘“‘scourge inexorable ”’ 
of small children in great cities. The causal agent 
of the symptom-complex so graphically described 
by Sydenham and so familiar to every mother that 
it is apt to breed contempt is generally considered 
to be a filtrable virus. It is, however, not the virus, 
although this prepares the way, but the associated 
bacterial infections of the upper respiratory tract 
which makes measles one of the lethal diseases of 
early childhood. In recent epidemics in London these 
organisms have been chiefly strains of the hemolytic 
streptococcus ; much less usually, pneumococci and 
the H. influenze of Pfeiffer have been recovered from 
swabbings of the nasopharynx of measles patients 
admitted to hospital. Means of protection of the 
child population by active immunisation are yet to 
seek. P. Stocks has shown that some children 
acquire, during an epidemic, without overt clinical 
attack, a measure of latent active immunity which 
may tide them over until the next visitation; in 
a few the immunity so attained would appear to be 
permanent. Although a number of cases of measles 
in the new-born infant infected by the mother are 
on record, temporary passive immunity, transmitted 
through the placenta, is the prerogative of nearly all 
infants at birth. It lasts in full force for the first 
three months and then gradually wanes. By means 
of the injection of convalescent or adult immune 
serum, temporary protection may also be afforded 
at any age. With few exceptions, solid active 
immunity is only to be purchased at the price of a 
clinical attack the severity of which, it is true, may be 
mitigated by the injection of human immune serum. 
Serum-attenuation apart, the age of the child at the 
time of attack, its nutrition and environment before 
and during the illness, and the season of the year 
at which this takes place are factors of the utmost 
importance in prognosis. 


Age 


For the reason already stated, infants under 
3 months of age, however intimately exposed, 
generally escape attack. The waning of maternally 
transmitted immunity is to be observed in the 
attenuated attacks which may occur from the third 
up to the sixth or seventh month. By the eighth 
month the infant is at full risk not only from the 
virus of measles, but, of course, from his constant 
enemy broncho-pneumonia reinforced by the virus. 
The toll of life from this complication of measles 
is greatest during the first two years; the fatality- 
rate then falls with each succeeding year of age and 
among children over 5 is small. During the 1933-34 
epidemic the fatality-rate at all ages of 12,730 
patients admitted to the measles wards of the fever 
hospitals of the London County Council was 5-1 per 
cent. 


Nutrition.—Environment.—Season 


Both the severity of the attack and the likelihood 


of complications are enhanced among children whose 
diet has been deficient in vitamins. The prognosis 
of active rickets, measles, and broncho-pneumonia 
in conjunction is, to`say the least, not very hopeful. 
The addition of extra vitamins A and D to the diet 
during the attack is, however, as Dr. Helen Mackay 
showed in the wards of this hospital, without effect. 


Hardly separable from nutrition is environment; 
the two so often go hand in hand. Halliday showed 
that in the crowded tenements of Glasgow the 
maximum incidence of measles fell upon children 
under school age; in working and middle-class 
households upon those between 5 and 10 years; 
and among the public school class at still later ages. 
When it is added that he estimated the fatality-rate 
at ages up to 2 years at from 10 to 20 times greater 
than that which obtained between the fifth and 
tenth year, the influence of environment upon 
prognosis is obvious. The older age at which the 
public school class, due to a sheltered childhood, is 
attacked may not be an unmixed blessing. A. I. Simey, 
when at Rugby, preferred outbreaks of measles little 
and often rather than extensive epidemics which 
occurred at longer intervals, and strained the sana- 
torium accommodation. 

Epidemics of measles ordinarily commence in 
October or November, the maximum prevalence 
being attained during the first quarter of the new 
year. A late start and therefore a climax reached 
when seasonal conditions are less favourable to the 
occurrence of broncho-pneumonia must clearly tend 
to a reduction in the incidence of this complication 
and therefore the number of deaths. 


Clinical Factors 


Epidemics of measles, qua measles, like those of 
other specific infections, vary in severity. Toxic 
cases may be few or many in individual outbreaks, 
but death purely from toxemia is uncommon. On 
the whole, the belief of the old nurses that a brilliant 
and profuse rash is of favourable import is justified. 
The dusky, velvety, maculo-papular eruption, which 
may be relatively sparse, is of bad omen, whilst true 
hemorrhagic measles with bleeding from mucous mem- 
branes, now rarely encountered, is almost invariably 
fatal. Pyrexia in measles starts with the onset of 
the catarrhal stage and persists until the rash begins 
to fade. A temperature of 104°F. or more during 
the eruptive stage is not inconsistent with an 
uncomplicated attack especially if the rash is robust. 
But should the temperature not fall with the fading 
of the rash or should it again rise appreciably after 
an interval of hours or days, the coexistence or 
development of one of the major complications 
must be suspected. The common ones, each due to 
an extension of the concomitant bacterial infection 
of the upper respiratory tract to mucous membranes 
rendered more vulnerable by the virus are three: 
broncho-pneumonia, enteritis, and otitis media. 
All three may coexist or may follow speedily one 
after the other, the commonest sequence being in the 
order named. Ordinarily beginning during the 
eruptive period, broncho-pneumonia and enteritis 
are occasionally late complications. Otitis media 
may also occur quite early in the attack, especially 
if the middle ear has been previously damaged, 
but its incidence is more usual during the second week 
of the disease. 


BRONCHO-PNEUMONIA 


Prognosis in broncho-pneumonia depends primarily 
upon the general factors already discussed, and 
secondly upon the stage at which the patient comes 
under treatment. Too often practitioners are called 
in to treat the broncho-pneumonia of measles only 


678 THE LANCET] 


PROGNOSIS IN MEASLES 


[maROH 21, 1936 


when the condition is far advanced and the prognosis 
hopeless. The first requirement of any measles 
patient is an abundance of fresh air, which may be 
quite unobtainable in his home. Provided that 
bodily warmth is maintained and there is protection 
from rain, the child suffering from broncho-pneumonia 
is best nursed under the open window or upon a 
balcony. For the desperate case it may be deemed 
necessary to administer oxygen; if so, the funnel 
method is merely wasteful; administration by 
nasal catheter is an improvement but far from 
efficient. Observation has led me to the conclusion 
that failing Poulton’s or some other type of oxygen 
tents (which are now available in all the infectious 
diseases hospitals of the London County Council) 
circulating air from an open window is preferable 
to oxygen from a funnel or catheter. It need not 
be added that the condition of the right heart must 
be watched and improved by cardiac drugs such as 
coramine nor that, if the temperature fails to drop 
with the abatement of the broncho-pneumonic process, 
the presence of pus must be suspected, probably in the 
pleural cavity but possibly in the middle ear or 
mastoid antrum. 


ENTERITIS 


The clinical diagnosis is obvious ; bacteriologically, 
non-lactose fermenters are rarely found ; the enteritis 
has resulted from the swallowing of muco-pus derived 
from the upper respiratory tract. Prognosis depends 
upon the promptness with which dehydration is 
countered and the coexistence or not of broncho- 
pneumonia. 


OTITIS MEDIA 


From the point of view of the physical and educa- 
tional future of the child, rather from that of its 
immediate effects, otitis media is the most important 
complication of measles, since, if neglected, it is 
a potent cause not only of chronic ill-health, but of 
deafness and deaf-mutism. Promptly and adequately 
treated, the prognosis as regards a healed drum- 
head and unimpaired hearing is favourable. The 
advice of an otologist should be sought as soon as 
possible in every case of otorrhcea in measles. A 
number of cases of catarrhal otitis media occur and 
subside spontaneously without perforation, but when 
perforation does occur it may be with so little warning 
that primary paracentesis is out of the question. 
Mastoiditis is of rare occurrence if the middle ear 
is treated early and upon proper lines; otogenic 
meningitis is an occasional sequel of mastoiditis. 

Among the less common complications of measles 
which may affect prognosis the following must be 
noted. 


LARYNGITIS 


Towards the end of the catarrhal stage laryngitis 
sometimes causes such a degree of obstruction to the 
airway that tracheotomy is contemplated and has, 
on occasion, been performed. Provided that laryngeal 
diphtheria can be excluded, the operation is better 
avoided not only because the results are almost 
uniformly bad, broncho-pneumonia being a nearly 
inevitable sequel, but also because in most cases the 
severity of the laryngitis abates as the rash appears. 
The child should be placed in an atmosphere of steam, 
and although, in the absence of diphtheria, the effect 
must be non-specific, a moderate dose of antitoxin 
(16,000 units) frequently appears to afford relief 
in a few hours. Laryngitis which persists into 
convalescence probably indicates ulceration which 
may ultimately result in stenosis; expert advice 
should be sought. 


CORNEAL ULCER 


Pronounced conjunctival injection and photo- 
phobia are of common occurrence in the catarrhal 
and early eruptive stages and the conjunctiva there- 
after is prone to bacterial invasion which may be 
minimised by daily nursing attention to the eyes. 
Corneal ulcers even when promptly treated leave 
nebulæ which, if central, may impair vision per- 
manently ; if ‘they are not promptly treated, pan- 
ophthalmitis and possibly sympathetic ophthalmia 
may result. Daily attention reduces the incidence, 
too, of the minor but tedious infections of the lids, 
blepharitis, hordeolum, and chalazion, to which 
measles patients are liable. 


AFFECTIONS OF THE BUCCAL MUCOSA 


In many cases of measles, especially in infants, the 
erythemato-pultaceous stomatitis of Comby may be 
troublesome during the catarrhal stage, but usually 
subsides with the exanthem; it may persist and 
become ulcerative. This is a serious condition 
which may result in the death of the child from septic 
absorption or from aspiration broncho-pneumonia. 
Attention must be drawn also to the significance 
in measles of the Plaut-Vincent infection of spirochete 
and fusiform bacillus; this may involve the mucous 
membranes of the buccal cavity during the con- 
valescent stage in debilitated children. The complica- 
tion may take the form of Vincent’s angina, stomatitis, 
or gingivitis, and unless promptly treated, preferably 
by injections of N.A.B. and local applications of 
potassium chlorate, may result not only in great 
debility but by extension to the mucous membrane 
of the cheek in the dreaded, but fortunately rare, 
cancrum oris. When this supervenes nothing short 
of surgical measures may avail to save life. 


ENCEPIIALITIS 


Encephalitis, possibly due to the activation of an 
existing virus infection by the virus of measles, is 
a rare but serious complication which may occur 
at any stage of the attack, but most usually as the 
rash is fading. Pyrexia, drowsiness, and convulsions 
passing into stupor, together with muscular twitchings, 
are characteristic. This syndrome may clear up 
completely without residual damage or may be 
followed by spastic paralyses and other manifestations 
of damage to the central nervous system (see F. R. 
Ford, Bull. Johns Hopkins Hosp., 1928, xlui., 140, 
for an analysis of cases in the literature and a full 
clinical description). 


Associated Specific Infections 


Concurrent whooping-cough is not unusual and 
increases the liability to broncho-pneumonia. Diph- 
theria, which may involve the larynx, is obviously 
a severe additional handicap. Scarlet fever, chiefly 
because it implies the addition of other strains of the 
hamolytic streptococcus to the flora of the upper 
respiratory tract, increases the likelihood of otitis 
media. If there is reason to suppose that the measles 
patient may have been exposed to diphtheria or 
scarlet fever it is wise to inject at once a prophylactic 
dose of the appropriate antitoxin, Schick and Dick 
tests being omitted in young children. It is still 
wiser to combine the two antitoxins in one injection 
containing in 5c¢.cm. 2000 units of diphtheria anti- 
toxin and about 4c.cm. of scarlet fever antitoxin. 
Diphtheria and scarlet fever patients who have been 
exposed to measles should receive convalescent or 
adult immune serum, preferably with the aim of 


(Continued at foot of opposite page) 


THE LANCET] 


[magcon 21, 1936 679 


SPECIAL ARTICLES 


FOOD, HEALTH AND INCOME 
A NATIONAL SURVEY OF NUTRITION 


For the first time the food position of the country 
has been surveyed on a large scale to show the relation- 
ship of income, food, and health. The investigation, 
which relies largely upon statistical methods, has been 
undertaken by the staff of the Rowett Institute in 
coöperation with the staff of the Market Supply 
Committee. It is described by Sir John Orr, M.D., 
F.R.S., director of the institute. 


Instead of discussing minimum requirements, about 
which there has been so much controversy, the report 
considers optimum requirements. These are based 
on the physiological ideal, defined as ‘a state of 
health such that no improvement can be effected by 
a change in the diet,” and the standard of adequacy 
of diet adopted is one which will maintain this 
standard of perfect nutrition. 


The survey attempts to find out the proportion of 
the population attaining this standard; and the 
state of health of the country is reviewed to determine 
how far inadequacy of diet is reflected in poor 
physique and impaired health. The tentative con- 
clusion is found that a diet completely adequate for 
health according to modern standards is reached at 
an income level above that of half the population. 
The important aspect of the survey is the inadequacy 
of the diets of the lower income-groups and the much 
lower standard of health of the people (especially of 
the children) in these groups compared with those 
who have more money. 


HISTORICAL COMPARISONS 


In 1835 the prices of bread and flour were much 
the same as they are to-day, but the average con- 
sumption per head was 80 per cent. greater. The 
consumption of sugar was 20 lb. per head, whereas 
now it is 100. This increase has, of course, been 
rendered possible by the great fall in price; sugar, 
which was about 6d. a lb. in 1835, now costs less than 
half as much. 

A committee of the British Association appointed 
in 1881 gave the first estimates of food consumption. 
Comparing the figures of 1934 with those estimates, 
the most striking changes are: consumption per 


Report on a Survey of 
By John Boyd Orr. 
Pp. 72. 2s. 6d. 


3 Food, Health, and Income. 
Adequacy of Diet in relation to Income. 
London : Macmillan and Co., Ltd. 1936. 


(Continued from preceding page) 
prevention rather than attenuation, especially children 
under 3 years of age. 

According to Kohn and Koiransky, radiological 
evidence supports the belief that peribronchial 
infiltration occurs in every case of measles, mild or 
severe. The frequency with which measles lghts 
up a latent focus of tuberculosis is disputed, but there 
is no doubt that it occasionally does so and that 
rapid dissemination may result. Tar more important, 
but as yet not accurately assessed, is the extent to 
which measles complicated by broncho-pneumonia 
is the starting point of fibroid lung and bronchiectasis. 


E. H. R. Harries, M.D., D.P.H., 


Medical Superintendent, North-Eastern 
Hospital (L.C.C.). 


head of bread and potatoes is 30 per cent. less; of 
meat 45 per cent. more ; of sugar 40 per cent. more ; 
of tea and butter the consumption is double. The 
same trend of changes is shown by comparison of the 
figures of 1934 with those of 1909-13 and 1924-28. 


METHODS OF INVESTIGATION ' 


To get an idea of the diet in different sections of 
the community, the whole population was classified, 
according to the income per head, into six groups ; 
those at the top and bottom consisting of 10 per 
cent., and the four intermediate groups of 20 per 
cent. of the population. The composition of these 
groups was obtained by statistical analysis of a large 
number of figures, taken from income-tax statistics, 
wage statistics, and data relating to unemployment, 
old-age pensions, and other forms of social income. 
These figures were correlated with a sample taken 
from the 1931 Population Census and designed to 
yield information on the sizes of the families and the 
ratio of earners to dependants in different occupation 
groups. 

The six groups had average incomes per head per 
week of 10s. and less (group I.), 10—15s., 15—20s., 
20-30s., 30-45s., and 45s. and over (group VI.). 
The corresponding estimated average expenditures 
on food were 4s. (group I.), rising by 2s. increments 
to 14s. per head weekly (group VI.). The average 
income per head was 30s. and the average expenditure 
on food 9s. 

Since the income per head is the income of the 
family divided by the number of persons supported, 
an average per head income of (say) 30s. per week 
may be reached in many ways—for instance, by a 
skilled worker at £3 per week with only a wife to 
support, by a worker and his wife both in employ- 
ment with earnings of 38s. and 22s. per week, or by 
aman earning £550 per year with a wife, four children, 
and a maid. This means that any one group will 
contain a heterogeneous collection of occupations, 
wage-earners, and non-earners. The poorest 10 per 
cent. of the population (group I.) consist in the main 
of families having a disproportionate number of 
children or other dependants per earner. It is 
estimated that half the persons in this group are 
children under 14 and that it contains between 
20 and 25 per cent. of the children in the country. 

The total food-supply of the country having been 
estimated, its distribution among the different 
income groups was estimated from 1152 family 
budgets. These ranged from very poor families 
spending less than 2s. per head weekly on food, 
up to families with an income of £2000 per annum 
spending 15s. or more per head weekly on food. 
The composition of the average diet of each group 
was then examined. 


CONSUMPTION OF PARTICULAR FOODS AT DIFFERENT 


INCOME LEVELS 


The consumption of flour (see Tig. 1) and of 
potatoes is remarkably uniform in all groups except 
I. and VI. In group VI. there is evidence that 
more expensive foods are substituted for potatoes 
and bread. In the lowest group there is no indication 
of any substitution, nor indeed is there any cheaper 
food' which could be substituted for potatoes and 
bread. It looks as if the purchasing power of this 
group is so low that the consumption of even the 
cheapest foodstuffs is limited; or, what is more 
probable, the appetite in the lowest income-group is 


680 THE LANCET] 


below the average—one of the first 
signs of sub-optimal nutrition being 
diminished appetite. 

Graphs published in the report show 
that as income rises the consumption 
of margarine falls and of butter rises ; 
but if butter, margarine, lard, suet, 
and dripping are grouped together the 
total fat consumption rises steadily 
with income. The consumption of meat, 
fish, milk, eggs, sugar, vegetables, and 
fruit increases with income. The figures 
for milk, fish, and fruit are shown in 
Fig. 1. 


D 


COMPARISONS OF DIET AND STANDARD 60 


REQUIREMENT 


The next step is the comparison 
of the quantities of the constitu- 
ents in the average diets of each 
group with the amounts required 
for health. The standards of require- 
ments adopted are those compiled 
by Stiebeling, of the United States Government 
Bureau of Home Economics. The vitamin require- 
ment for health is taken as twice that which will 
prevent the occurrence of obvious deficiency disease. 
An ample supply is necessary since it is known that 
there are minor degrees of ill-health caused by 
deficiencies of vitamins not great enough to show 
obvious symptoms. For mineral elements the 
standards are based on the minimum requirements 
for the maintenance of a positive balance plus an 
allowance of 50 per cent. for additional requirements 
of maintenance of health. 

Assuming the validity of the standards, the average 
diet of group I. is found to be inadequate for perfect 
health in all the constituents considered. Group II. 
is adequate only in total proteins and total fat; 
group III. is adequate in energy value, protein, and 
fat, but is below standard in minerals and vitamins ; 
group IV. is adequate in iron, phosphorus, and 
vitamins, but probably below standard in calcium ; 
group V. has ample margin of safety in everything 
with the possible exception of calcium ; in group VI. 
all standard requirements are exceeded. These 
results are shown in Fig. 2. The quality of the protein 
is important, especially for children ; and the per- 
centages of protein and fat of animal origin, which 
arevof higher biological value than those of plant 
origin, increase from group to group. Hence the 
intake of the several constituents increases in quality 
and in quantity with expenditure. 

It should be kept in view that the standards with 
which the above comparisons are made are for the 
maintenance of perfect health, which is a standard 


PERCENTAGE OF STANDARO REQUIREMENTS 


GROUP I 


te 

Wy 6 Ye 

> FRESH MILK ù BREAD & FLOUR 
$ à 

a Q 

Q4 Q 

N ` l 
% zl- Q 

pe x 

Ù & 

Qa 9 Uj 

o Q 

R o 

N Ik N 


GRouP] U U E VY I 


FIG. 1.—Consumption per head of certain foodstuffs by income-groups. 


in Group VI. itis 45s. or over. 


FOOD, HEALTH AND INCOME 


[maRcH 21, 1936 


LEVEL OF ADEQUACY 


10 ore REO ISHe NATO err eseeere Se" O20 


H It Ww Vv WI 


FIG. 2.—Average intake of vitamins and minerals by income-groups. 


(Modified from the Report.) 


very different from the average health of the com- 
munity. That average diets of the lower income- 
groups are inadequate according to these standards 
does not mean that these people are starving or even 
suffering from such ill-health as is recognised in the 
term disease. These diets may suffice to maintain 
life and a certain degree of activity, yet may be 
inadequate for the maintenince of the fullest degree 
of health. 


EVIDENCE OF IMPERFECT NUTRITION 


Owing to differences in their diet, a comparison of 
the health of children of the lower income-groups 
with that of children of the higher should show 
a slower rate of growth and a greater incidence of 
deficiency diseases in the former. Stature is largely 
determined by heredity but the extent to which a 
child will attain the limit set by heredity is affected 
by diet. Because of these hereditary factors, data 
which are numerically few are of little value. Ample 
data on height and weight of the same race do, 
however, give an indication of the relative adequacy 
of diets. A conspicuous difference in the heights of 
boys drawn from different classes is shown by a 
large number of observations of council schoolboys 
and employed males (belonging mainly to groups 
I. to IV.), and those attending Christ’s Hospital 
School (groups III. to VI.). Thus at 13 years of 
age the boys of Christ’s Hospital School are on the 
average 2-4 inches taller than those of the council 
schools. At 17 they are 3-8 inches taller than 
“employed males ”? of the same age. Figures taken 
from observations of public schoolboys (belonging 


PENCE PER HEAD PER WEEA 
OZS PER HEAD PER WEEK 


I O 


mW VMM 1 


Ii UU XN vn 


The income in Group I. 


is less than 10s. a week; 
(Modified from the Report.) 


i Shane OS T ee ne a ee ne | 


THE LANCET] 


almost entirely to group VI.) show further increase 
on those for Christ’s Hospital. 

Three characteristic signs of malnutrition in 
children—rickets, bad teeth, and ane#mia—are fairly 
widespread in the lower income-groups, the only 
groups in which extensive observations have been 
made. There is evidence to show that the same 
dietary deficiencies which cause these conditions also 
affect resistance to some infectious diseases, such as 
pulmonary and intestinal disorders of children. 

Such imperfect nutrition in childhood should be 
traceable as poor physique in adult life and has been 
found, for instance, in army recruits. Furthermore, 
susceptibility to some infections, more especially to 
tuberculosis, is influenced by nutrition and the report 
states that the most effective line of attack on 
tuberculosis is probably by improvement of diet. 

Figures are insufficient to show the incidence of 
anemia in the higher income-groups, but some degree 
of anemia is known to be common in women in the 
lower income groups. This is at least in part preven- 
table and diet is an important factor in its prevention. 

The correctness of the general picture presented 
here has been confirmed by various experiments, in 
some of which (e.g., Corry Mann) a supplement of 
milk increased the rate of growth among children. 
In another, groups of rats kept on diets similar to 
those of various Indian tribes showed to a remarkable 
degree the physique and incidence of diseases corre- 
sponding to those of the respective tribes (McCarrison). 
In similar experiments in Scotland, reported in the 
Journal of Hygiene (1935, xxxv., 476), two groups of 
rats have been given a diet resembling that of income- 
group I., one group of rats having in addition an 
abundance of milk and green food. Not only were 
the rates of growth markedly divergent but the 
death-rates of the two groups differed conspicuously. 
The mortality to 140 days of age on the supple- 
mented diet was 11-6 per cent., while for those on 
the experimental diet the rate was 54:3 per cent. 
This heavy death-rate was mainly due to epidemic 
infections to which both groups were equally exposed. 


SUMMARY AND CONCLUSION 


We reproduce substantially Sir John Orr’s con- 
cluding statements :— 

The food position of the country has been investi- 
gated to show the average consumption of the main 
foodstuffs at different income levels. The standard 
of food requirements and the standard of health 
‘adopted are not the present average but the 
optimum—i.e., the physiological standard, which, 
though ideal, is attainable in practice with a national 
food-supply sufficient to provide a diet adequate for 
health for any member of the community. The 
nain findings are as follows : 

1.—Of an estimated national income of £3750 
millions, about £1075 millions are spent on food. 
This is equivalent to 9s. per head per week. 

11.—The consumption of bread and potatoes is 
practically uniform throughout the different income 
level groups. Consumption of milk, eggs, fruit, 
vegetables, meat, and fish rises with income. Thus, 
in the poorest group the average consumption of 
milk, including tinned milk, is equivalent to 1-8 pints 
per head per week ; in the wealthiest group 5-5 pints. 
The poorest group consume 1-5 eggs per head per 
week ; the wealthiest 4-5. The poorest spend 2-4d. 
on fruit; the wealthiest ls. 8d. 

r11.—An examination of the composition of the 
diets of the different groups shows that the degree 
of adequacy for health increases as income rises. 
The average diet of the poorest group, comprising 


MEDICINE AND THE LAW 


[mancH 21, 1936 682 


44 million people, is, by the standard adopted, 
deficient in every constituent examined. The second 
group, comprising 9 million people, is adequate in 
protein, fat, and carbohydrates, but deficient in all 
the vitamins and minerals considered. The third 
group, comprising another 9 million, is deficient in 
several of the important vitamins and minerals. 
Complete adequacy is almost reached in group IV. 
and in the still wealthier groups the diet has a surplus 
of all constituents considered. 

Iv.—A review of the state of health of the people 
of the different groups suggests that, as income 
increases, disease and death-rate decrease, children 
grow more quickly, adult stature is greater, and 
general health and physique improve. 

v.—The results of tests on children show that 
improvement of the diet in the lower groups is 
accompanied by improvement in health and increased 
rate of growth, which approximates to that of 
children in the higher income-groups. 

vi.—To make the diet of the poorer groups the 
same as that of the first group whose diet is adequate 
for full health (i.e., group IV.) would involve increases 
in consumption of a number of the more expensive 
foodstuffs—viz., milk, eggs, butter, fruit, vegetables, 
and meat—varying from 12 to 25 per cent. 


If these findings be accepted as sufficiently accurate 
to form a working hypothesis, they raise important 
economic and political problems. Consideration of 
these is outside the scope of the investigation. It 
may be pointed out here, however, that one of the 
main difficulties in dealing with these problems is 
that they are not within the sphere of any single 
Department of State. This new knowledge of 
nutrition, which shows that there can be an enormous 
improvement in the health and physique of the 
nation, coming at the same time as the greatly 
increased powers of producing food, has created an. 
entirely new situation which demands economic 
statesmanship. 


MEDICINE AND THE LAW 


The Ruxton Murder Trial 


In his summing-up to the jury at the trial of Dr. 
Buck Ruxton for murder, Mr. Justice Singleton paid 
a compliment to the medical witnesses who had been 
called by the Crown. ‘“ Never,” he said, “have I 
seen expert witnesses more careful or more eager 
not to strain a point against an accused person: 
there was no evidence to contradict them except by 
Ruxton himself.” Their evidence indeed was vital. 
Dr. Ruxton’s wife and Mary Rogerson, the nurse to 
his children, were last seen at his house in Lancaster 
on Sept. 14th; on the 29th dismembered parts of 
human bodies were found in a ravine at Moffat, 
Dumfriesshire; there were two heads, and the 
remains were referred to during the proceedings as 
body No. 1 and body No. 2, these being alleged to 
be the remains of Mary Rogerson and Mrs. Ruxton 
respectively. Dealing with body No. 1 Prof. Glaister, 
Regius professor of forensic medicine at Glasgow 
University, described the extent to which tissue and 
skin had been cut from the face ; both eyes had been 
removed. Asked by the judge if he could see any 
other reason than the prevention of identification, 
he observed that the removed parts of the body 
included those which might have borne signs of 
asphyxia. The dismemberment had been done by 
cutting through the joints. There had been bruising 
before death ; blood had been drained away before 


682 THE LANCET] 


it had time to clot. Prof. Glaister put the time 
between the death and the mutilation as a few hours : 
he gave 10 to 14 days as the approximate time 
between death and his examination of the bodies on 
Oct. Ist, but added that the period could not be 
scientifically estimated. As for body No. 2 he thought 
five hours was the minimum time for dismemberment. 
He found bone changes on the left great toe which 
frequently accompanied a bunion (there was other 
evidence that Mrs. Ruxton suffered from a bunion 
of this nature). He had at first thought that head: 
No. 2 was that of a male: after careful examination 
and tests he had no personal doubt the head and 
limbs of No. 2 were those of a female. He described 
the colour of the hair of the two bodies. Prof. J. G. 
Brash, professor of anatomy at Edinburgh Univer- 
sity, gave his opinion that there were only two bodies 
and that both were female. He showed that the 
cast of the left foot of No. 1, on which a stocking 
was placed, fitted the shoe of Mary Rogerson ; simi- 
larly that of the left foot of No. 2 fitted the shoe of 
Mrs. Ruxton. Dr. A. C. W. Hutchinson, dean of 
the dental school at Edinburgh University, described 
the state of the teeth in the two skulls; 14 teeth 
had recently been removed, after or just before 
death, from head No. 2. Prof. S. Smith, Regius 
professor of forensic medicine at Edinburgh Univer- 
sity, and Dr. W. G. Miller, lecturer in pathology at 
that University, corroborated details and opinions 
of the previous witnesses. In addition the officer 
in charge of the fingerprint department of the 
Glasgow City Police explained the points of similarity 
between prints on various articles at the Ruxtons’ 
home and the fingerprints of body No. 1, and between 
photographs of a palm impression on a table in the 
house and the left palm of body No. 2. 


The rest of the evidence against Dr. Ruxton will 
‘be within the recollection of readers of the daily 
press—his blood-stained clothes, his cut hand, his 
taking up of the stair carpets, their saturation with 
blood, the scraping of the walls, the fires in the 
yard, the locked rooms and the unpleasant smell, 
the quarrels with his wife and the motive of jealousy, 
the attempt to persuade witnesses to give untrue 
evidence as to dates, the sudden disappearance and 
total silence of the two women, the absence of anyone 
“who saw them leave the house, their omission to 
take with them any of their clothes or possessions, 
and the fact that some of the gruesome relics in the 
ravine were wrapped in a child’s garment belonging 
to the Ruxton nursery. Two other points may be 
mentioned. Among the remains collected from the 
ravine were 43 parts, mostly soft parts, which were 
unassigned to either body: in these was a portion 
which was taken to be a cyclops eye. Counsel for 
Dr. Ruxton asked questions apparently suggesting 
that this might be the sole remaining portion of a 
human fetus. Dr. Ruxton had at one stage said 
that Mary Rogerson was pregnant and that she had 
gone off with Mrs. Ruxton to procure an abortion. 
Prof. Glaister did not regard this cyclops eye as 
human. Prof. Brash believed it to be the eye of a 
pig; had it been human, it would have been the 
eye of a monstrous fœtus. The second point was a 
question of the admissibility of evidence. Dr. Ruxton 
stood committed for trial on charges of murdering 
both his wife and Mary Rogerson; he was actually 
tried for the murder of his wife only. When evidence 
was being tendered of Mary Rogerson’s clothing, 
counsel for the defence objected. The Crown con- 
tended that the circumstances of Mary Rogerson’s 
death and the identity of one body must materially 


MEDICINE AND THE LAW 


_after the accident ; 


. [Manon 21, 1936 


assist the identity of the other body. The judge 
agreed. The issue for the jury was whether or not 
Dr. Ruxton was proved guilty of the murder of Mrs. 
Ruxton. If it were the fact that she and Mary 
Rogerson were both in the house on the evening of 
Sept. 14th, and thereafter there was evidence that 
portions of the bodies of both were found in a ravine 
together, the evidence of the body of Mary Rogerson 
might be material to the issue. The court would 
not exclude evidence of her clothing which might be 
one stage towards identification of her body. The 
jury must bear in mind that they were inquiring into 
the death of Mrs. Ruxton only. Admission of the 
evidence involves the legal subtlety that the presence 
of remains of Mary Rogerson in the rayine might 
assist identification of the remains of Mrs. Ruxton 
in the same place but that no inference must be 
drawn that the accused, because he had possibly 
murdered one woman, had probably murdered another. 
Do juries appreciate these fine distinctions ? A like 
question arose over the direction to the jury recently 
in R. v. Waddingham, where there was a suggestion 
of the poisoning of Mrs. Baguley though the issue 
for the jury was the poisoning of her daughter. 


Gynzcomasty and Accident 


In Murray v. Northey, last month at the Surrey 
assizes, the plaintiff, a young man aged 23 who was 
employed as a gardener, claimed damages against a 
motorist. The defendant having admitted negligence, 
the court had merely to assess the amount of the 
damages. It was part of the plaintiffs case that 
enlargement of the mammary gland had developed 
as a result of the accident. He was knocked off his 
bicycle a year ago by the defendant’s car and was 
bruised all down the right side from shoulder to 
ankle; there was a fractured right fibula. Pneumo- 
thorax was suspected on the right side but, on 
examination of X ray photographs, was not estab- 
lished. With regard to the gynecomasty the plaintiff 
said that the bruising began to disappear three weeks 
a swelling then begun on the 
right side of the front of his chest, the place being 
red, throbbing, and tender. These symptoms sub- 
sided fairly soon but during the summer months 
the swelling slowly increased in size; since October 
there has been no change in size. Mr. R. M. M. 
Handfield-Jones, I'.R.C.S., giving evidence for the 
plaintiff, said there was a right-sided development of 
a normal breast comparable to that of a small virgin 
female breast at 17 years of age; there was no doubt 
it was true breast tissue. There appeared to be indis- 
putable evidence that the young man was normal 
before the accident; his mother and the vicar testi- 
fied to this. Upon these facts Mr. Handfield-Jones 
expressed the opinion that the breast development 
was directly attributable to the injury which had 
stimulated the breast rudiments. In answer to 
questions he explained to the court the development 
of the breasts in both sexes, the abortive effort made 
by the male breast at puberty, and the known 
examples of the connexion between trauma and 
growth. Mr. Russell Howard, F.R.C.S., called as a 
witness on the other side, described the condition as 
that of a girl about 12 to 14 years of age. He said 
he had never known a development of this sort to 
result from an accident. He did not think that a 
slight enlargement of the mammary gland in a man 
of 23 was likely to be so caused. Mr. Justice Finlay 
accepted Mr. Ifoward’s view and considered that 
the hypertrophy was a freak of nature which was not 
due to the accident. Of course there was pain and 


THE LANCET] 


suffering as the result of the plaintiffs injuries. 
The court awarded £300 damages for these. 


Dispute over a Locum Tenens . 


In Browne-Carthew v. Divecha at the Westminster 
county court last month a medical practitioner claimed 
damages for breach of contract to employ him as 
locum tenens for the last fortnight of August. He 
had been engaged through a medical agency and 
apparently, when he arrived at the house of the 
defendant doctor for whom he was to act, there was 
a refusal to let him do the work on the ground that 
he was too old. The plaintiff was, as a matter of 
fact, 80 years of age ; he asserted that he was never- 
theless perfectly fit to do the work required of him. 
Evidently the court agreed with his assertion ; after 
deducting £3 10s. for board and lodging, the judge 
awarded him £18 4s. (with costs) as damages for the 
breaking of the engagement. The judge held that 
the medical agency was authorised by the defendant 
doctor to engage a locum tenens, and that the defen- 
dant, forming a wrong impression of the plaintiff 
as a ‘“‘ tottering old man,” refused to let him proceed 
with the contract. There seems to have been some 
dispute between the defendant and the agency 
whether the defendant had stipulated for a young 
man. This did not affect the plaintiff if, as the judge 
decided, the agency had the defendant’s authority 
to engage him. Doctors who desire to make such a 
stipulation should remember to make their instruc- 
tions clear. 

Unlawful Use of‘ Doctor ”’ 


The Medical Defence Union does good service to 
the public as well as to the medical profession when 
it invokes the law against unregistered practitioners 
who unlawfully, wilfully, and falsely use the title of 
doctor, thereby implying that they are registered 
under the Medical Act. In a prosecution at Brighton 
last week it was stated that there had been corre- 
spondence between the Union and the defendant in 
September, 1934, when he was calling himself an 
osteopathic physician and surgeon. He then changed 
his description to osteopathic practitioner. Last May 
he described himself as ‘‘ Doctor’’ on his notepaper 
and on the plate outside his premises. The Brighton 
magistrates fined him £20 with £10 costs. 

There may be members of the public who will 
regard the case as one more instance of professional 
jealousy and petty persecution. Let it be added then 
that a detective inspector informed the court that 
the accused, Francis D. Deacon, aged 57, had been 
previously convicted for larceny and frauds for which 
he had been sentenced to two terms of three years’ 
penal servitude and two terms of five years’ penal 
servitude; his last conviction was in July, 1933, 
when he was sentenced to 12 months’ hard labour 
at Surrey assizes for obtaining credit by fraud. 
Deacon, said the witness, had often adopted the 
rôle of doctor in the execution of these frauds. Cases 
of this kind may persuade laymen that the Medical 
Act has some modest service to perform for the 
public in distinguishing the registered from the 
unregistered practitioner. -Since a criminal conviction 
is a statutory ground for removing a name from the 
Medical Register, it is all the grosser fraud when a 
man who has served terms of penal servitude puts 
‘“ Dr. Deacon ” on his notepaper and name-plate. 


Iliness Supervening upon Accident 


In McCann v. Scottish Coéperative Laundry Ltd. 
a woman had an accident to her hand in a steam- 
presser, She lost a finger and her thumb became stiff 


PARIS 


[maron 2], 1936 683 _ 


and shrivelled. For a time she received compensa- 
tion for total incapacity. Presently she became fit 
for light work and her employers gave her work 
within her powers at her old wages. She had a 
permanent partial incapacity, resulting from the 
accident which occurred in the course of her employ- 
ment; but she was able to accept her employer's 
offer of suitable work. Then, as it happened, she was 
removed to hospital suffering from appendicitis and 
for six months she was unfit for any work at all. 
This total incapacity was due to illness entirely uncon- 
nected with the accident. Was she entitled to com- 
pensation during these six months? Her employers 
were still offering her light work of a suitable nature, 
but she was unable to accept the offer. The House 
of Lords has now decided that the claim to com- 
pensation is not satisfied by an offer of work which 
the workman, through old age or illness, cannot 
accept. An offer by the employers of work which 
they know the workman is unable to accept is no 
better than making no offer at all. 

In delivering this judgment of the House of Lords 
in the workwoman’s favour Lord Thankerton found 
a precedent in Stowell v. Ellerman Lines (1923). 
There an accident made a workman’s left hand stiff. 
Two years later he was found to have total incapacity 
due to the stiffness and also to hernia, prostate trouble, 
and old age. This total incapacity could not really 
be attributed to the accident and the county court 
judge considered that the total incapacity, due to 
old age or disease, swallowed up the partial incapacity 
due to the accident. The Court of Appeal held he 
was wrong, and the employers had to pay. 


” PARIS 
(FROM OUR OWN CORRESPONDENT) 


BCG STATISTICS 


THE French Academy of Medicine lives up to its 
reputation as an international as well as a national 
forum ; and at a recent session two of the principal 
reports came from abroad. One of them was pre- 
sented by Dr. Guérin on behalf of Dr. Baudouin, of 
Montreal, and its subject was eight years’ experience 
of BCG in the province of Quebec. Between June, 
1926, and the end of 1934, as many.as 5126 children 
were given BCG. Of these, 582 were living in con- 
tact with persons suffering from open or presumably 
closed tuberculosis, the open cases numbering 249. 
Serving as controls were 971 children who, though 
not given BCG, continued to live in tuberculous 
surroundings, as many as 500 of their tuberculous 
contacts representing open forms of the disease. 
All the 1553 children living in tuberculous surround- 
ings were kept under close supervision, and in the 
calculations of their mortality and morbidity no 
account was taken of the deaths occurring during 
the first month of life. Between the ages of one month 
and seven years the general mortality was 10-3 per 
cent. for the BCG children and 18-7 per cent. for 
the controls, the deaths from tuberculosis among 
the BCG children claiming 2-1 per cent., and among 
the controls 7 per cent. When account was taken 
only of the children living in contact with open cases 
of tuberculosis, it was found that, between the age 
of one month and seven years, the tuberculosis mor- 
tality among the BCG children was only 2-4 per 
cent., whereas it was 11-1 per cent. among the con- 
trols. As for the tuberculosis morbidity among the 
children in contact with open cases, it was 1-7 per 
cent, for the B C G children and 6-2 per cent. for the 


6S4 


THE LANCET] -- 


SCOTLAND.- == IRELAND 


[MARCH 21, 1936 


controle. Dr. Baudouin soneludes foun these obser- 
vations that the closer the problem of B C G inocula- 
tion’ is studied, the more evident does its efficacy 
become. : 


IS SILICOSIS IN MINERS A DISEASE SUI GENERIS ? 

The other foreign report was presented to the 
Academy by Dr. Rist on behalf of Dr.. Vossenaar 
and Dr. Doubrow, and it concerned miners in Holland. 
Among 600 miners working as such for more than 
ten years were 60 who had been. employed in the 
mines for more than 20 years. With only one excep- 
tion, all these long-term miners possessed radio- 
scopically normal lungs. On the basis of this and 
other observations, the conclusion is drawn that 
prolonged work in the dusty atmosphere supposed to 
generate silicosis does not, as a matter of fact, pro- 
voke any clinical or radiological pulmonary sclerosis 
provided the persons concerned were originally 
healthy. It is only when chronic pulmonary disease, 
tuberculosis in particular, has prepared the soil that 
the lungs may become the seat of disease which in 
some quarters it is at present fashionable to call 
silicosis. After presenting this report, Dr. Rist 
dotted its every t and crossed its every tł, concluding 
that the problem of silicosis, recently supposed to 
have been solved, is in reality more obscure than 
ever. , He added that a breach had been made in the 
wall surrounding the notion yeh silicosis is a disease 
sui generis. 

RATE-BITE FEVER 


A good illustration of the dangers of. amateur rat 
baiting is given by Dr. Louis Ramond in the Presse 
Médicale of March 7th. The rat-baiter in question 
was a floor-polisher, aged 60, who one morning last 
December saw a large drain-rat enter his premises 
uninvited. The floor-polisher pursued his guest 
with a broom-handle, chasing him till the rat was 
cornered. In an effort of more or less legitimate self- 
defence, the rat turned on his pursuer, jumping up 
and biting his left hand in two places. Having laid 
out the rat, the floor-polisher made his wounds bleed 
freely before disinfecting them with chlorinated 
water. There was practically no local reaction, and 
the whole incident faded so completely into the 
background that when the floor-polisher fell ill 
four days later with high fever and vomiting he did 
not dream of connecting the rat with his symptoms, 
and he failed to entertain his doctor with an account 
of his experiences. So, for many days, his doctor 
puzzled over such alternative diagnoses as influenza, 
acute rheumatism, tuberculosis, endocarditis, malaria, 
typhoid fever, undulant fever, erythema nodosum, 
syphilis, and measles. It was only when Dr. Ramond 
was called in to consultation over this case that 
memories were revived and the necessary clue was 
given to the correct diagnosis. Apart from the 
brevity of the incubation period and the almost 
complete absence of a local reaction, the case was 
typical enough, with its characteristic rash, the recur- 
rence of bouts of fever punctuated by periods of 
apyrexia, headache, great general fatigue, and pain 
in the muscles and joints. Injections of novarseno- 
benzol were prescribed, and after the third injection 
had been given, complete apyrexia was achieved. 
‘The improvement in other respects was so great 
that the patient could with confidence anticipate 
an early return to the polishing of floors. The pity 
of it was that he was ill for six weeks before a con- 
sultant was called in and the correct diagnosis made. 
Why this delay? Is it that rat-hunters are more 
diffident about neeounnNe their exploits: than. lion- 
-hunters ? | | 


SCOTLAND. 


(mou OUR OWN CORNE EONDEN) l 


_ “THE HOLMES-ADIE SYNDROME 

AT the recent meeting of the Medico- Chirurgical 
Society of Edinburgh, Prof. Edwin Bramwell drew 
attention to the syndrome in which the pupils do not 
react to light but show a myotonic contraction on 
convergence, and in which the tendon-jerks are 
absent. The condition may affect one or both pupils : 
the latter are often large, but on maintaining con- 
vergence for a period of several seconds they slowly 
contract to a very small size.. Prof. Bramwell 
emphasised the importance of the syndrome as it is 
not in any way related to syphilis and is apparently 
a benign condition. He suggested that, as the cause 
of the condition is unknown, it should be: known as 
the Holmes-Adie syndrome in recognition of its 
description by Dr. Gordon Holmes and the late 
Dr. W. J. Adie. 

VOLUNTARY HOSPITALS 


Dr. Robert F. Barclay at the annual meeting of 
the Glasgow Royal Hospital for Sick Children gave 
some figures. He said there are more than a thousand 
voluntary hospitals in Great Britain containing 85,000 
beds; last year there were 1,250,000 in-patients and 
5,500,000 out-patients The total expenditure and 
maintenance was abo1t £15,000,000 and the income 
exceeded that figure by about £1,000,000. In 
addition, over £3,000,000 was raised for the provision 
of new buildings and equipment. In the last five 
years the amount expended on maintenance had 
increased by £2,500,000. Dr. Barclay submitted 
that the figures give striking proof of the widespread 
determination to support voluntary hospitals in the 
country. He pointed out that, while the local 
authorities had a duty to see that health services of 
all kinds are adequate for the needs of the people, 
it was not their legitimate sphere to use their rating 
powers to compete with voluntary hospitals. The 
voluntary hospitals in the west of Scotland, of which 
there are over fifty, have formed themselves into an 
association, and he emphasised the importance of the 
voluntary hospitals in Great Britain being onecivels 
codrdinated. 


IRELAND 


(FROM OUR OWN CORRESPONDENT) 


| ENFORCED RETIREMENT OF MEDICAL OFFICERS 


THE Minister for Local Government and Public 
Health has recently issued a circular to all local 
authorities suggesting that the normal age for retire- 
ment of their various officials should be 65, and that 
in some cases 60 would be a more suitable age. The 
circular is intended to cover all officers, professional 
as well as administrative and clerical, of local 
authorities. At present in few cases is there any 
age-limit to the holding of office and all medical 
Officers have been appointed without such limit, 
and on the understanding that they could not he 
retired against their will except in case of proved 
incapacity. Many dispensary medical oflicers have 
continued to perform their duties to a much higher 
age than 65, and in fact the retirement of one at the 
age of 80 was announced within the last few weeks. 
There is much to be said against continuance in a 
strenuous occupation to so advanced an age, but a 
change cannot be made without a due consideration 
of existing rights. The Minister has as yet made no 
statement as to the manner in which he will com- 


THE LANCET] 


pensate those whose terms of appointment may be 
varied without their consent. As the law. stands it 
does not appear. that a local authority has power. to 
dismiss an officer on the ground of age alone, but 
only when it has been proved to the satisfaction of 
the Minister that there is incapacity to perform the 
duties. It is true that the Minister has power to 
remove an Officer under sealed order, but up to the 
present this power has been understood to be exer- 
cisable only in cases of rearrangement of duties, of 
incapacity, or of misconduct, and has not been 
exercised in other cases. | 


FEES FOR REGISTRATION OF, BIRTHS AND DEATHS 


Most of the work of registration. of births and 
deaths in the Irish Free State is carried out by the 


PANEL AND CONTRACT PRACTICH 


(MAROH 21, 1936 685 


dispensary medical officers, who are appointed 
assistant registrars for the purpose. It is admitted 
that the work is performed efficiently and carefully. 
There has long been discontent as to the adequacy of 
the fees paid for this work which have not been 
altered for some eighty years. Representations have 
been made to successive Governments asking for an 
adjustment of the fees to modern conditions. Last 
year the Minister for Local Government and Public 
Health promised that the matter would have early 
attention, and last week, in answer to a parliamentary 


question, his parliamentary secretary stated that the 


Government draftsman was engaged in the preparation 
of a Bill to deal with the matter. He was unable 
to say, however, how soon the Bill might be 
expected. i | | 


PANEL AND CONTRACT PRACTICE 


Almost a Representation 


THE London medical benefit subcommittee recently 
submitted a report in which they recommended that 
a representation should be made to the Minister for 
the removal of a practitioner’s name from the medical 
list. This action by a subcommittee other than the 
medical service subcommittee is unusual, but the 
circumstances attending it are even more extra- 
ordinary. 

Three doctors, A., B., and C., were involved. By 
direction of the Minister the name of Dr. A. was removed 
from the medical list, following a representation by the 
committee, as from March Ist, 1935. From that date 
therefore Dr. A. was debarred from taking part in insurance 
medical practice either as a principal or as a deputy, and 
his insured patients were given notice of their right to 
select another doctor. 

On Feb. 19th, 1935, the committee were informed by 


Dr. B. that he proposed to practise at the surgery occupied | 


by Dr. A. as well as at another address in respect of which 
his name was already included in the medical list. The 
committee agreed to Dr. B.’s application, subject to the 
fulfilment of certain conditions, and he accepted a large 
proportion of the insured persons formerly on the list of 
Dr..A. Dr. B. relinquished the address as from July 3lst, 
1935, and nominated Dr. C. as his successor, to whom 
were transferred the patients attached to the surgery, 
some 950 persons. 

The committee had reason to think that one of the 
difficulties leading to the retirement of Dr. B. was the 
continued occupation of the premises by Dr. A., and when 
Dr. C. joined the list an inquiry was made of him whether 
Dr. A. was still residing at that address. Dr. C. replied 
in the negative. On Jan. 29th, 1936, the surgery was 
visited and the representatives of the committee were then 
informed by Dr. C. that the practice did not belong to him, 
and that he was acting merely in the capacity of an 
assistant to Dr. A. from whom he was receiving a weekly 
salary. Dr. C. added that he was unable to prevent 
interference in the practice by Dr. A., and: he gave 
particulars of the case of an insured person who had been 
attended by Dr. A. and from whom fees had been received. 
Dr. C. also stated that he had been induced to give a 
certificate of incapacity to the mother of the insured person 
although in fact he had not seen the patient at all. Prior 
-cto this visit- Dr. C. had called at the committee’s office-and 


had complained: of-the conditions under’ which “he -was 


conducting the practice, admitting that his previous state- 
ment that Dr. A. did not reside at the surgery was untrue. 


The subcommittee’s view of the position was that 
a practitioner (Dr. A.) having been removed from the 
medical list by order of the Minister of Health was 
nevertheless still the owner of the insurance medical 
practice and was continuing to conduct that practice 


by means of an agent who acted in the capacity of an 


assistant and received a weekly salary for his services. 


‘This appeared to be nothing less than a travesty of the 


intention of the Minister when he declared that the 
continuance of Dr. A. on the medical list would be 
prejudicial to the medical service -of the insured. 
While no action could be taken against Dr. A. 
(although doubtless this will be borne in mind in the 
event of his applying to the Minister for reinclusion 


in the medical list, for in such circumstances com- 


mittees are invited to submit their observations on 


the application) it appeared to the subcommittee 


that Dr. C. could not be absolved from complicity, 
and it was the intention-to invite the committee to 


make a representation to the Minister that the 


continuance of Dr. C. on the medical list would be 
prejudicial to the efficiency of the medical service of 
the insured on the grounds that he had conspired and 
was conspiring with Dr. A. in the conduct of an 
insurance medical practice contrary to the provisions 
of the Act. 

The chairman of the subcommittee withdrew the 


recommendation as Dr. C. had resigned from the 


medical list and the committee were satisfied that his 
successor had taken the necessary steps to secure that 
Dr. A. vacated the premises and had no further 
interest in the practice. - 7 


A Complaint that Failed 


An insured person complained that an insurance 
doctor had refused to continue to provide treatment 
forhim. On June 21st, 1935, he applied to the doctor 
for treatment for a swollen hand, having previously 
given. notice of his desire to transfer to another doctor 
as from July Ist, 1935. According to the com- 
plainant the doctor questioned him as to why he 
was transferring and suggested he should obtain 
treatment from the new doctor, to which he replied 
that he was transferring because he had changed his 
address but the transfer would not be effective until 


-the end of the quarter. The insured person added 


that the doctor prescribed ointment but upon being 
asked whether the patient should attend again said 
that it was not necessary. The man, thinking that 
-the doctor was off-hand in his manner towards him, 


assumed that the doctor was not willing to treat 


him and accordingly consulted the doctor to whom 
he was going to transfer, paying him 12s. 6d. and 
incurring further expense amounting to 4s. for 
dressings. The doctor denied that he told the patient 
to obtain treatment from the new doctor and said he 
knew the man was entitled to treatment from him 
until the end of the quarter, and added that if he had 


686 THE LANCET] 


PUBLIC HBALTH 


[marca 21, 1936 


wanted the patient to go elsewhere for treatment 
he would have given his consent to an immediate 
transfer. 

The medical service subcommittee thought there 
had been a misunderstanding on the part of the insured 


person and were satisfied that there was no failure 
on the part of the doctor to comply with the terms 
of service. The case does however illustrate the 
embarrassment caused both to doctors and patients 
by existing arrangements for local transfers. 


PUBLIC HEALTH 


A New English Life Table 


THE series of English life tables begun by William 
Farr in 1841 has been regularly carried on by his 
several successors, a new table being constructed 
at the conclusion of each decade. The latest addition, 
just published by the Registrar-General, and officially 
designated English Life Table No. 10, has been 
constructed by the Government Actuary, Sir Alfred 
Watson, on the basis of the 1931 census and the 
mortality experienced in England and Wales in the 
three years 1930-32. Although the finer points of 
actuarial practice, as displayed in graduation for- 
mule for instance, may escape the attention of the 
public health worker, there can be no doubt that 
he will find matters of considerable value and interest 
in the finished product. 


EXPECTATION OF LIFE 


For example, taking the expectation of life at 
birth we find that it has increased for males from 
40-2 years in 1841, to 51-5 years in 1910-12, 55-6 in 
1920-22, and 58-7 in 1930-32, the corresponding 
figures for females being 42-2, 55-4, 59-6, and 62-9. 
Thus, at the mortality-rates of 1930-32 the average 
duration of life from birth for both sexes is a little 
more than three years above the value given by the 
death-rates of 1920-22. 


It is of some interest to compare the latest values 
with those of some other countries. Using this 
expectations of life at birth we find that the present 
English figures differ inappreciably from those for 
the white population of the United States, are 24-34 
years better than the corresponding figures for Scot- 
land, but are still 5-6 years below the figures for 
New Zealand, the country which at present enjoys 
the highest expectation of life at birth in the world. 

The value at birth gives, of course, only a limited 
view of the mortality experience. Comparing the 
expectations of life at different ages in England and 
Wales in 1920-22 with the values in 1930-32 we 
find that for both sexes the values have increased, 
by decreasing amounts as age rises, until age 69 is 
reached in males and age 78 in females. At these 
advanced ages the average duration of subsequent life 
is now rather less than it was in 1920-22 or in 1910-12. 
It is possible that this deterioration can be explained 
in terms of the survival of the fittest, that there is a 
survival to old age in the present generation of 
weaker members of the community who under the 
conditions prevailing in the past would have suc- 
cumbed before old age was reached. 


VITALITY OF MARRIED WOMEN 
In addition to the National Tables the Govern- 


ment Actuary has calculated a valuable series of 


sectional tables, by means of which the rates of 
mortality of females according to marital condition 
can be compared as well as different sections of the 
country one with another. The most striking feature 
in the former investigation is the increase at the 
younger adult ages in the vitality of married women 
as compared with single women. Although the 


maternal mortality-rate (ratio of deaths assigned to 
childbirth to total births) has slightly increased, the 
large reduction in the number of births in recent 
years has led to a smaller total of deaths from puer- 
peral causes. The reduction in the birth-rate has 
thereby diminished the rate of mortality among 
married women at the child-bearing ages. 

A comparison of the county boroughs of Durham 
and Northumberland with the rural districts of the 
east of England also gives very striking results. 
Out of every 1000 boys born in the former 96 fail 
to survive the first year of life compared with only 
57 in the latter; of 1000 girls 73 fail to survive 
in the former and only 45'in the latter. At age 60 
the number out of 1000 males who fail to survive 
to age 60 is in England and Wales 149, in the county 
boroughs of Durham and Northumberland 165, 
and in the eastern rural districts 100 only, the corre- 
sponding numbers for females being 111, 125, and 97. 


HEALTHINESS OF THE OUTER RING 


Finally, a special investigation has been made of 
the mortality of Greater London divided into its 
two constituent sections (1) London administrative 
county and (2) the outer ring. The figures indicate 
the superiority of the mortality experience of the 
latter over that of the former. Comparison of the 
London suburban areas with other urban areas in 
the country as a whole shows that the outer ring of 
London is conspicuous for the lightness of its death- 
rates over the whole span of life. 

This volume, it will be clear, carries on most 
effectively the long and honourable line of English 
life tables. 


Medical Members of L.C.C. Committees 


The London County Council last Tuesday re-elected 
Lord Snell as chairman for the ensuing year, and on 
the recommendation of the general purposes com- 
mittee approved (amongst others) the names of a 
number of medical members to serve on various 
standing committees : 

Establishment : Miss E. Rickards, F.R.C.S. 

Hospitals and Medical Services: Dr. C. W. Brook, 
Dr. S. Monckton Copeman, Mr. Somerville Hastings, 
F R C.S., Dr. S. W. Jeger, Dr. F. Barrie Lambert, Miss 
Rickards, and Dr. Henry Robinson. 

Housing and Public Health ;: Dr. J. A. Gillison. 

Mental Hospitals : Dr. Robinson. 

Parliamentary : Dr. Bernard Homa and Dr. Jeger. 

Public Assistance : Dr. Barrie Lambert. 

Public Control: Dr. Homa. 

In addition to these Dr. Sophia Jevons was codpted 
on the Education Committee; Dr. H. L. Eason and 
Mr. R. H. P. Orde, Secretary of the British Hospitals 
Association, on the Hospitals Committee. 


Medicine is thus thinly but well represented over the 
various fields of the Council’s activities. 


a 


CUMBERLAND INFIRMARY.—Presiding at the annual 
meeting of this hospital the Bishop of Carlisle spoke of 
the heavy expense involved by motor and accident cases. 
During the year their cost to the hospital was £888, of 
which only about £379 had been recovered. 


THE LANCET] 


[magcon 21, 1936 687 


OBITUARY 


JOHN SCOTT HALDANE, C.H. F.R.S. 


THE death on Sunday last of Prof. J. S. Haldane 
in his 76th year ends the life and work of one of the 
greatest—perhaps the greatest—of modern physio. 
logists who for practically half a century has been 
continuously producing work and thought of the 
highest order in a great diversity of fields. 

In Edinburgh, where he was born and brought up, 
Haldane began as a philosopher and philosophy 
remained a lasting interest with jhim and explains 
a good deal of what he did and said in later life. 
His discoveries were made by thinking out what 
ought to happen and he generallymade experiments 
simply to verify suspicions or conclusions at which he 
had already arrived ; for experimentation to see what 
would happen he 
had little use. And 
yet, while labora- 
tory work was a 
relatively minor 
thing in his life, 
he is best known to 
the general run of 
workers in medical 
schools nowadays 
as the originator 
of incomparably 
simple and accurate 
technical methods ; 
the hæmoglobino- 
meter came from 
an interest in the 
oxygen-carrying 
power of the blood, 
the gas analysis 
apparatus from an 
inquiry into deaths 
after explosions and 
fires in mines, the 
alveolar air method 
of determining the 
condition of the respiratory centre from meditation 
on what probably regulated ordinary respiration. 
And these three examples explain too the position 
he held among such diverse people as clinical patho- 
logists, mining engineers, and physiologists: to 
anything with which he concerned himself, he made 
additions of knowledge which put him in the front 
rank. Breathing was perhaps his greatest interest, 
and he has fortunately left behind him an adequate 
monument in his ‘“ Respiration,” Silliman lectures 
of 20 years ago of which his wonderful vitality 
allowed him to write a new—really new—edition 
long after he was 70. In this he covers normal and 
abnormal breathing as well as other topics which 
he had illuminated—carbon monoxide poisoning, 
mountain sickness, and work in compressed air. 
His interest in mining led him on to some pioneer 
work on silicosis, the discovery of ankylostomiasis 
in Cornwall, and the examination of the effect of high 
temperatures which has more recently matured 
into an explanation of miners’ cramps by salt depletion. 
Not long ago he surprised us with some striking experi- 
ments on colour vision which recalls an earlier interest 
in the twinkling of stars. 

The versatility of which these are but instances— 
a catalogue would be far too long—was not the product 
of a volatile mind which is about the last thing 
of which anyone who knew Haldane would suspect 
him. For most physiologists, the theme which 


PROF. HALDANE 
[Photograph by Russell 


holds their various inquiries together is depart- 
mental—an interest in the circulation or the central 
nervous system, sometimes even a liking for some 
technique. With Haldane, the ‘principle which 
made all his work coherent was a passion for a 
philosophical physiology on which he often wrote 
and lectured: any physiological subject would do 
to illustrate his general faith. What exactly this 
was it was often difficult to understand and as was 
only natural his views went through an evolution 
and development as his thought and experience 
progressed. But throughout he had an implacable 
disbelief in the possibility of explaining what animals 
did by any available system of chemistry and physics. 
At first he argued on such things as the apparent 
secretion of oxygen by the lungs, at any rate im times 
of stress. Later he attached less importance to the 
nature of the mechanisms and laid more stress on the 
ideas that the body works as a whole, and as a whole 
which is something more than its parts, that organisms 
cannot be detached from their environments and that 
their responses follow no hard-and-fast line without 
respect to circumstances. These views are fairly 
intelligible to anyone, and his constant insistence 
that physiology must be looked at in this kind of 
way has permeated much of the modern work and 
produced a change of view which has to be seen 
historically to be appreciated: Haldane’s general 
influence in this way has probably been as important 
as the special impression which he made on the 
topics which he took up in detail. Finally he 
expresses himself as convinced of the necessity of a 
spiritual interpretation of biology with God as the 
final reality, a point of view which is perhaps difficult 
to pass on to anyone who has not felt it for themselves. 
Haldane’s whole career is proof that he found such 
an outlook a most profitable basis for effective research 
of all kinds: those who would like to know more 
of it would do best to read the volume of essays and 
addresses called ‘“‘ Materialism,” and they may be 
less bewildered than the lady who went to hear one 
of his Gifford lectures in Glasgow and on being asked 
how she liked it said “‘ Well enough, though I was a 
bit disappointed: I thought it was to be about 
God and he talked about nothing but kidneys” : 
to Haldane the connexion would be clear enough. 


Haldane was also a great personality—one of 
those men who go about with an aura—and those 
who were lucky enough to be among his pupils at 
Oxford will know what a pity it is that he had not 
done any undergraduate teaching for more than 
20 years. And yet his freedom from the cares of 
routine gave him time and opportunity for his 
wonderful output and there are many graduate 
students who are profoundly in his debt. Kindly, 
courteous, considerate, he did not suffer fools gladly, 
and he was apt to be a little impatient with criticism. 
There was indeed seldom much room for it. 


JAMES RUTHERFORD, L.R.C.P. Edin., 
F.R.F.P.S. Glasg. 


Dr. James Rutherford was born in Kirkmichael 
in 1858, the son of Robert Rutherford, a distinguished 
Greek and Hebrew scholar. He received his medical 
training at Anderson’s and St. Mungo’s Colleges, 
and at the latter institution was medallist in clinical 
medicine. He gained his first diplomas in 1894 and 
served as house physician at the Royal Infirmary, 
Glasgow. Later he went into practice at Harrogate 


688 THE LANCET] 


OBITUARY 


[maron 21, 1936 


where he had a large connexion and also took a 
prominent part in municipal politics, serving as 
deputy-mayor of the town during the war. In 1926 
he was elected F.R.F.P.S. Glasg. Dr. Rutherford 
married Amy Eleanor, daughter of Mr. R. Hyde- 
Parker, of the Wesley College, Sheffield, and was 
the father of three prominent Harrogate prac- 
titioners, Dr. Raphael Rutherford and Mr. Eric 
Rutherford, who succeed him in his practice, and 
Dr. Kathleen Rutherford, who is also a practitioner 
in the town. 


THOMAS BABINGTON GRIMSDALE, M.B.Camb. 


HONORARY GYNZCOLOGICAL SURGEON, LIVERPOOL ROYAL 
INFIRMARY 


Thomas Babington Grimsdale, who died suddenly 
at Seaton, Devon, on March llth, was the son of 
Dr. Thomas Frederick Grimsdale, a widely known 
physician and gynecologist in Liverpool. He was 
educated at Uppingham and Trinity College, 
Cambridge, proceeding to St. George’s Hospital for 
his medical training. At the hospital he was assistant 
medical registrar and assistant house physician, 
and graduating as M.B. Camb. in 1883 returned to 
Liverpool, where he practised with success as a 
gynecological surgeon for nearly 40 years. 

His first appointments in Liverpool were as assistant 
medical officer to the Liverpool Hospital for Women 
and the Liverpool Infirmary for Children, and he was 
shortly elected to the staff of the Liverpool Royal 
Infirmary as gynecological surgeon. The fame of 
the father and Grimsdale’s own merits soon secured 
for him a high position and a large practice, but 
just after his appointment to the Royal Infirmary 
he entered upon a struggle, the recollection of which 
still remains, It is thus described by “W. M. C.’’: 
‘“ Convinced from observation of the work of 
others and the results of his own experience that 
aseptic methods should supersede those of the 
older antiseptic practice, Grimsdale set himself 
zealously to have the new take the place of the old. 
In this endeavour he was strongly opposed by certain 
of his senior colleagues, notably by one who had the 
ear of the then committee. New-fangled ideas, 
especially when they involved considerable expense, 
did not find favour and for a time it seemed that the 
suggested new enterprise must go to the wall. But 
Grimsdale, strong in the right of his cause, kept 
fighting on, an unremitting fight against continued 
opposition from above, until he won on every point and 
was successful in getting the new régime established. 
What is now taken as a matter of course involved 
the pioneers in a struggle against prejudice almost 
unbelievable. It is gratifying to be able to record 
that eventually the chief opponent admitted with all 
chivalry that Grimsdale had been right.” 

In the medical school Grimsdale was a successful 
clinical lecturer and in his contributions to the 
North of England Obstetrical and Gynecological 
Society—of which he became president—and in his 
communications to the Liverpool Medico-Chirurgical 
Journal he showed his practical knowledge of his 
subjects. He wrote only occasionally but always 
delivered a practical message. In his practice he 
was noted for his scrupulous attention to detail, 
while he was a very skilful operator. When the war 
broke out Grimsdale, who had been an acting surgeon 
in the 4th Lancashire Volunteer Artillery, was too 
old to go abroad, but he gave valuable surgical help 
to the St. John Ambulance Brigade V.A.D. Hospital 
in Liverpool, coming to the assistance of the heavily 
overworked surgeon to the hospital, the late Mr. G. P. 


Newbolt. He retired from the staff of the Royal 
Infirmary in 1921 being made honorary consulting 
gynecological surgeon to the Infirmary, and for the 
remainder of his life lived in the South of England. 

Dr. Grimsdale married Helen, daughter of Mr. Henry 
Jevons, but had no family. His younger brother, 
‘Dr. Harold Grimsdale, is consulting ophthalmic 
surgeon to St. George’s Hospital. 


W. M. C. further writes: ‘“‘By the death of 
T. B. Grimsdale a long and eminent family medical 
connexion with our city of Liverpool comes to an 
end—a connexion dating from 1848 when his father 
Dr. T. F. Grimsdale began a brilliant career. T. B. 
Grimsdale, who followed his father in residence at 
29, Rodney-street—a Grimsdale home since 1862— 
would describe himself as the oldest inhabitant of 
Rodney-street, a thoroughfare of medical renown 
in the city. He succeeded his father as gynecological 
surgeon first on the staff of the Liverpool Hospital 
for Women and later on that of the Royal Infirmary. 
The family was a gifted one, and T. B. Grimsdale 
inherited considerable artistic talent which he 
exhibited on occasion in the sketches which it was 
his habit to make of his fellow guests at public 
dinners during post-prandial eloquence. In his 
professional work he was meticulous to the last 
degree, not tolerating carelessness on the part of his 
coéperators, whether doctors or nurses, while to 
assist him in his operative work was an education 
in the technique of abdominal surgery. I often had 
this privilege and have often felt that I never did so 
but I learned something in the minutiæ of technique. 
In his time he was an active sportsman. As a 
cricketer he made occasional appearances in the 
Lancashire county eleven, while he was captain of his 
golf club. After retirement he became devoted to 
fishing.” 


ERNEST HARRISON GRIFFIN, D.S.O., M.C., 
M.R.C.S. Eng. 


THE death occurred on March 10th of Dr. Ernest 
Griffin, to the regret of a large number of patients 
and friends acquired in the course of an interesting 
and adventurous career. 

Ernest Harrison Griffin was born at Walsall in 
1877 where his father was connected with the Walsall 
Observer. He was educated at Queen Mary’s School, 
Walsall, and entered Peterhouse, Cambridge, as 
an undergraduate in 1895 where he graduated in 
arts. He proceeded to Guy’s Hospital as a medical 
student and did some post-graduate work in Paris. 
He obtained the L.S.A. diploma but did not proceed to 
medical graduation, commencing at once his pictur- 
esque career. He took a post as medical officer 
in the Venezuelan Rio del Oro Goldfields Company 
and was for a time surgeon to the El Dorado Gold- 
‘mining Company. He received in Venezuela the 
Order of the Liberator. On his return to England 
he developed an interest in psychological medicine 
and for a time acted as assistant physician and 
pathologist to the Camberwell House Asylum. He 
also gained the diploma at Cambridge of D.T.M. and 
Hy. But he had a veritable spiritfor adventure and 
he became surgeon to the Red Crescent Society 
in the Italo-Turkish war of 1911. In Tripoli he 
saw very much fighting in a campaign complete 
with the incidents of guerrilla warfare and was 
Seriously wounded and left on the battlefield for dead. 
He was, however, rescued, and the recollection of the 
courage and devotion of his Turkish comrades was 
always vivid with him. His brief work “Letters of 


{ 


THE LANCET] 


OBITUABY 


[marnoH 21, 1936 689 


a Wanderer,” written in 1913, deals with many exciting 
experiences of which he later gave more in a volume 
entitled ‘‘ Adventures in Tripoli.”’ 

Taking up his life again in England he held the post 
of resident medical officer to the French Hospital, 

. where he had once 
been a clinical assist- 
ant, but he joined 
up on the outbreak 
of the European War 
as a temporary cap- 
tain in the R.A.M.C. 
He soon became con- 
spicuous for his devo- 
tion to duty and his 
remarkable courage. 
He was wounded 
several times and 
thrice mentioned in 
dispatches; was 
awarded the M.C. 
and bar and received 
the D.S.O. for con- 
spicuous gallantry, 
the occasion being 
thus described in the 
Gazette :— 

“ He established his 
dressing station well 
ie aan during an attack, and went up to the front line 
chrough a storm of artillery and machine-gun fire utterly re- 
gardless of personal safety. He moved about in the open for 
36 hours without food or rest, attending to the wounded, 
often leading parties of bearers through heavy barrages 
until every wounded man had been carried back. He 
remained behind after the battalion was relieved, still 
searching for wounded, under heavy fire, though he was 
several times badly shaken by the explosion of shells.” 


In 1918 he was reported dead as he had been 
reported nine years before in the Italo-Turkish war. 
This occurred during the last great German offensive, 
when he was found on the battlefield by the Germans 
to be stillalive. In the war hospital he was recognised 
by the Turkish ambassador through whose representa- 
tions his release was obtained, and he returned to 
England, with his health seriously damaged by his 
terrible experiences, though he remained at work 
as a specialist in venereal diseases with the Aldershot 
command. 

At the conclusion of hostilities he picked up the 
threads of his academic career, graduated M.A. 
at Cambridge, took the English double diploma, and 
started in practice in Upper Berkeley-street, specialis- 
ing in medico-physics. He met with considerable 
success; his interesting personality counted here, 
while his outspokenness secured confidence and he had 
thoroughly equipped himself. He always retained 
his deep interest in Turkey. He became honorary 
secretary of the British Red Crescent Society and 
medical officer to the Ottoman Embassy. He was 
the main founder of the Near and Middle East Associa- 
tion, and was prominent in the development of a 
body that has done much to shed public light upon 
many serious political and racial difficulties in Asia 
Minor and Palestine. He was unmarried. 


DR. GRIFFIN 


[Photograph by Swaine 


SIDNEY HERBERT CLARKE, M.D. Camb. 


Dr. Sidney Herbert Clarke, who died on March 5th, 
was the son of the late Dr. J. St. T. Clarke and was 
educated at Oakham and Gonville and Caius College, 
Cambridge. He proceeded for his medical education 
to the London Hospital and graduated as M.B., 


B.C. Camb. in 1905. His first direction of practice 
was in psychiatry, and he was assistant medical 
officer to the Leicester and Rutland Asylum, the 
Newport Borough Asylum, and the County Asylum,,. 
Prestwich. In 1909 he obtained the M.D. degree 
and later commenced practice in St. Albans, being 
at the time of his death surgeon to the St. Albans 
and Mid-Herts Hospital, and honorary secretary of 
the Hertfordshire Medical and Panel Committee. 


ROBERT RENDLE LEATHEM, M.B. R.U.I. 
CONSULTING PHYSICIAN, BELFAST HOSPITAL FOR SICK 
CHILDREN 


Dr. Robert Leathem, who died recently at his 
home, Mountnorris, Newcastle, Co. Down, was 
educated at the Royal Academical Institution, 
Belfast, and entered the Queen’s College as Pakenham 
Scholar. He graduated in arts with first-class honours 
in 1889, won the Dunville Studentship two years 
later, and qualified M.B., B.Ch., B.A.O. with honours 
in 1893. After holding various resident hospital 
appointments he commenced practice in Belfast. 
From the first he took a special interest in children 
and quickly won their confidence and affection. 
He loved his work as physician at the Belfast Hospital 
for Sick Children. His lectures attracted large 
numbers of students to the hospital for his clinical 
teaching was always arresting, lucid, and practical, 
illustrated from his rich clinical experience and his 
wide knowledge of the literature of pediatrics. 
Possessing a logical and analytical mind, he studied 
each patient with absorption both from a physical 
and psychological standpoint. The words of Trousseau 
were true for Leathem—‘“ Il n’y a pas de maladies : 
il n’y a que des malades.” He gave to his patients 
of his very best, no matter what the giving cost 
him in nervous energy and physical strength. Thirty 
years of concentrated work told on a frame never 
robust, and taking heed to certain subjective cardiac 
warnings he retired from practice some years ago. 


A friend writes: ‘All though Leathem’s life 
beauty—in nature, in art, in literature, in architecture 
—had struck a responsive chord in him. On his 
retirement, still in his prime, he was fortunate in 
being able to, surround himself with the beautiful 
things he loved. His home, which lay on the foothills 
of the Mourne Mountains, was surrounded by a 
garden which at every season of the year was lovely, 
and his home was filled with beautiful things, 
furniture and pictures, for he was a connoisseur and 
a keen and gifted collector. His interest in the 
Children’s Hospital never waned. Ceaselessly he 
urged the board of management to leave their cramped 
quarters in the heart of the city and to build a 
modern hospital in the open space facing the Antrim 
Hills available close by the Royal Victoria Hospital. 
Having carried this point he threw himself with 
enthusiasm and thoroughness into the consideration 
of plans, and the new Children’s Hospital embodies 
many of his ideas. To-day it stands a permanent 
memorial to his courage, faith, and generosity.” 


MEDICAL CONGRESSES AT WIESBADEN. — Owing 
to the Reichstag election the various congresses 
arranged to be held at Wiesbaden in the last week in 
March have been postponed. The Gesellschaft für innere 
Medizin will meet from April 20th to 23rd, the Röntgen 
Gesellschaft from April 23rd to 25th; and from April 
18th to 20th will meet the Reichsarbeitsgemeinschaft 
fir eine Neue Deutsche Heilkunde. Room reservations 
are now to be sent to the Städtische Kurverwaltung, 
Wiesbaden, Germany. 


690 THE LANCET] 


CORRESPONDENCE 


THE NUTRITION QUESTION 
To the Editor of THE LANCET 


Sir,—May I reply to Dr. Hutchison’s contention 
that practitioners in touch with the poorer classes 
would deny the existence of widespread malnutrition ? 
In assessing malnutrition we are bound to get a great 
divergence of opinion, as the term is ill-defined. 
It is also unsatisfactory as it is an etiological defini- 
tion. If in its place we substitute the term “ unsatis- 
factory physique,” and give this as specific a meaning 
as we Can, we are on safer ground. By unsatisfactory 
physique I mean a child (I am confining myself here 
to discussing children) who is below weight, generally 
below average height, thin, with poor muscle tone and 
poor posture, who is pale, whose mucous membranes 
are pale, and who has baggy eyes and a tired look. 
Such children look prematurely old. I recently 
found some 70 such cases amongst 240 boys in a 
poor East End district. 

Dr. Hutchison contends that sheer poverty is 
not a cause of malnutrition. Be that as it may, 
I think the following figures in connexion with the 
“unsatisfactory physique” may be of interest. 
In the course of an investigation, I had occasion to 
compare two groups of 40 East End children. One 
group was especially picked to contain only children 
of the best physique. The other consisted of the 
type of child described above. In the “good ” 
group, ‘“‘ poor circumstances” (meaning long spells 
of unemployment, irregular work, or disablement 
of the father during the child’s life) were present 
in 6 cases; in the “ bad ” group, poor circumstances 
occurred in 26. In the “good” group there was 
only 1 case where the parent declared that at any 
time during the child’s life it had been short of food ; 
in the “ poor” group this history was elicited eight 
times. Parents give notoriously bad histories, but 
chance alone would not give such a difference. More- 
over parents who think their children have not had 
enough to eat look upon this as a reflection upon 
themselves, and it needs close questioning to elicit 
such an admission. Then the most one gets is 
an answer such as “‘ Well he didn’t get all we should 
have liked him to.” This means the child may have 
had only two meals a day. In bad times it appears 
that the diet contains little besides potatoes, greens, 
meat on alternate days, porridge and bread and 
margarine for breakfast, and for supper tea with 
some milk and bread and jam. 

A number of parents have told me they have gone 
short themselves to feed their children. The average 
wage of a family is about £2 5s. a week—seven 
living on £2 10s. and one case of three on 22s. a week 
—9s. rent are a few cases that come to my mind. 
Such cases certainly appear to avoid the dangers of 
over-nutrition against which Dr. Ifutchison warns us! 


Obviously other factors such as overcrowding 
and nervousness play a part. Again, if I may further 
quote my own figures, 7 cases of nervousness occurred 
in the ‘“‘ good”’ group, 13 in the “bad ” one, where 
conditions dependent on poverty predominated. 

I submit that it is very important that we should 
not allow a discussion on malnutrition to become 
academic because of difficulty in defining the term, 
or because of prejudices which may have become 
attached to the word. What is essential to realise is 
that an enormous number of working-class children 
are in an unsatisfactory condition compared to those 


of the well-to-do classes, and that their condition 
is due to factors associated with poverty. 
I am, Sir, yours faithfully, 


W. L. NEUSTATTER. 
Devonshire-place, W., March 14th — 


PROGNOSIS IN SPINAL CARIES 
To the Editor of THE LANCET 


Smr,—I have read with interest Mr. Persy Fisher’s 
kindly criticism of the statistics in my article and 
hasten to reply. Mr. Fisher has misread the figures. 
I did deal with only those cases in which a con- 
clusion had been reached, which is exactly what he 
advocates. The figures then are— 


Total cases the outcome of whichis known 1582 
Of these there died eee cs ss sa 61 


Percentage of deaths bce ; 3-8 
Of the total number of cases admitted (1666) 84 
remained under treatment on March 3lst, 1935; 


these do not count for mortality statistics as treatment 
was not concluded. The error in the causes of death 
is accounted for in this way: In the causes of death 
it was stated that 16 children (1-01 per cent.) had 
died of sepsis and amyloid disease, but in the 
following table 15 were stated to have died of that 
condition and 14 other causes. The discrepancy was 
due to the fact that one of the patients, a child with 
a tuberculous spine, had a non-tuberculous empyema, 
which was the cause of death. She was septic and 
amyloid but death was not due to tubercle and so 
was entered under “‘ Other causes.” 
I am, Sir, yours faithfully, 
March 16th. HENRY GAUVAIN. 
INTRAVENOUS ANASTHESIA FOR 

CHILDBIRTH IN A MENTAL HOSPITAL 


To the Editor of THE LANCET 


Sir,—The care of a pregnant psychotic patient 
presents a series of problems for which there is no 
authoritative solution. In spite of the supposed 
stigma to the coming child it is generally agreed 
that the primary consideration is the proper treat- 
ment of grave mental illness. Antenatal care must 
be more than usually thorough, since psychotic 
patients séldom reveal the early symptoms of toxemia. 
Special difficulties occur in the diagnosis and manage- 
ment of labour. There is a real danger of depressed 
or stuporose patients passing quietly and unnoticed 
through all the stages of labour, and this risk can 
be avoided only by frequent examinations and careful 
observation as the patient approaches term. The 
actual management of labour involves exceptional 
risks, including violence and a tendency to excessive 
uterine action. These risks can be avoided by 
means of continuous anesthesia. The method of 
choice is intravenous anxsthesia with Evipan or 
Pentothal. 

Pentothal sodium 1 g. is dissolved in 10 c.cm. redistilled 
water. Intravenous injection is begun at the onset of 
strong and regular labour pains. The initial dose of 2 c.cm. 
is followed a minute later by a further 2 c.cm. The patient 
is now unconscious and the syringe can be fastened to the 
forearm. Labour is unaffected but the patient becomes 
increasingly suggestible and amenable. Gradual emer- 
gence from this twilight state is an indication for a further 
l c.cm. This degree of narcosis is conducive to adequate 
coéperation during the second stage of labour. Repeated 
injections of 1 c.em. may bo given as often as required, 
and the twilight state can be deepened into surgical 
anzsthesia by injecting a further 3 c.cm. This is invaluable 


THE LANCET] 


~~ 


PRURITUS OF THB VULVA AND ANUS 


[MARCH 21, 1936 691 


for the performance of obstetric operations or perineal 


repairs., 

At the end of labour it is convenient to inject 
ergometrine intravenously before removing thesyringe. 
The recovery-rate is very quick and unaccompanied 
by restlessness. 
tion is that there is no apparent ill-effect on the child. 
This technique is on the lines suggested recently 
in your columns by Dr. Jarman and Mr. Abel (THE 
LANCET, Feb. 22nd, p. 422, and March 14th, p. 600). 

I am, Sir, yours faithfully, 
- Dorchester, March 14th. STEPHEN -HORSLEY.. 


PRURITUS OF THE VULVA AND ANUS 
To the Editor of THE LANCET 


Smr,—The causes of the above conditions which 
are enumerated in the interesting article by Dr. 
Elizabeth Hunt in your last issue differ widely from 
those which I see in private practice. In 1929, at 
your request, I wrote on the treatment of these 
maladies, and subsequent experience confirms my 
opinion that the chief cause of vulvar pruritus is 
a discharge from the vagina, cervix, or uterus. 
Perhaps it is because gynecological cases are sent to 
me for treatment with local ionisation or diathermy 
that a discharge forms so high a causal proportion 
among my list of cases of vulvar pruritus and eczema. 
The most irritating of such discharges is usually due 
to B. coli infection, and when this is accompanied 
‘by fecal streptococci the pruritus soon becomes 
eczematous. Next in order comes B. coli urinary 
infection, and an eruption which I label (perhaps 
wrongly) streptococcal dermatitis; this may be the 
rash which others call seborrheic dermatitis. It 
shows a vivid erythema on and round the vulva, 
whilst the thighs, groins, and lower abdomen are 
covered with small round or ovoid patches, slightly 
scaly at their edges; where these join the eruption 
has a circinate margin. On staining the scales no 
bottle bacilli are seen, nor fungi, but only cocci. 
Later fissures and weeping develop; the condition 
responds to the treatment for streptococcal derma- 
titis. Sometimes this rash follows a vaginal discharge, 
but quite as often it arises without apparent 
cause. Tight combinations, with thick folds, 
especially in winter, appear in some cases to set up 
this rash. Other causes are friction and perspiration, 
especially in summer, in stout women, and tight 
clothing which is contaminated with urine and 
fæces. Fungal infection was often seen after the 
war, but of recent years, although it appears to be 
as common on the feet, I have not seen so many 
cases of vulvar infection due to this source. Leuco- 
plakia, lichen planus, and diabetes figure rarely in 
my list of cases. I saw one case of leucoplakia clear 
up when unnecessary vaginal douches were stopped ; 
but the very next case which came my way soon 
developed malignant disease, and neither radium 
nor surgery could avert a fatal issue. 
these cases do not immediately respond to soothing 
remedies I prefer to send them to a surgeon. Krau- 
rosis in elderly women, on the other hand, usually 
answers to diathermy with surprising success. I 
have comparatively recently become aware of another 
cause of relapsing irritation—namely, B. coli infection 
of the urethra. 

As regards the anus, the chief cause of pruritus 
appears to be extension from streptococcal vulvar 
infection, paraffin leakage, mucous leakage in asso- 
ciation with hzmorrhoids, and threadworms. I am 
always glad I heard the masterly address by Colonel 
MacArthur to the British Medical Association at 


Hence, when: 


A last and most important observa- » 


Eastbourne on this subject. Since then I have found 
several cases of severe, extensive eczema of the ano- 
genital region, which had been cured more than 
once and relapsed at varying intervals of time, 
clear up rapidly and for good when treatment was 
focused on the threadworms. | 

I am, Sir, yours faithfully, 

.Devonshire-place, W., March 16th. AGNES SAVILL. 


TREATMENT OF VAGINAL DISCHARGE 
To the Editor of THE LANCET 


S1r,—It has been my experience in Germany that 
leading professors of gynecology and obstetrics, 
as masters of the scalpel and the X rays, sometimes 


. do not take much interest in vaginal discharge and 


leave the treatment of this minor malady to their 
assistants. Progress in this field is therefore slow. 

‘The pharmacological industry has produced a 
great many preparations for treating the condition 
and Devegan is one of the newest and best recom- 
mended of these. A remedy for vaginal discharge, 
however, has often to be applied for weeks and even 
months, so that expensive drugs have to be abandoned 
as the cost becomes too high. I have therefore 
tried to find a cheaper preparation. I read that 
Prof. C. J. Gauss, of Würzburg, was recommending 
Vagintus, a granulated form of aluminium acetate. 
The salt, which in Germany costs only about 5s. 
per lb., should be procurable from any chemical 
manufacturer. But it must be in granulated 
form; the ordinary powder would clot together. 
Before using it the vagina and cervix is lightly 
cleaned, through a speculum, with cotton-wool and 
hydrogen peroxide to remove the alkaline mucus. 
A teaspoonful of the acetate is placed near the cervix 
and the vagina is closed with a dry tampon, which 
the patient removes some hours later. This is 
done twice a week. If it is convenient for the 
patient to attend, boric acid powder is introduced 
on the other days in the same way. The treatment 
has remarkable effects even after the first application, 
and nearly always at the second attendance the 
patients appear happy and pleased at the sudden 
disappearance of an evil-smelling discharge. 

The advantages of the dry aluminium acetate 
powder treatment are: (1) the remedy is extremely 
cheap; (2) it has an immediate effect, giving 
confidence to a patient sometimes in despair through 
having the discharge for years ; (3) it is based on the 
physiological principle that the reaction of the 
healthy vagina must be acid. It produces twice or 
three times a week a strong acid reaction, lasting 
many hours from the big quantity introduced ; and 
nature generally finds a way to restore the normal 
healthy flora formed by Déderlein’s bacillus of acidum 
lacticum. 

I agree with Mr. Gordon Luker that we have to 
consider endocervitis or even salpingitis as a common 
cause of discharge but, in practice, even the most 
skilful gynecologists cannot arrive quickly at this 
diagnosis. I am well acquainted with the American 
literature of my specialty and I know how many 
methods, especially that of electrocauterisation of the 
cervix, have been advocated by them; but all are 
complicated and give the patient the impression 
that her condition is serious. In Prof. Gauss’s 
opinion, if we merely cleanse the vagina and produce 
an acid reaction, the self-helping and self-healing 
forces of nature may also heal an endocervitis. 
Medicus curat, natura sanat. 

I am, Sir, yours faithfully, 

London, March 17th. R. Kunn. 


. we 


692 THE LANCET] 


A QUESTION OF PROFESSIONAL 
CONFIDENCE 


To the Editor of THE LANCET 


Siz,—Particulars of a recent tragedy may serve as 
a warning to more than one section of your readers. 
A is a practitioner attending a family in which B 
is a general servant. B develops what A thinks is an 
“acute abdomen >° and is sent into hospital for 
operative treatment. In hospital B is found to be 
suffering from gonococcal salpingitis not requiring 
operation and is transferred to the “V.D.” ward. 
While in this ward B is visited on the ordinary 
visiting day by A who, without permission and in 
the presence of the nurse, takes down and reads the 
case record on the bed-card. Two days later, and 
while still in bed in the ward, B receives notice of 
dismissal from her mistress who is A’s patient. 
B, whose’ previous record is highly creditable, is now 
contemplating suicide. I should like to know what 
my fellow practitioners think of A’s action. It is 
important to add that B is still on his panel. 


I am, Sir, yours faithfully, 


March Ist. TATROS. 


*.*The case raises medico-legal issues that are 
repeatedly cropping up in practice. We think A’s 
conduct cannot be defended, because (1) he made 
use without permission of case records belonging to 
the hospital; (2) information might be contained in 
these records which B did not desire to disclose 
to A; (3) if A communicated to B’s mistress (presum- 
ably without B’s knowledge and consent) information 
which led to the notice of dismissal two days after 
his visit to the hospital, A committed a serious 
breach of professional confidence ; (4) if the dismissal 
was the result of information conveyed by A as to 
the nature of B’s illness, his conduct must be held 
responsible for the nervous upset made manifest by 
B’s threatened suicide. The fact that B’s previous 
record was “‘highly creditable ” suggests an inquiry 
whether the diagnosis of gonococcal salpingitis was 
correct. Was the gonococcus identified in the dis- 
charge from the cervix? Was a cultivation made ? 
If not, the precise nature of the salpingitis could 
hardly be determined unless the tubes were inspected 
and examined under the microscope. Tuberculous 
salpingitis may occasionally be acute, or, what is 
more common, salpingitis may complicate appendicular 
or colonic inflammation. Infection from contra- 
ceptive appliances must also be excluded before 
assuming a venereal infection. On the other hand, 
if the diagnosis were correct it is the business of the 
hospital to make sure that B is treated until she 
is no longer a possible source of infection, when she 
could have resumed her employment.—ED. L. 


STAMMERING 
To the Editor of THE LANCET 


Sir,—Miss Kate Emil-Behnke and her family 
have contributed so much to the literature and 
analysis of the technique of speech that I am not 
prepared to argue with her, but she seemed to me 
to advocate the use of elocution and, in almost the 
same breath, to say that it was useless. As a self- 
cured stammerer long before I undertook the cure 
of other stammerers I believe that the coérdination 
of all the muscles concerned in speech—that is, true 
elocution—will correct stammering, which is first 
of all due to unbalanced speech or lack of coérdination. 
From personal experience I know the confidence 


A QUESTION OF PROFESSIONAL CONFIDENCE 


‘([marnon 21, 1936 


which results from a full understanding of the 
mechanism of speech. | 
I am, Sir, yours faithfully, 
H. St. JOHN Rumsey, M.A., 


March 16th. Speech Therapist, Guy’s Hospital. 


INFECTIOUS DISEASE 


IN ENGLAND AND WALES DURING THE WEEK ENDED 
MARCH 7TH, 1936 


Notifications.—The following cases of infectious 
disease were notified during the week: Small-pox 0, 
scarlet fever 2491, diphtheria 1162, enteric fever 28, 
acute pneumonia (primary or influenzal) 1431, 
peurperal fever 44, puerperal pyrexia 152, cerebro- 
spinal fever 26, acute poliomyelitis 3, encephalitis 
lethargica 6, dysentery 49, ophthalmia neonatorum 
86. No case of cholera, plague, or typhus fever was 
notified during the week. 

The number of cases in the Infectious Hospitals of the London 
County Council on March 13th was 5656, which included : Scarlet 

973; diphtheria, 1069; measles, 2138; whooping- 
cough, 729; Puce pers. fever, 17 mothers (plus 11 babies); 
encephalitis ethargica, 283; poliomyelitis, 4. At St. 
Margaret’s Hospital there were 28 babies (plus 15 mothers) 
with opbthalmia neonatorum. 

It will be noted that the number of cases of measles now 
hospitalised in London amounts to 2183, which is :409 more 


than last week, and is evidence of the rapid spread of the 
epidemic of measles in the county. 


Deaths.—In 121 great towns, including London, 
there was no death from small-pox, 3 (0) from enteric 
fever, 84 (22) from measles, 3 (1) from scarlet fever, 
37 (9) from whooping-cough, 41 (1) from diphtheria, 
64 (20) from diarrhoea and enteritis under two years, 
and 112 (28) from influenza. The figures in paren- 
theses are those for London itself. 


It will be noticed that the mortality from measles is rising, 
although not rapidly, the figures for the last six weeks (working 
backwards) being 84, 88, 78, 58, 34, 41 for the country as a 
whole and 47, 38, 18, 14, 13, 9 for Greater London. There is 
a corresponding or even larger rise in the number of cases for 
which hospital treatment has been sought at L.C.C. hospitals. 
The inference may be drawn either that the disease is not 
present in severe form or that the prompt measures taken in 

ondon to get serious cases into surroundings where they can 
be looked after have been successful. Liverpool reported 
8 deaths from measles during the week, Willesden and Man- 
chester cach 5, Ilford, Leeds, and Preston each 3. 

Deaths from influenza throughout the country remain nearly 
constant. This week they are scattered over 51 great towns, 
Middlesbrough reporting 5, Newcastle-upon-Tyne, South 
Shields, and Birmingham each 4, Ealing, Leeds, Sheffield, 
Leicester, and Nottingbam each 3. Manchester reported 
6 deaths froin whooping-cough, Leeds 3, no other great town 
more than 2. Deaths from diphtheria were reported from 
27 great towns, 3 each from Hull, Liverpool, and Newcastle- 
upon-Tyne. 


The number of stillbirths notified during the week 
was 300 (corresponding to a rate of 44 per 1000 total 
births), including 44 in London. The number 300 
has not been reached before since official notification 
was instituted. 


Ivory Cross Funp.—The annual general meet- 
ing of the Ivory Cross National Dental Aid Fund 
was held on March 12th. The council confirmed 
the decision of the executive committee, publicly 
announced over a year ago, not to accept donations 
which are the proceeds of gambling parties, nor in 


‘future to be associated with anyone employing such 


methods for raising money. The hope was expressed 
that their action would be widely followed by many 
charitable organisations which in the past had, under 
the pressure of need, accepted money that had been 
raisod in this way. It was announced that the executive 
committee were negotiating with the commissioner for 
the special areas with a view to extending the work of 
the Ivory Cross Fund in certain special areas, with parti- 
cular reference to the treatment of adolescents at junior 
instruction centres and at juvenile clubs. In present 


circumstances youths from 14 or 15 to 19 years of age. 


are not entitled to dental benefit under the present health 
insurance Acts which, in any case, only give dental benefit 
to 50 per cent. of the male and 30 per cent. of the female 
members of approved societies. 


ry ee 


7 a ieee Ay ete es ed 


THE LANCET] 


[magos 21, 1936 693 


MEDICAL NEWS 


University of Oxford 

On May 5th a proposal to establish an institute of 
experimental psychology at Oxford is to be put forward 
in convocation. An anonymous donor has already offered 


£10,000 towards the scheme, and Dr. William Brown will 


be proposed as first director. 


‘University of Cambridge | 
On March 13th the following degrees were conferred :— 


M.D.—R. Huxley Fish and M. S. Spink. 
M.B. & B.Chir.—*J. R. Duffield, R. M. Yeo, and W. G. Q. 


B.Chir.—C. U. Gregson and W. M. Beattie. 
* By proxy. 


University of Edinburgh | 

The senatus of the University has resolved to offer 
the hon. degree of LL.D. to Dr. Mervyn Gordon, F.R.S., 
consulting bacteriologist to St. Bartholomew’s Hospital, 
and Colonel the Hon. Murray Maclaren, M.D., lieutenant 
governor of New Brunswick. 

The Paterson travelling scholarship has been awarded 
to Dr. G. Bowman Ludlam. 


Congress of Experimental Cytology 

The fourth International Congress for Experimental 
Cytology will be held in Copenhagen from August 10th 
to 15th. The chief subjects to be discussed are: the 
physical chemistry of the cell, histochemical problems 
and cell metabolism, experimental morphology, the 
electrophysiology of the cell, experimental cell pathology, 
and the biology of irradiation Further information may 
be had from Dr. Harald Okkels, Institute for Pathological 
Anatomy, 11, Frederik 5’ Vej, Copenhagen. 


Royal College of Surgeons of England 

A meeting of the council was held on March 12th 
with Sir Cuthbert Wallace, the president, in the chair. 
Mr. E. K. Martin was elected to the court of examiners, 
and Mr. F. N. Doubleday to the dental section of the 
board of examiners in dental surgery. It was decided 
that a graduate in dental surgery (M.D.S. or B.D.S.) of 
a recognised university in the United Kingdom shall in 
future be exempt from the whole of the first examination 
for the licence in dental surgery, and be admitted direct 
to the second and final examinations. It was also decided 
that private pupilage in dental mechanics need not neces- 
sarily be taken after the preliminary examination in 
general education has been passed. 

A reception will be held at the College on Monday, 
July 6th. 

It was decided that a further guarantee of £1625 from 
the Prophit trust fund should be given towards the expen- 
diture of the governing body of the Radium Beam Therapy 
Research for 1937. Mr. G. E. Gask has undertaken to 
give a lecture on Feb. 15th, 1937, on the recently acquired 
Hunterian manuscripts relating to the British campaign 
in Portugal in 1762-3. Mr. Ernest W. Hey Groves was 
elected to represent the college on the General Medical 
Council, and on the inter-departmental committee of the 
Ministry of Health on the restoration of the working 
capacity of persons injured by accidents, and Sir Holburt 
Waring was elected representative of the college at the 
centenary celebrations of the University of London. 

Licences in dental surgery were granted to the following : 

Cecil Adair, G. H. Austin-Smith, N. A. Blay, O. B. Brears, 
W. H. Burndred, F. J. M. Bustard, A. O. Chick, G. R. Cogdon, 
R. F. Collens, D. C. J. Constable, W. F. Cooper, H. F. W. 
Dornhorst, T. P. Ellis, C. B. Frost, M. E. Gascoine, S. N. Ghose, 
W. H. Groom, G. A. B. Hoby, R. L. B. Hollick, Sidney Hurst, 
P. B. John, Tobias Kaufman, G. R. Lamont, J. L. MacDougall, 
J. D. Moore, M. R. Preston, H. C. Siggers, Erich Strasburger, 
E. F. J. Sumner, P. H. Tatchell, D. K. Toulson, K. J. Tovey, 
and R. S. Yates. 

Diplomas in ophthalmic medicine and surgery were 
granted jointly with the Royal College of Physicians to 
the following : 


Frank Badrock, P. N. Chaudhuri, J. E. Clark, T. K. Clifford, 
S. P. Divatia, G. B. Ebbage, W. H. V. D. Ferdinands, Frank 
Heckford, T. J. Howell, H. A. Ibrahim, F. J. Jensen, A. de B. 
Joyce, Joshua Mazell, B. F. Moore, Sidbeshwar Nath, Triloki 
ans George Pollock, E. P. Tulloh, Norman Wren, and E. C. 

orab. 


University of London 


The following have been recognised as university 
teachers at the schools indicated: Dr. Una Ledingham 
(Royal Free Hospital), Dr. C. E. Brunton (London Hos- 
pital medical college), Mr. D. H. MacLeod (St. Mary’s 
Hospital medical school), Mr. J. O. Irwin, D.Se. (London 


School of Hygiene), and Dr. Duncan White (British Post- 


graduate medical school). Mr. J. D. Barris and Prof. 
F. J. Browne have been appointed examiners in obstetrics 
and gynecology for the M.D. examination in 1936, and 
Dr. Doris Baker, Dr. Charles Porter, and Dr. Anna Broman 
as examiners for the diploma in the theory and practice 
of physical education in 1936. 

A university chair of biochemistry tenable at St. 
Bartholomew’s Hospital medical college and a university 
readership at the London Hospital medical college have 
been established. Applications should be sent to the 
registrar of the University at South Kensington, S.W.7, 
not later than March 31st for the chair, and April 15th 
for the readership. 

The subject chosen for the Rogers prize essay for 1936 
is the natural history of peptic ulcers. The competition 
is open to all registered practitioners of the United King- 
dom, and the essays should reach the vice-chancellor by 
April 30th. Further information may be had from the 
academic registrar. \ 


National University of Ireland 

On March 12th the degree of M.D. was conferred on 
M. P. O'Connor. Dr. Timothy Donovan was appointed 
to the lectureship in materia medica, and Dr. E. V. 


Cantillon to the lectureship in therapeutics, in University 
College, Cork. 


Auxiliary Royal Army Medical Corps Funds 


‘The annual meeting of members will be held at 5.15 p.m. 
on Friday, April 3rd, at 11, Chandos-street, when the 
financial statement for 1935 will be presented and the 
officers and committee for the current year elected. 


Congress on Physical Medicine 


The sixth International Congress of Physical Medicine 
will be held in London from May 12th to 16th under 
the presidency of Lord Horder. The hon. secretary is 
Dr. Albert Eidinow, 4, Upper Wimpole-street, W. 1. 
Lord Horder will take the chair at a luncheon at the 
Langham Hotel on April 8th, when he is to give an 
address on the progress of physical medicine with special 
reference to the congress. 


Institute of Medical Psychology 

The research fellowship offered by the Rockefeller 
Foundation and tenable at this institute has been awarded 
to Dr. A. T. Wilson for research into the relation between 
the emotional and organic factors in certain physical 
disorders. Dr. Wilson, a graduate of Glasgow and an 
assistant physician at the institute, was formerly senior 
assistant in the department of physiology at the Middlesex 
Hospital. 


British Postgraduate Medical School 

An intensive course intended primarily for practitioners 
will be held at this school from April 15th to 26th (10.30 
to 4.30 daily). Among those giving lectures and demon- 
strations will be Prof. F. R. Fraser, Dr. John Parkinson, 
Prof. James Young, Dr. Chassar Moir, Mr. B. W. Williams, 
Dr. R. D. Lawrence, Mr. A. J. Watson, Dr. R. T. Brain, 
Sir David Wilkie, Dr. H. Crichton-Miller, Dr. Janet 
Vaughan, Mr. P. H. Mitchiner, Mr. F. M. Loughnane, 
and Dr. G. W. Bray. Sessions will also be held at the 
Royal London Ophthalmic Hospital; the Hospital for 
Sick Children, Great Ormond-street; the National 
Hospital, Queen-square ; and the Central London Throat, 
Nose, and Ear Hospital. Early application for member- 
ship of this course is recommended, and further informa- 
tion may be had from the dean of the school, Ducane- 
road, London, W.12. . 

On Thursdays from April 9th to May 14th at 2.30 r.m. 
Dr. W. S. C. Copeman will give six lectures on arthritis. 


? 


694 THE PROT 


The King has given permission to Dr. S.M. Vassallo. 


to wear the insignia of the third class of the order of the 
Brillaint Star of Zanzibar which has been conferred on 
him by the Sultan. 
Aberdeen University Club, London 

The ninety-fifth half-yearly dinner wil be held at the 
Café Royal at 7.30 p.m. on Thursday, April 2nd. The 
chairman of the evening will be Lord Alness, and the 
hon. secretary’s address is 51, Harley-street, London, W.1. 


Medical Meeting at Manchester 

In connexion with a two-day regional conference of 
the British Social Hygiene Council a special meeting, for 
medical men and women only, will be held in the chemistry 
theatre of the University of Manchester, on Friday, 
March 27th, at 8 P.M., when Dr. Morna Rawlins, of Guy’s 
Hospital, will speak on the treatment of gonorrhea in 
women, and Dr. Tytler Burke, of Salford, on the child 
with congenital syphilis. Dr. J. J. Butterworth, county 
medical officer of Lancashire, will be in the chair. 


A Badge for Medical Motorists 

As reported in our Parliamentary Intelligence, the 
Minister of Transport was recently asked if he would 
authorise the attachment of a special badge or the use 
of a distinctive horn on the cars of medical practitioners, 
in order that the police might allow them facilities in 
emergency. Assured that the plan had worked well in 
Canada, Mr. Hore-Belisha said he would look into the 
question. We are now informed that the National 
Motorists’ Association is issuing to 40,000 medical men a 
badge incorporating the red cross, which, it is hoped, 
will help the public to identify their cars, and give their 
owners priority or preferential treatment. 


British Red Cross Units in Abyssinia 

Mr. J. M. Melly, in charge of the first British Red Cross 
Ambulance Unit, which is now in the neighbourhood of 
Lake Ashangi, and is treating about a hundred wounded 
daily, reports heavy losses of stores and material as the 
result of air bombing. Ten tents have been totally 
destroyed and 25 are perforated and unusable. All but 
two weeks’ supply of medical and surgical stores are 
destroyed. Native personnel from the Kenya and Soma- 
liland border, who after the bombardment asked to be 
repatriated, have left for Dessie in charge of an officer 
returning to their own country. 

Subscriptions towards the work of the two units now 
in Abyssinia may be sent to the British Red Cross Society, 
14, Grosvenor-crescent, London, S.W.1. The cost of 
maintaining them in the field, apart from unexpected 
losses, is estimated at £3000 a month. 


Tuberculosis Association 

The provincial meeting of this society will be held at 
the Physiology School, Cambridge, on April 2nd, 3rd, 
and 4th under the presidency of Dr. L. S. T. Burrell. 
The conference will be opened by a discussion on dis- 
pensary organisation at which Dr. R. H. Hazemann 
(médecin inspecteur of the Seine prefecture), Dr. Heynsius 
van den Berg (director of the Amsterdam tuberculosis 
service), and Dr. N. Tattersall (tuberculosis officer, Leeds) 
will speak. Dr. Russell Reynolds will also give a demon- 
stration of cinematography of the chest. On Friday 
morning there will be a joint meeting of the association 
with the international after-care committee of the Union 
International contre la Tuberculose which will be opened 
by Prof. Ferd. Bezangon (secretary -general of the union). 
Dr. Maurice Davidson and Dr. L. B. Stott will read a 
paper on the capacity for work in pulmonary tuberculosis, 
and Prof. von Weizsaeker (director of the Heidelberg 
medical clinic) and Dr. IX. Bachmann (secretary of the 
after-care committee) will also speak. A visit will be paid 
in the afternoon to Papworth, where there will be a dis- 
cussion on schemes for after-care to which Dr. Bronkhurst 
(Berg en Bosch, Bilthoven) and Dr. Pattison (Potts 
Memorial Hospital, New York) will contribute. On 
Saturday Prof. Sayé (Barcelona) will speak on chronic 
miliary tuberculosis, and cases for discussion will be 
presented by Dr. S. Vere Pearson, Dr. G. T. Hebert, 
and Mr. H. P. Nelson. The hon. secretary of the associa- 
tion is Dr. Frederick Heaf, Colindale Hospital, London. 
N.W.9. 


MEDICAL NEWS 


* [margc 21, 1936 


Demonstrations of Contraceptive Technique 

On Thursday, April 2nd, at 2.30 p.m., at the clinic of 
the Society, a demonstration of the technique of the use 
of a variety of contraceptive methods will be given by 
Mrs. Marie Stopes, D.Sc., and Dr. Evelyn Fisher. Applica- 
tions for tickets from medical practitioners and senior 
students should be sent to the hon. secretary, C.B.C., 
108, Whitfield-street, London, W.1. 


Naval Medical Compassionate Fund 

A meeting of the subscribers of this fund will be held 
at 3.15 P.M. on Friday, April 24th, at the Medical Depart- 
ment, Admiralty, London, S.W.1, to elect six directors. 


Fellowship of Medicine and Post-Graduate Medical 

Association 

All-day courses have been arranged in infants’ diseases 
(March 30th to April 4th); in proctology, at St. Mark’s 
Hospital (April 20th to 25th); and in medicine, surgery, 
and gynecology, at the Royal Waterloo Hospital 
(April 27th to May 9th). Afternoon courses will also be 
held in psychological medicine, at the Maudsley Hospital 
(April 27th to May 30th), andin ophthalmology, at the 
Royal Eye Hospital (April 20th to May Ist); and week- 
end courses at the Victoria Park Hospital in diseases of 
the heart and lungs (April 18th and 19th), and at the 
National Temperance Hospital in medicine and surgery 
(April 4th and 5th). Courses are open only to members and 
associates of the Fellowship, and further information may 
be had from the secretary of the Fellowship, 1, Wimpole- 
street, London, W.1. 


University Travel Guild 

The University Travel Guild inaugurated a series of 
Travel Lunches at the Criterion Restaurant on Tuesday 
last. It is the first organisation of the kind to arrange an 
air tour for its members, so it was appropriate that the 
speakers, Mr. Lindsay Everard, M.P., and Miss Amy 
Johnson, should be famous figures in the flying world. 
The room was crowded and the audience were much 
interested in Mr. Everard’s address and no doubt noted 
his remarks on the low cost of the Easter tour to Central 
Europe which was being organised by the Guild. The 
flying, he said, worked out at 334d. a mile, while hotel 
accommodation, all meals, and sightseeing only added 
lłd. a mile to the expense. 

The next lunch is being held on May 5th, when 
H.E. The Yugoslav Minister will be the speaker. All 
particulars can be obtained from the secretary of the 
Guild, 25, Cockspur-street, S.W.1. 


Dinner to Dr. and Mrs. Fairbairn 

On March 5th a dinner was held in the Langham Hotel 
to bid farewell to Dr. and Mrs. J. S. Fairbairn on the 
occasion of their leaving London to reside in Lossiemouth. 
Over one hundred guests were present. Sir Ewen 
Maclean, president of the British College of Obstetricians 
and Gynecologists, was in the chair, and in a happy 
speech pointed out how much Dr. Fairbairn had furthered 
the teaching and practice of midwifery throughout Britain. 
He expressed the general regret at the retirement of 
Dr. Fairbairn from active practice, and assured him of a 
warm welcome whenever he came back to London. Dr. 
Herbert Spencer referred to the impulse which had 
attracted Dr. Fairbairn to London. Miss Pye, president 
of the Midwives’ Institute, spoke of the support which 
the interests of the midwives had always received from 
him, and Lady Richmond, on behalf of the Central Mid- 
wives Board, endorsed ‘this acknowledgment. Sir William 
Willcox, master of the Society of Apothecaries, spoke in 
warm terms of the affection in which Dr. Fairbairn and 
Mrs. Fairbairn were held. Dr. Fairbairn, who was greeted 
with song and cheers, expressed the pleasure it gave him 
to be received so kindly by so many of his colleagues on 
the various bodies on which he had served. He preferred 


-~ 


to say goodbye and go when the going was good. Ho 
would always carry with him the memory of this welcome 
and farewell. A silver rose bowl with an album of signa- 
tures was presented to Dr. and Mrs. Fairbairn by the 


chairman on behalf of the guests present, and many 
colleagues from far and near who wrote regretting their 
inability to attend. 


7 a 


w * 


THE LANCET] 


NOTES ON CURRENT TOPICS 


Health Conditions in Offices 


In the House of Commons on March 138th Mr. 
CREECH JONES moved the second reading of the 
Offices Regulation Bill. He said that there was 
practically no systematic or routine inspection of 
offices to-day, and in view of the appalling conditions 
which existed in many offices it was evident that 
the existing legislation was inadequate. All the 
organisations concerned with clerical workers were 
pressing for this Bil. There was to-day increasing 
nervous strain on the workers. It was important 
that they should have a standard of conditions 
which would ensure their health. Doctors had 
said that there was a tendency among clerical workers 
towards tuberculosis and digestive and nervous 
disorders arising in part from the conditions of 
employment. The Bill was based on the report of 
the Select Committee on Shop Assistants in 1931 
and was in accordance with its recommendations 
and with the methods adopted by the Home Office 
in recent legislation. The first part of the measure 
dealt with the sanitation and general conditions in 
offices, and the second part with the employment of 
young persons in offices. 

Mr. LATHAN, in seconding, said that the Bill 
provided the Government with an opportunity to 
show that they were desirous of doing something 
to protect the health and interests of the non-manual 
workers. The existing factory and shops legislation 
would not meet the needs of the situation. 


Mr. LEVY moved: 


“This House declines to give a second reading to a 
Bill which, so far as it is efficiently workable, merely 
re-enacts the existing law in different words, and which 
will lead to confusion in administration because it brings 
under its provisions offices which in many cases are 
regulated either by the Factory Acts or the Shops 
Acts.” 


He said that the passing of the Bill would lead to 
confusion in administration, because it brought under 
its provisions offices which in many cases were regu- 
. lated either by the Factory Acts or the Shops Acts. 


After further debate, 

Sir FRANCIS FREMANTLE said he could reinforce 
what had been said about the difficulty of complaints. 
Medical officers of health knew that the law relied 
upon complaints being brought forward, and it was 
ridiculous to think that the ordinary employee in 
an office would bring forward complaints. Vital 
statisticians themselves had shown that those who 
entered offices were often those who were less robust ; 
in fact a considerable proportion of those who entered 
offices were in one way or other delicate. If they were 
not definitely affected with tubercle they were 
susceptible to it. Certainly the conditions of working 
in offices were very inferior from the health point 
of view compared with those affecting agriculture. 
Therefore there was all the more reason for improving 
office conditions. There had been an immense 
advance in public health in recent years because 
of the system under which sanitary inspectors and 
medical officers of health worked, and latterly 
because of the appointment of health visitors. Much 
could be done by settling matters through persuasion. 
There was however the old-time conflict between 
the Ministry of Health and the Home Office. The 
medical officers of health for the metropolis did not 
think that they had the power of inspection. It 
would be greatly to the advantage of the adminis- 
tration if the law definitely said that work place 
did include offices and that there was power of 
inspection without the medical officers having to 
wait for suspicion of a nuisance. 


[marcH 21, 1936 695 


_ PARLIAMENTARY INTELLIGENCE 


THE UNDER-SECRETARY’S REPLY 


Mr. GEOFFREY LLOYD agreed with what had been 
said about the increasing importance of office workers. 
Between 1921 and 1931 the total number of the 
employed population increased by 10 per cent., but 
the number of clerical workers increased by 38 per 
cent. Figures had been given of the tuberculosis- 
rate among office workers, but there were other 
classes of indoor workers who unfortunately had a 
higher tuberculosis mortality. It was argued that 
the tuberculosis-rate among office workers was due 
to their working conditions, but certain classes of 
workers who had higher mortality-rates were subject 
to the stringent conditions of the Factory Acts in 
their work. The Government were taking steps to 
improve the health of office workers and others. 
There were proposals for the increased organisation 
of physical education and recreation. Also the 
provision whereby clerical workers who were not at 
present governed by a pension scheme could come 
in on a voluntary basis was valuable. Nobody was 
quite certain how far the Public Health Acts would 
be a solution of the problem, or what the position 
regarding them was. Those Acts dealt with the 
most important of the provisions concerning sanita- 
tion, ventilation, overcrowding. and so on, which 
were dealt with in the Bill now before the House. 
But he would not say that the present position 
under the Public Health Acts was completely satis- 
factory. Doubts had been continuously raised whether 
the definition ‘‘ workshop ” included an office and 
about the general powers of inspection irrespective 
of complaints. The draft Bill for the Consolidation 
of the Public Acts—which would be introduced almost 
immediately—would effect very important changes 
in matters as they stood at present. It would give 
powers for the inspectors of local authorities to enter 
offices. That would produce a body of opinion and 
knowledge for dealing with special abuses. As the 
consolidating Bill was being introduced by the 
Government and would meet the most important 
needs of the situation he asked that the present Bill 
should not be given a second reading. 
~ The motion for the second reading of the Bill was 
negatived by 134 votes to 93. The amendment was 
then agreed to 109 votes to 78. . * 


Disposition of the Dead 


At a meeting of the National Health and Housing 
Committee on March 11th, Sir FRANCIS FREMANTLE 
in the chair, Mr. Murray Phelps spoke on the work of 
the National Council for the Disposition of the Dead. 
The Council, he said, was concerned to secure revision 
and codification of the laws in relation to burial and 
cremation. Under the leadership of Lord Horder, 
and with the support of affiliated bodies, they were 
emphasising the public health importance of this 
question, it being increasingly recognised that the 
sanitary disposition of the dead and the health of 
the living are closely related. With the continuous 
growth of great towns, the sterilisation of land for 
the erection of cemeteries was regrettable and 
uneconomic, especially now when crematoria were 
becoming easily accessible in most parts of the 
country. Since 1926 the number of cremations had 
increased from 2800 to over 9000 per annum, and it 
was hoped to reach the 10,000 mark this year. 
Mr. Phelps closed by asking the committee to give 
sympathetic consideration to a Bill for the regisfra- 
tion of undertakers that would be introduced in the 
near future. Mr. R. B. V. Perkins, of the Cremation 
Society, followed with a brief account of the insurance 
scheme which now enables the working classes to 
provide for cremation on the lines which have proved 
so successful on the continent. 

Mr. E. H. Keeling, M.P., has been elected to assist 
Captain G. S. Elliston in the secretarial work of the 
Ilealth and Housing Committee. 


696 


THE LANCET] 


National Physique and Fitness of Recruits 


In the House of Lords on March 17th a debate 
took place on a motion by Viscount SWINTON, 
Secretary of State for Air, approving the Government’s 
defence proposals as outlined in the White Paper. 

The Earl of CAVAN said that the only disquieting 
thing in the White Paper was the shortage of picked 
men. Roughly, 50 per cent. of the applicants were 
rejected. That was a national reproach.. It could 
be remedied, not by lowering the recruiting standard, 
but by paying much more attention to the physical 
condition of the young men of the nation. What was 
wanted were more food and more open-air games. 
If measures were now taken seriously to improve 
the physical welfare of the youth of this country, 
our recruiting problems would soon be solved. 

The debate was adjourned. 

In the House of Lords on March 17th, on the motion 
of Earl De LA Warr, Parliamentary Secretary to the 
Board of Education, the Milk (Extension of Temporary 
Provisions) Bill was read the third time, and passed. 


On March 17th, in the House of Lords, Lord 
BALFOUR OF BURLEIGH introduced the Public Health 
London Bill and Viscount GAGE introduced a Bill to 
consolidate the enactments relating to National Health 
Insurance. 

Both Bills were read a first time. 


HOUSE OF COMMONS 
WEDNESDAY, MARCH lITH 
Motor Facilities for Medical Practitioners 


Mr. Day asked the Minister of Transport whether, 
in view of the many urgent calls made on registered 
medical practitioners, he would authorise the attachment 
on their cars of a special badge, and/or consider allowing 
them the use of a distinctive horn, in order that the police 
might allow them special facilities to proceed on their way 
in the case of emergency.—Mr. Hore-BeE.Isua replied : 
This suggestion has always been considered impracticable 
in view of the impossibility of preventing abuse. 

Mr. Day : Is the Minister aware that this plan has worked 
very satisfactorily in Canada ?—Mr. Hore-BELIsHa : 
I was not aware of that fact. If the hon. Member will 
submit the facts to me I will be glad to look into them. 


Guide Dogs for Blind ex-Service Men 


Colonel SANDEMAN ALLEN asked the Minister of Pensions 
whether he was aware that a centre existed at New 
Brighton for the training of guide dogs for the blind; 
and whether he was prepared to assist in the provision 
of these dogs for blind ex-Service men.—Sir JAMES 
BLINDELL (Lord of the Treasury) replied: The answer 
to the first part of the question is in the affirmative. I 
am informed that the Ministry have no Fund out of which 
such assistance could be given. It may be pointed out, 
however, that a special weekly allowance, in addition 
to pension, is provided by the Ministry for all cases of 
total blindness needing constant attendance. Having 
regard to present-day conditions of road traffic, this is 
considered to be the more suitable form in which assistance 
in such cases should be given. 


THURSDAY, MARCH ]2TH 
Medical Attention in Juvenile Training Centres 


Brig.-General Spears asked the Minister of Labour 
whether the recommendation of the commissioner for the 
special areas that simple medical treatment should be 
given to boys and young men who were prevented from 
benefiting by training schemes on medical grounds was 
being complied with; and, if not, if he would assure the 
House that a decision in regard to this matter would be 
announced shortly.—Lieut.-Colonel Murrueap ` (Parlia- 
mentary Secretary to the Minister of Labour) replied : 
Education authorities in England and Wales have power 
to provide medical treatment for juveniles attending the 
junior instruction centres conducted by them, and it is 
my right hon. friend’s policy to encourage authorities 
to make this provision. As regards young men my right 


PARLIAMENTARY INTELLIGENCE j 


[marca 21, 1936 


hon. friend is considering with the Departments concerned 
the medical services already available and the extent, 
if any, to which it may be necessary to supplement them 
in the special areas to fit young men for training. I 
hope that it will be possible to reach a decision shortly. 


Vermin-infested Bricks 

Mr. Kirsy asked the Minister of Health whether he was 
prepared to introduce legislation whereby vermin-infested 
old bricks taken from demolished dwelling-houses should 
be prohibited from use in the construction of new dwelling- 
houses of any kind.—Sir KincstEy Woop replied: In 
view of the power conferred on local authorities by 
Section 82 of the Housing Act, 1935, to cleanse from 
vermin any house to which a demolition order or clearance 
order applies before it is demolished, I do not consider 
further legislation necessary. ' 


Sulphuric Acid and the Poisons Act 


Mr. WILLIAM Duckworts asked the Home Secretary 
whether he would take steps to amend the Pharmacy and 
Poisons Act, 1933, so as to make it clear that it was not 
obligatory for garages and wireless dealers who engaged 
in the charging of accumulators to be registered as sellers 
of poisons in so far as such charging involved the use 
of sulphuric acid.—Sir JoHN Sm™oN replied: No, Sir. The 
sale of sulphuric acid in accumulators is clearly exempted 
from the provisions of the Act by Rule 11 and the third 
Schedule of the Poisons Rules, 1935. 


MONDAY, MARCH 16TH 
Bombing of British Red Cross by Italian Aircraft 


Mr. WepGwoop asked the Secretary of State for Foreign 
Affairs what had now been done concerning the bombing 
of the British ambulance by Italian airmen.—Viscount 
CRANBORNE (Under-Secretary for Foreign Affairs) replied : 
Since the statement which I made on this subject on 
Monday last, the Italian Government have communicated 
a written reply to the representations made by H.M. 
Ambassador in Rome, a telegraphic summary of which 
has been communicated by Sir Eric Drummond to my 
right hon. friend. So far as can be judged from this 
summary, the Italian Government admit the bombing 
on March 4th of an encampment furnished with at least 
one Red Cross sign, but claim that this bombing was in 
retaliation for the opening of fire upon the aircraft both 
on March 3rd and 4th. It is claimed that the Italian 
aircraft were fired on yet again on March Sth from the 
same locality, but the summary does not show that the 
Italians admit having bombed the encampment again 
on that day. The Italian note apparently states that 
the coincidence of the locality and of the facts permits the 
identification of this alleged incident with that of which 
H.M. Government had complained. As to this I can only 
say that my right hon. friend has noticed considerable 
discrepancies between the account given in the Italian 
communication and the report previously communicated 
by the leader of the British Red Cross Unit concerned, 
particularly as regards the number of lorries and of Red 
Cross insignia as well as the location of the encampment. 
The Italian official statement does not apparently specify 
who is supposed to have fired on the aircraft, but the 
Italian press of March 12th explain that it was done by 
at least a thousand armed men in khaki uniform who 
emerged from the tents on the approach of the aircraft. 
Dr. Melly has already denied that there was any firing 
upon Italian aircraft from the neighbourhood of his 
camp, but further detailed information is being sought 
from him. The right hon. gentleman may be assured that 
H.M. Government will pursue this matter with the utmost 
energy with the Italian Government as soon as my right 
hon. friend has obtained Dr. Melly’s further comments, | 


Coal Fires and Atmospheric Pollution 

Mr. Davip ApaAms asked the First Commissioner of 
Works if he was aware that the department of industrial 
and scientific research and the leading municipalities of the 
United Kingdom agreed that coal-burning fires were the 
prime cause of atmospheric pollution causing injury to the 
public health and public buildings, added risks to aviation, 
and other disabilities; why almost all the offices and 
departments under his control in London were heated 


—_ 


ees cee eG eal a — nar 


A T amet T a A eam 


THE LANCET | 


PARLIAMENTARY INTELLIGENCE.— BIRTHS, MARRIAGES, AND DEATHS [MARCH 21, 1936 697 


with raw coal; and whether he would introduce and 
gradually extend the use of smokeless fuel as in the lobbies 
of this House.—Mr. OrmsBy-GoreE replied: Yes, Sir. 
I am aware of the causes and effects of atmospheric 
pollution, but I understand that there is a ready market 
for all the present production of smokeless fuel suitable 
for open fireplaces; the total sale would not be increased 
by any order I might give and the question of atmospheric 
pollution would not be affected. About two-thirds of the 
accommodation under my control in London is heated 
by plants consuming smokeless fuel of various kinds; 
for open fireplaces suitable smokeless fuel is used where- 
ever local circumstances make it possible without unreason- 
able increase of cost. Apart from the fact that there was 
some dissatisfaction when smokeless fuel was used in the 
lobby fires some time ago, I should not be justified at 
present prices in using smokeless fuel in the fireplaces 
of this House. 
Blind and Insane Pensioners 

Mr. McGovern asked the Minister of Pensions the total 
number of blind and insane persons on pension in Great 
Britain from the result of the war 1914-18.—Sir James 
BLINDELL (Lord of the Treasury) replied : I am informed 
that the number of pensions in payment in respect of 
eye affections assessed at 100 per cent. is approximately 
1990. The number of pensioners certified as of unsound 
mind in mental institutions is about 5990. 


Sir John Orr’s Report on Malnutrition 


Mr. ELLIS SMITH asked the Prime Minister if he would 
consider the Report prepared by Sir John Boyd Orr, 
and take steps to set up a ministry for food-supply and 
organise a national distribution of food.—Mr. BALDWIN 
replied: The report is being referred by my right hon. 
friend the Minister of Health to the Advisory Committee 
on Nutrition for examination. The answer to the last 
part of the question is in the negative. 

Mr. JOHNSTON asked the Minister of Health whether 
he was aware of the serious reports by Sir John Boyd Orr 
and the staffs of the Rowett Institute and the Market 
Supply Committee as to the under-nourishment of 10 per 
cent. of the population and the under-nourishment 
combined with defective nutrition of other 40 per cent. 
of the population ; whether he was aware of the increasing 
public health expenditure required as ambulance work 
owing to this defective nutrition; and what steps the 
Government proposed to take to cope with the situation.— 
Sir KineGstey Woop replied: I am aware of these reports 
and I am referring them to my Advisory Committee on 
Nutrition for examination. 


General Nursing Council Rules 

Mr. Oswantp Lewis asked the Minister of Health if 
he would give the British Hospitals’ Association an 
opportunity of expressing their opinion upon the new 
regulations drafted by the General Nursing Council for 
England and Wales, regarding a proposed educational 
standard for nurses before he gave his formal approval 
of such regulations.—Mr. SHAKESPEARE (Parliamentary 
Secretary to the Ministry of Health) replied: Yes, Sir. 
My right hon, friend has already done so and he is in 
communication with the Association on the matter. 


Infectious Disease in County Durham 

Mr. Davip Apams asked the Minister of Health whether 
he was aware of the high incidence of infectious disease 
in the Stanley, County Durham, area, and that this was 
declared by members of the local authority to be due to 
the low nutritional standards of the area; and whether 
he would investigate this situation.—Mr. SHAKESPEARE 
replied : My right hon. friend is aware of this outbreak ; 
the situation has been under close investigation for some 
time past, and he is now awaiting a report by the county 
medical officer of health. 

Pasteurisation 

Mr. DE ROTHSCHILD asked the Minister of Health 
whether, in view of the health value of pure clean raw 
milk, and in view of the high standard of cleanliness of 
tuberculin-tested milk, he would reconsider the proposal 
to institute a separate grade of tuberculin-tested 
pasteurised milk, in order not to restrict the market for the 


highest grades of pure raw milk by fostering the idea - 


that the safety of even tuberculin-tested milk would be 


enhanced by pasteurisation.—Mr. SHAKESPEARE replied : 
My right hon. friend is giving consideration to this matter 
in the preparation of the new Special Designations Order. 


Milk for Nursing Mothers and Infants 

Mr. JOHNSTON asked the Minister of Health whether 
his attention had been called to the report of the Medical 
Research Council for 1934 to 1935, just issued, urging the 
importance of the consumption of more liquid milk by 
pre-school children and nursing mothers; and whether 
he would consult with the Secretary of State for Scotland 
and the Minister of Agriculture with a view to immediate 
steps being taken to give effect to this reeommendation.— 
Mr. SHAKESPEARE replied: Yes, Sir. My right hon. 
friend intends to give full consideration to this report in 
consultation with my right hon. friends the Secretary of 
State for Scotland and the Minister of Agriculture. 


TUESDAY, MARCH 17TH 
Typhoid Fever in Derbyshire 


‘Mr. HoLLAND asked the Minister of Health if he was 
aware that the outbreak of typhoid fever in the village 
of Langwith, Derbyshire, was reported to be due to a 
previous water-supply which was pronounced by the 
district medical officer to be polluted; that at a recent 
date one person died from the alleged effects of typhoid 
fever; and in what way compensation would be made, 
as there was much local indignation concerning this matter. 
—Sir Kinestey Woop replied: The answer to the first 
two parts of the question is in the affirmative. As regards 


.the last part, the question of liability to pay compensa- 


tion is not one on which I can express any opinion. It is 
a matter which can be determined only by the courts. 


Influenza at Chatham Barracks 


Captain PLUGGE asked the Secretary of State for War 
the number of cases of influenza or similar complaints 
which had occurred within the last month in the Brompton 
Barracks, Chatham ; what had been the death roll; and 
why in the case of normal colds the mortality had been 
relatively high.—Mr. Durr Cooper replied: During the 
last month there have been 25 cases of influenza, 5 of 
pneumonia, 3 of bronchitis, and 198 of common cold at 
Brompton Barracks, Chatham. Four deaths have occurred, 
three being the result of broncho-pneumonia, influenzal in 
origin, and the other of lobar pneumonia. Every possible 
precaution has been taken to prevent the spreading of the 
outbreak, and reports show that, since the beginning of 
this month, there has been a steady reduction in the 
number of admissions to hospital and of barrack treatment. 


Births, Marriages, and Deaths 


BIRTHS 


Kirrs.—On March 9th, at Hitchin, the wife of Dr. Jean Kies, 
of Letchworth, of a daughter. 

ROBERTS.—On March 15th, the wife of O. W. Roberts, M.D. 
Lond., F.R.C.S. Eng., Medical Superintendent, Dulwich 
Hospital, S.E., of a daughter. 

WHITCHURCH HOWELL.—On March llth, 1936, to Frances, née 
Roper Blackwood, wife of Bernard Whitchurch Howell, 

F.R.C.S., of 123, Harley- -street, W.1—a daughter. 


MARRIAGES 


PRANCE—POTTER.—On March 8th, at the Parish Church, 
Ashtead, Herbert Prance, M.R. C. S. Eng., to Muriel Beatrice 


Potter. 
DEATHS 


ANDREWS.—On March 13th, at St. Briavel’s House, Gloucester- 
e Surg. Capt. O. W. Andrews, ©C.B.E., M.B. Durh., 


CasH.—On March 14th, at Bovey Tracey, S. Devon, Alfred 
Midgley Cash, M.D. Edin., aged 85. 

CAWTHORNE.—On March 12th, Benjamin Walker Cawthorne, 
M.D. Edin., late of Bath, aged 78. 

Rm ae .—On p March, I 10th, Ernest Harrison Griffin, D.S.O., 

HALDANE. A midnighe. March 14th-—L5th, at Cherwell Oxford, 
Prof. John Scott Haldane, C.H., F.R.S., M.D KA LL.D. 
Edin., Fellow of New College, Oxford, i 75. 

McGEAGH. —On March we at Ramsey, Isle of Man, Robert 
Thomas McGeagh, M.D. "RU. I.,in his 78th year. 

Wason.—On March corns at Lichfield, Clevedon, Richard 
Llewhellin, M.R.C.S., L.R.C.P. Lond. , eldest son of the 
late J. E. F. and ‘Annie Wason, and beloved husband of 
Mary Kathleen Wason. 


N.B.—A fee of 78s. 6d. is charged for the insertion of Notices of 
Births, Marriages, and Deaths. 


698 THE LANCET] 


Medical Diary 


Information to be included in this column should reach us 
in proper form on Tuesday, and cannot appear if it reaches 
us later than the first post on Wednesday morning. 


SOCIETIES 


ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W. 
MONDAY, March 23rd. 

Odontology. 8 P.M. Mr. F.N. Doubleday : 1. Third Molar 
Removed from Behind the Orbit. 2. Third Molar 
Removed from Beneath the Tongue. 3. A Case of 
Facial Deformity Referred by an Industrial Firm. 
Mr. W. E. Herbert: 4. Unerupted Supernumerary 
Tooth Causing Death of the Pulp of a Central Incisor. 
5. Congenital Absence of Teeth. 6. Fracture of the 
Roots of Two Incisors where the Pulps have Remained 
Vital. Mr. G. T. Hankey: 7. Bilateral Perforation 
of the Antrum and Nose following Chronie Necrosis 
of the Maxilla. 8. Complete Caries of Permanent 
Dentition—except Wisdoms—at the age of 13, in an 
otherwise Normal Boy. 

TUESDAY. 


Medicine. 5 P.M. Sir Walter Langdon-Brown, Dr. 
A. P. Thomson, and Dr. P. M. F. Bishop: Medical 
Aspects of the Menopause. 

WEDNESDAY. 

Comparative Medicine. 4 P.M. (Royal Veterinary 
College, Great College-street, N.W.) Demonstrations 
in Research Institute and College. 

THURSDAY., 

Urology. 8.30 P.M. Mr. John Everidge: 1. “ Stag- 

born ?” Calculus Removed from a Single Kidney. 


Mr. A. E. Roche: 2. Nephrectomy for Uretero- 
vaginal Fistula. Mr. Reginald T. Payne: 3. Hyper- 
parathyroidism, including Renal Calculi. Mr. Morton 
Whitby: 4. Enlarged Prostate (Enucleation-supra- 
pubic with Complete Closure of Bladder). 5.. Left 
Pelvic Renal Calculi with Hydronephrosis Complicated 
by Acute Gonorrhea. Mr. H. P. 
6. Two Cases of Retention of Urine in Women. Mr. 
James Carver: 7. Blind Supernumerary Ureter. 
8. Tuberculous Ureteric Stump. 9. Stricture of the 
Ureter with Hydro-ureter and Hydronephrosis. Mr. 
Edgar Freshman: 10. Infected Hydroncphrosis in a 
Horse-shoe Kidney. 


FRIDAY. 

Physical Medicine. 5.30 P.M. (St. Jobn Clinic and Insti- 
tute of Physical Medicine, Ranelagh-road, S.W.) 
Demonstrations and Clinical Cases by Sir Leonard 
Hill, Mr. Timbrell Fisher, Dr. Francis Bach, Dr. A. P. 
Cawadias, Dr. Philip Ellman, Dr. Charles Robinson, 
Dr. Gordon Calthrop, and Dr. Albert Eidinow, 

Disease in Children: Obstetrics and Gynecology : Epide- 
miology and State Medicine. 4.45 P.M. Dr. J. B. 
Blaikley and Dr. G. F. Gibberd: Mechanisin of Ate- 
lectasis and its Treatment by Intratracheal Insuffla- 
tion. Dr. N. B. Capon, Prof. G. I. Strachan, Dr. 
Letitia Fairfield, and Dr. Ethel Cassie : The Prevention 
of Neonatal Death. Injury. and Disease. 

MEDICAL SOCIETY OF LONDON, 11, Chandos-street, W. 

MONDAY, March 23rd.—2.30 P.M., Prof. G. Grey Turner: 
Surgery of the Cfsophagus. 

MEDICO-LEGAL SOCIETY. 

THURSDAY, March 26th.—8.30 P.M. (Manson House, 26, 
Portland-place, W.), Dr. L. A. Weatherly : Debatable 
Medico-legal Episodes in the Long Life of an Alienist. 

ea JOHN’S HOSPITAL DERMATOLOGICAL SOCIETY, 
5, Lisle-street, W.C. 
WEDNESDAY, March 25th.—4.30 P.M., Clinical Mecting. 
BRITISH PSYCHOLOGICAL SOCIETY. 

WEDNESDAY, March 25th.—8.30 P.M. (11, Chandos-street, 
W.), Dr. H. Godwin Baynes: The Importance of 
Dream Analysis for Psychological Development. 
Dr. J. A. Hadfield and Dr. C. Wilson will also speak. 
(Medical Section.) 

SOCIETY OF MEDICAL OFFICERS OF HEALTH. 

FRIDAY, March 27th.—3.45 P.M. (Park Hospital, Hither 
Green, S. k.), Dr. H. S. Banks: Clinical Demonstration. 
(Fever Hospitals Medical Service Group.) 

ASSOCIATION OF INDUSTRIAL MEDICAL OFFICERS. 

FRIDAY, March 27th.—5.45 P.M. (Londonu School of Hygiene 
and Tropical Medicine, Keppel-street, W.C.), Air Vice- 
Marshal Sir David Munro and Dr. T. M. Ling : Physical 
Standards in Industry. Dr. Ling: Psychological 
Factors in Sickness Absenteeism. 

SATURDAY.—10 A.M., Dr. R. E. Lane: 
Industrial Plumbisin. 


LECTURES, ADDRESSES, DEMONSTRATIONS, &c. 


ROYAL COLLEGE OF PHYSICIANS, Pall Mall Fast, S.W.1 
TUESDAY, March 24 th, and THURSDAY.—5 P.M., Mr. Joseph 
Needhain, Sc.D.: Chemical Aspects of Morphogenetic 
Determination. ‘(Oliver-Sharpey Lectures.) 
ROYAL COLLEGE OF SURGEONS, Lincoln’s Inn-fields, W.C. 
MONDAY. March 23rd.—5 P.M., Dr. L. W. Proger: New 
Additions to the Museum. 
UNIVERSITY OF BIRMINGHAM. 
FRIDAY, March 27th.—3.30 P.M. 
Philip Cloake : Diabetes 


The Prevention of 


(Queen’s Hospital), Prof. 
Melitus. 


MEDICAL DIARY 


Winsbury-White : | 


[marcH 21, 1936 


ROYAL INSTITUTION, 21, Albemarle-street, W. 
TUESDAY, March 24th. —5.15 P.M., Prof. Edward Mellanby, 
F.R.S.: Drug-like Actions of Some Foods. 


INSTITUTE OF HYGIENE, 28, Portland-place, W. 


WEDNESDAY, March 25th.—3.30 P.M., Dr. J. F. Halls 
Dally : Psychological Influences on the Circulation. 
PROT C ORADUATE MEDICAL SCHOOL, Ducane’ 
road, : 
MONDAY, March 23rd.—2.30 P.M., Dr. Gordon Holmes, 
F.R.S.: Cerebro-spina! Syphilis. 


TUESDAY.—2.30 P.M., Dr. 
Bacterial Flora. 
WEDNESDAY.—Noon, Clinical and pathological conference 


Miles: Normal and Abnormal 


(medical). 2.30 P.M. Clinical and pathological con- 
ference (surgical). 3.30 P.M., Mr. Aleck Bourne: 
Disproportion and Ditlicult Labour. 

TRURSDAY.—2.15 P.M., Dr. Duncan White: Radiological 
demonstration. 3 P.M., Dr. Chassar Moir: Operative 
Obstetrics. 

FRIDAY.—Noon, Dr. A. A. Davies: Gynecological Patho- 
logy. 3.30 P.M., Dr. Alan Moncrieff: Hygiene of the 


New-born Child. 5 P.M., Sir James Walton: 
Aspects of Dyspepsia. 

Daily, I0 A.M. to 4 P.M., Medical Clinics, 
operations, 
operations. 

FELLOWSHIP OF MEDICINE AND 
MEDICAL ASSOCTATION 


Surgical 


] Surgical Clinics or 
Obstetric and Gynecological Clinics or 


POST-GRADUATE 
» 1, Wimpole-street, W. 


MONDAY, March 23rd, to SUNDAY, March 29th.—INFANTS 
HosPITAL, Vincent-square, S.W. Mon., Wed., and Fri. 
at 8 P.M., primary F.R.C.S. course in anatomy and 
physiology.— ROYAL CHEST HOSPITAL, City-road, B.C. 
Mon.. Wed., and Fri., 8 P.M., special M.R.C.P. class in 
chest and heart diseases.— NATIONAL TEMPERANCE Hos- 
PITAL, Hampstead-road, N.W. Wed., 8.30 PM., 
Dr. Reginald Lightwood: Modern Views Concerning 
Tuberculosis in Children.— ALL SAINTS’ HOSPITAL, 


Austral-street, S.E. Sat. and Sun., course in urology. 
Courses are open only to membe rs of the fellowship. 
KING’S COLLEGE HOSPITAL MEDICAL SCHOOL. 
TUESDAY, March 24th.—4.30 P.M., Mr. H. A. T. Fairbank: 
Some General Affections of the Skeleton. 


ae le FOR EPILEPSY AND PARALYSIS, Maida 
ale, $ 
THURSDAY, March 26th.—3 P.M., Dr. Russell Brain: 
Demonstration. 
NATIONAL HOSPITAL, Queen-square, W.C. 
MONDAY, March 23rd.—3.30 P.M., Dr. Symonds: Head 
Injuries (III.). 
TUESDAY.—3.30 P.M., Dr. Grainger Stewart: Meningitis 
and Cerebral Abscess. 
WEDNESDAY.—3.30 P.M., Dr. Kinnier Wilson: Clinical 
Demonstration 
THURSDAY.—3.30 P.M., Dr. Riddoch: Cerebral Tumours. 


FRIDAY.—3.30 P.M., Dr. Denny-Brown : 
Out-patient clinic daily at 2 P.M. 


ape TAL FOR SICK CHILDREN, Great Ormond-:street, 


WEDNESDAY, March 25th.—2 P.M. » Dr. Wilfred J. Pearson : 
Deformities of the Chest—Etfect upon Respiration. 


3 P.M., Dr. W. W. Payne: Sedimentation-rate in 
Tuberculosis. 
Out panai Cliuics daily at 10 A.M. and ward visits at 
2 P.M 
NATIONAL HOSPITAL FOR DISEASES OF THE HEART, 
Westmorcland-street, W. 
TUESDAY, March 24th.—5.30 P.M., Dr. F. W. Price : Angina 
Pectoris. 
HAMPSTEAD GENERAL HOSPITAL, N.W. 
WEDNESDAY, March 25th—4 P.M., Dr. H. Van Praagh: 
Some Pitfalls of General Practice. 
MANCHESTER ROYAL INFIRMARY. 
FRIDAY, March 27th.—4.15 P.M., Mr. W. 
Demonstration of Surgical Cases. 
ANCOATS HOSPITAL, Manchester. 
THURSDAY, March 26th.—4.15 P.M., Mr. E. E. Hughes: 
Acute Surgical Conditions of the Kidney. 
LEEDS GENERAL INFIRMARY. 
TUESDAY, March 24th.—3.30 P.M., Dr. J. T. Ingram: 
Some Dermatological Nouroses. 
GLASGOW POST-GRADUATE MEDICAL ASSOCIATION. 


WEDNESDAY, March 25th.—4.15 P.M. (Victoria Intirmary), 
Mr. Robert Tennent: The Gall-bladder. 


Neuritis. 


R. Douglas: 


ST. ANDREW’s HOSPITAL, DOLLIS HIıLL.— Plans 
are being prepared for an extension to the nurses’ 
home of this hospital, and building will probably begin 
in the spring. The cost will be about £6000, and there 
is already a debt on the first part of the home and new 
buildings of £3623. The hospital’s income for last year 
amounted to £13,812 and its expenditure was £15,600. 


BaTit IAR, NOSE, AND THROAT HosPITAL.— This 
hospital celebrates its centenary next year when 
a special effort will be made to remove its large debt. 
It is hoped in the near future to undertake more pre- 
ventive work among children recovering from measles 
and scarlet fever when the seeds of future deafness are 
often sown. 


a ee 


‘THE LANOET] 


[MAROH 21, 1936 699 


. NOTES, COMMENTS, AND ABSTRACTS 


MEALS FOR THE MILLION 


AT a meeting in London on March 12th, with 
Mr. Julian Huxley, D.Sc., in the chair, associates of 
the Committee against Malnutrition reported on the 
public food services of Soviet Russia. Mr. F. Le 
Gros Clark, the hon. secretary, spoke first of the 
efforts made to popularise the habit of feeding in 
restaurants and dining halls. At least five million 
industrial workers, he said, are now receiving one 
or two meals a day in the factory or public restaurants 
under the control of the State trusts; and this 
number does not include office employees or those 
of the collective farms, where the custom is now 
spreading rapidly. In earlier days no doubt most 
of the factory dining halls were little more than 
canteens; but now that is all changed, and great 
attention is paid to the esthetics of dining. Comfort, 
brightness, and the taste of food are nowadays 
carefully considered, and flavouring, gravies, and 
Mmayonnaises are tested to ensure that the meals 
constantly improve not only in wholesomeness but 
in attractiveness. 

In fairness to the system, said the speaker, one 
must prevent the British public from assuming that 
this social feeding implies the uncomfortable regi- 
mentation of the people. If this was granted, it 
was easy to see that the Soviet Union was wise in 
encouraging the habit of dining in restaurants ; 
since it could thus guarantee a large proportion of 
the population one, two, or even three meals a day 
cheaply and on a diet that was certified pure and 
varied. It could also in this way discover and deal 
with the inevitable difficulties associated with the 
growth of a new public service, the food service. 
Would the people of Soviet Russia develop further 
this custom of dining communally or would they 
revert later to the habit of family meals? This, he 
thought, was a matter for the people themselves. 
But with the steady drop in food prices that was 
now being experienced, the argument that the 
restaurant meals were cheaper would be removed. 
One of the decisive factors that would make for the 
permanence of the restaurant system was the saving 
in time for the women; another was the conversion 
of the factory restaurants into comfortable clubs, 
of which the workers were unquestionably proud. 

A further striking feature of the restaurant system 
was the opportunity it gave for prescribing special 
diets to those who required them. The science and 
art of cookery could ensure that these diets were 
palatable, while adhering strictly to the prescription. 
Well over half a million factory workers and others 
were now receiving daily diets on this basis, and 
figures seemed to indicate that their health was 
benefiting. Here, said Mr. Le Gros Clark, was the 
establishment of a great principle, and only by 
organising in the first stages some kind of communal 
feeding could the principle be properly tested and 
its results observed. Extensive studies were being 
made into the diets most beneficial to different 
occupations and in different climates. The question, 
for instance, of wear and tear on the human organism 
from work in heated conditions was being closely 
examined. The research was of a highly practical 
nature. In our own country there was a praise- 
worthy effort being made by a few employers to 
supply their young workers with extra milk. This 
was good, provided that low wages were not being 
depleted by making the young people pay for their 
own milk. In the Soviet Union the extra cost of 
the more expensive health diets referred to was 
met out of the social insurance funds; these, it must 
be noted, were on a non-contributory basis. 

Enlarging on the problem of tuberculosis, the 
speaker said that the figures examined showed a 
considerable drop in mortality and loss of working 
days in the last few years. In Moscow the tuber- 
culosis death-rate had risen during the civil wars 


to 40 per 1000 of population; it was now less than 


12, and great efforts were being made in the industrial 
centres to discover hitherto unsuspected cases. In 
this campaign the communal dining arrangements 


played a considerable part. It appeared that in all 


cases separate tables were allotted to tuberculosis 
patients, and in a growing number of cases separate 
compartments; their crockery had by regulation a 
distinctive pattern on it and must be kept apart. 

The report which formed the basis of Mr. Le Gros 
Clark’s address may be had from the Committee 
Against Malnutrition, 19c, Eagle-street, London, 
W.C.1. (1d., post free 2d.). 


\ FILING OF CURRENT JOURNALS 


THE weekly growing heap of periodicals is an 
increasing source of annoyance to anyone who has to 
collect and keep them for reference. He has the 
choice between a neat pile, useless if undisturbed, 
or an untidy chaos, recourse to which becomes more 
and more exasperating. An ingenious binding case 
has been devised by EASIBIND Ltd. (9, Mallow-street, 
London, E.C.1) which should help to solve the 
problem. Different covers can be obtained to fit 
the main medical and scientific journals and each is 
attractively made, bearing on the back the name 
and year of the publication; that for THE LANCET 
holds all the issues of one volume and costs 3s. 6d. net. 
Each issue can be inserted within half a minute. 
A thin wire rod is laid between the middle pages and 
attached by each end to the back of the cover; 
the whole is firmly secured by a thicker rod. The 
growing volume can then be placed among the other 
reference works on the library shelf. If desired, 
any particular issue can be removed in a few seconds 
without disturbing the others. When the case is 
filled it appears very little different from an ordinary 
bound volume, 


A BISCUIT FACTORY 
BIscuIts are the product of an age which has 
largely given up cooking for itself and likes to have 


its ready-cooked food elegantly served in known doses. 
It might be hard to say whether the demand 


-has created the supply or vice versa. Anyhow, Peak 


Freans has grown in three quarters of a century 
from a small factory to what is known as “ Biscuit 
Town,? employing 5000 workers in 29 different 
trades. There are tailors, carpenters, bakers, printers, 
engineers, a steam laundry, an internal postal service, 
and a fire brigade, as well as a medical and dental 
service. All these play some part in the making of 
such a product as the wholemeal “ crispbread ” 
Vita-weat, for example. The wheat is soaked over- 
night and subjected to a special ‘ gelatinising ”’ 
cooking process which preserve all the constituents 
of the fresh grain. This is crushed to a fine pulp 
between granite rollers; and the other ingredients, 
chiefly fat, are added in a large hopper. The mass 
is then rolled into thin sheets which receive a heavy 
impression of the shape of the biscuits. These are 
toasted on endless belts passing through long ovens 
with a carefully regulated temperature. Every 
batch is weighed and compared with two standard 
biscuits for colour, there being a different degree of 
toasting on each side. Each biscuit is therefore of 
uniform composition, with a known calorific value 
and a high vitamin B content. They are then packed 
in conta'ners made and printed in the factory. 

The workers are drawn from the surrounding 
districts, and have to pass as physically sound, first 
the employment authorities, then the factory’s 
medical officer, and finally the Home Office inspectors ; 
all new workers are vaccinated. Their work is graded 
from the results of tests in manual dexterity and men- 


- tal alertness, but misfits are treated sympathetically, 


and it is rare for a recruit once accepted to be dis- 
missed on account of ill-health or incompetence. 
The health of the workers is in the charge of the 


700 THE LANCET] 


" APPOINTMENTS.—VACANCIES 


[maRoH 21, 1936 


medical officer, a nurse, and two dentists, equipped 
with a surgery and dispensary, which is claimed to 
be one of the first of its kind, for it began in 1908, 
and a dental surgery. There were 15,000 dressings 
in 1935, and a record number received dental treat- 
ment. More serious conditions are referred to the 
patient’s insurance doctor, but employees not eligible 
for insurance are treated in their own homes by the 
factory’s medical officer. 


A HANDBOOK OF PHOTOGRAPHY 


THE photographer who, whilst not finding the need 
for regular perusal of a weekly journal, yet wishes 
to keep informed of progress and development in 
` technique, will find the British Journal Photographic 
Almanac a convenient means of doing so. This well- 
known annual gives brief descriptions of new 
apparatus and. methods of working, and a short 
section deals with new models of cine-projectors 
and cameras designed mainly for amateur use. The 
projectors described vary in price from £75 for a 
machine suitable for use in a small hall to £17 for 
one for home use, both being designed for use with 
16 mm. film, and from £33 to 37s. 6d. for machines 
to take the smaller size film, the latter price applying 
to a hand machine. The descriptions given do not 
exhaust the models available, and those of our readers 
to whom this branch of photography appeals will 
be able to obtain more detailed information from 
dealers. The formulz presented in the handbook 
are as varied and useful as ever and the whole produc- 
tion will be found a valuable work of reference. It 
is issued at 3s. (cloth) and 2s. (paper) by Henry 
Greenwood and Co., Ltd., 24, Wellington-street, 
London, W.C.2. 


Appointments 


BAKER, A. H. L., L.M.S.S.A. Lond., has been appointed Resi- 
dent Anesthetist at the West Middlesex County Hospital. 

Cookson, C. C., M.B. Birm., Casualty Medical Oilicer at the 
West Middlesex County Hospital. 

GILBERT, B., M.D. Lond., F.R.C.S. Eng., M.C.O.G., Registrar 
ana Tutor to the Obstetric Department at St. Thomas’s 

ospi 

RIDLEY, N. H. L., M.B. Camb., F.R.C.S. Eng., Registrar to 
the Ophthalmic Department at St. Thomas’s Hospital. 

SEARLE, W. N., M.B. N.Z., F.R.C.S. Edin., M.C.O.G., Registrar 
and Radium Officer at the Chelsea Hospital for Women. 


Royal Masonic Hospital.—The following appointments are 
announced :— 
CRITCHLEY, MACDONALD, M.D. Brist., F.R.O.P. Lond., Neuro- 
logical Physician ; 
LINDSAY, E. C., M.B. Lond., F.R.O.S. Eng., Surgeon; and 
SHORTER, A. A., M.B. Sydney, Resident Surgical Officer. 


V acancies 


For further information refer to the advertisement columns. 
Aylesbury, Royal Buckinghamshire Hospital.—Second Res. 
M.O. £150. 


Barnsley Municipal General Hospital.—First Asst. M.O. £650. 
Bean aoe Victoria Hospitul.—Res. Biochemist. At rate 


Belgrave „Hospital Jor Children, Clapham-road, S.W.—Two 
H.P.’s and one H.S. Each at rate of £100 

Birmingham City, Maternity and Child Welfare Dept.—Three 
Temp. M.O.’s. Each £10 per week. 

daa Ak ceru Borough.—Asst. M.O.H. and Asst. School 

Bollon Royal Infirmary.—H.S. £125. 

Bradford, Royal Infirmary.—H.S. At rate of £135. 

Bee Peele roe Hospital and Sanatorium.—Jun. Asst. Res. 


British pO DECAE Medical School, Ducane-road, W.—Three 


Buzton, "Derbyshire, Devonshire Royal Hospital.—Hon. Asst. 

ysician 

Cambridge, Addenbrooke’s Hospital.—H.P. Also H.S. to Special 
Depts. Each at rate of £130. 

Canin pls Kent and Canterbury Hospiltal.—H.S. At rate of 
£125 


Canterbury, Kent Sone Mental Hospital, Chartham Down.— 


‘Med. Supt. £1000 
Cardiff, King Edward VII. Welsh National Memorial Associa- 
tion.—Res. Asst. Tuber. M.O. £500. Res. M.O. £350. 


Also Asst. Res. M.O. £200, for Sully Hospital, Glam. 
charg os Hospital.—Hon. Clin. Asst. to Dermatological 
cpt. 


Chelsea Hospital for Women, Arthur-street, S.W.—Surgeon for 
Ear, Nose, and Throat. 
Cheshire, Institution aor Mental Defectives, Cranage Hall.—Res. 
Med. Supt. £800 
Chester, East Lancashire Tuberculosis Colony, 
Hall.—H.P. At rate of £150. 
City of London Hospial for Diseases of the Heart and Lungs, 
Victoria Park, E.—H.P. At rate of £100. 
pe: Bee Hall Orthopedic Hospital, near Burton-on-Trent .— 
es ; 
Dewsbury, Infectious Diseases Hospital.—Res. M.O. £200. 
Durham County Council.—Asst. Welfare M.O. £500. 
Eastbourne Royal Eye Hospital, Pevensey-road.—H.S. £100. 
Elizabeth Garrett Anderson Hospital, 1 dé, Euston-road, N.W.— 
Hon. Asst. Obstetrician. 
Evelina Hospital for Sick Children, Southwark, S.E.—Dental 
Surgeon. Also H.S. At rate of £120. 
Exeter, Royal Devon and Exeter Hospital.—H.S. to Ear, Nose, 
and Throat Dept. At rate of £150. 
Hospital for Consumption and Diseases of the Chest, KOMPOR. 
S. W.—Res. Surg. O. £150. Also Asst. Res. M.O. and 
3 H.P.’s. At rate of £150 eis £50 respectively y+ 
Hospital for Epilepsy and Paral —Res, 
M.O. Also H.P. At rate of £156 and £100 fecal Aare is 
Hospital of St. John and St. Elizabeth, 60, Grore End-road, N.W.— 
Res. H.S. At rate of £75. 
Huddersfield Royal Infirmary.—Cas. O. £200. 
Ilford, King George Hospital.—H.P. and two H.S.’s. 
Infants Hospital, Vincent-square, Westminster, S.W.—H.P. 
At rate of £75. 
Isolation Hospital, ‘Muswell Hill.—Res. M. O, £400. 
Laboratories of Pathology and Public Health, 6 , Harley-street, W.— 
Third Asst. Pathologist. £450. 
Lancaster County Mental Hospital.—Asst. ren £500. 
Liverpool, Broadgreen Sanatorium.—Res. M.O. £200. 
London County Council. —Two Asst. M.O.’s me Grade I). Each 
£350. Four Asst. M.O.’s (Grade II). Each £250. Also five 
Temp. District M.O.’s. £300-£100. Temporary Asst. 
Aurist. 34s. 6d. a session. 
L.C.C. Central Histological Laboratory, 
Archway-road, N.—Asst. Pathologist. £650. 
London Lock Hospitals. —Two Res .O.’s. One for Male Dept. 
One for Female Dept. Each at rate of £175. 
London (R.F.H.) School of Medicine for Women, 8, Hunter- 
street, 1V.C.—Post-graduate Scholarships. Each £200. 
Macclesfield General Infirmary.—Second H.S. At rate of £150. 
Maidstone, Kent County Ophthalmic and Aural Hospital.— 
Ophth. H.S. At rate of £200. 
Manchester Royal Eye Hospital.—Jun. HS. £120. 
Mount Vernon Hospital, Northwood.—Asst. Radiologist. £350 
Newport, Mon., Royal Gwent Hospital.—Cas. O. Atrate of £175" 
Paddington Green Children’s Hospital, W.—H.P. and HS. 
Each at rate of £150. 
Port Said. British Hosnital.—Principal M.O. £700. 
Princess Beatrice Hospital, Earl’s Court, S.W.—Hon. ay ceed 
Queen Mary’s Hospital for the East End, Stratford, H.—Asst. 
Radiologist. £150. Also Obstet. H. S. £120. 
Reading, Royal Berkshire Hospital.—H.P. Also Cas. O. Each 
at rato of £125. 
PEANT, one Earlswood Institution.—Jun. Asst. M.O. At rate 


Richmond, Surrey Royal Hospital.—Jun. H.S. At rate of £100. 

Rochdale Í nfirmary and Dispensaru.—sSecond H.S. £150. 

Rotherham Hospital.—Cas.H.S. £150. 

Rotherham, Oakwood Hall Sanatorium.—Asst. Res. M.O. £250. 

Royal Free osha, Gray’s Inn-road, W.C.—Res. Cas. O. 
At rate of £150. 

Royal National Orthopedic Hospital, 234, Great Portland-street, 
W.—H.sS. At rate of £150. 

Royal Northern Hospital.—Asst. Pathologist. £500. 

Royal Waterloo Hospital for Children and Women, S.E.—Hon. 
Asst. Orthopedic Surgeon. 


Barrowmore 


Archway Hospital, 


. St. Mary’s Hospital, W.—Med. Reg. £200. 


Salford, Hope Hospital.—Res. Obstet.. Officer. £400. 

Samaritan Free Hospital for Women, Marylebone-road, N.W .— 
H.S. At rate of £100 

Sidmouth U.D.C.—M.O.H. "£260. 

Soul IA On Sea General Hospital.—Two H.S.’s. 
of £100. 

South Mimms, County (Tuberculosis) Sanatorium, Clare Flall.— 
Deputy Med. Supt. £4100. 

Swanley pte Convalescent Home, Parkwood.—Res. M.O. 
At rate of £ 

Torquay, Torbay a inapital. —H.S. £175. 

University College Hospital Medical School, W.C.—Jun. Fellows 
for Beit Memorial Fellowships. Each £400. 

Walsall General Hospital.—H.P. and Res. Asst. Pathologist. 
At rate of £150. Also H.S. £150. 

Walsall, Manor Hospital.—Jun. Res. Asst. M.O. £150. 

Warrington Infirmary and Dispensary.—Third Resident. At 
rate of £150. 

Warwick, King Edward VII. Memorial SALOT UNN Hertford 
Hill.—Jun. Asst. M.O. At rate of £250 

Western Ophthalmic Hospital, Marylebone-road, N.W.—Sen. and 
Jun. Res. H.S.’s. At rate of £150 and £100 respectively. 

West London Hospital, Hammersmith-road, W.—Physician. 

Wigan, Royal Albert Edward Infirmary and Dispensary, —Res. 
Men Ang Surg. O. and Reg. 2250. Also H.S. At rate 
of £156 

dala pons Hospital, Harlesder-road, N.W.—Hon,. Anses- 

etist. 

Wrerham and East Denbighshire War Memorial Hospital.—Res. 
H.S. At rate of £150. 

Mere e ares Orthopedic Hospital, Kirbymoorside.— 

D. 00. 


The Chief Inspector of Factories announces vacancies for 
Certifying Factory Surgeons at Knottingley and Hoyland 
Nether (Yorks, W.R.); and Stirling (Stirling). 


Each at rate 


vif ke 


j , 


THE LANCET] 


[MaRoH 28, 1936 


ADDRESSES AND ORIGINAL ARTICLES 


ON CERTAIN SEPTICAMIAS | 
DUE TO ANAEROBIC ORGANISMS * 
By A. LEMIERRE, M.D. 


PROFESSOR OF BACTERIOLOGY IN THE FAOULTY OF MEDICINE, . 
PARIS ; PHYSIOIAN TO THE CLAUDE BERNARD HOSPITAL 


THE septicemias dealt with in this address arise 
from several species of anaerobic organisms which 
are specifically distinct from one another but which 
possess the common character of living as saprophytes 
in the natural cavities of the human body, mouth, 
pharynx, intestine, and genito-urinary passages ; 
they are fragile, very slightly motile, and grow 
sparsely on culture media. To this group of 
organisms belong those Gram-negative and ‘non- 
spore bearing bacilli which certain bacteriologists 
group together under the name of “ bacteroides”’ ; 
their rôle in the production of non-traumatic gangrene 
has been described in France by Veillon, Zuber, Rist, 
Guillemot, and Hallé. With them must also be 
placed certain Gram-positive anaerobic micrococci, 
streptococci, and staphylococci, which have been 
variously named by the different authors describing 
them. 

These septicemias arise from inflammatory or 
suppurative lesions in the tissues or cavities where 


the above-mentioned anaerobic organisms exist under > 


physiological conditions. Having proliferated in these 
localities they pass into the blood stream and 
frequently give rise to septic emboli in distant areas. 
Such septicemias tend to arise— 

(1) From inflammatory lesions of the nasopharynx, 
particularly tonsillar and peritonsillar abscesses. 

(2) From similar lesions of the mouth and jaws. 

(3) In connexion with otitis media or mastoiditis. 

(4) From purulent endometritis following parturition. 

(5) From appendicitis. 

(6) From infections of the urinary passages, 


But whatever their origin, they present certain 
common clinical aspects which enable them to be 
grouped together. For that reason, as typical of the 
group as a whole, the post-anginal septicemias will 
be first described, and in later portions of this paper 
attention will be directed to the clinical and patho- 
logical similarity between such post-anginal septi- 
ceemias and those which arise from other sites. 

The post-anginal septicemias due to anaerobic 
organisms most frequently seen in Paris are due 
particularly to the Bacillus funduliformis, described 
in 1898 by Jean Hallé, which can usually be isolated 
in pure culture from the blood and from secondary 
abscesses; it is sometimes associated with an 
anaerobic streptococcus. The first cases of septi- 
cemia from this cause were described in 1929 and 
1931 by Prof. Pierre Teissier and his collaborators 
Jean Reilly, Rivalier, Layani, and Stefanesco ; later 
similar observations were published by the writer 
with Jean Reilly, Layani, Friedman, and André 
Meyer, by Cathala, Bourgeois, and Gabriel, by 
Jame and Jaulmes, and by P. de Font-Réaulx. In 
1935 Pham Huu-Chi published a considerable work 
on this subject. 

. In Germany, where Schottmtller must be given the 
credit of being the first to describe them in 1918, 
the importance of the anaerobic post-anginal septi- 
cemias has been emphasised by a number of 


* An address delivered on March 3rd, 1936, at the Middlesex 
aarti Medical School. 


physicians, including Buigold, Frankel, Claus, and 
Kissling. The name given by them to the usual 
causal organism of such septicemias is Bacillus 
symbiophiles, and they state that it is usually 
associated with an anaerobic. streptococcus. The 
present incertitude concerning the classification of 
anaerobic organisms and the diversity of bacterio- 
logical tests employed by different observers to 
identify them make it possible that B. funduliformis 
and B. symbiophiles are either identical or else belong 
to very similar species of bacteria. In any case the 
description which the German authorities give of the 
post-anginal septicemias corresponds feature by 
feature to what the present writer has observed. 


Clinical Picture 


The disease usually affects young adults or 
adolescents, both sexes being equally attacked. 
Claus and Kissling have observed that sometimes 
small epidemics occur, a fact which I can confirm. 
The most usual initial cause is a tonsillar or peri- 
tonsillar abscess, opened too late or to an insufficient 
degree. At times what appears to be a simple 
tonsillitis may conceal small. foci of suppuration in 
the depths of the tissues which cannot be demon- 
strated clinically ; an example of this was recently 
under my observation at the Claude Bernard Hospital 
in Paris. 

Since the original work of E. ‘Frankel in 1919 
German authorities have considered that these 
septiczemias are the result of a thrombophlebitis of 
the tonsillar and peritonsillar veins which can spread 
to the internal jugular vein or even to the facial vein. 
My own observations agree with this conception. 

The first symptom of septicemia complicating the 
pharyngeal inflammation is a notable rise of tempera- 
ture to 101° or 103° F., accompanied by an intense 
rigor. The rigor usually occurs on the fourth or 
fifth day after the beginning of the sore-throat, 
occasionally as late as the eighth, tenth, or even 
twelfth day, by which time the tonsillar inflammation 
appears to be cured and the initial fever has dis- 
appeared. After this rigors are repeated daily, 
several times per day, or at more remote intervals. 
In the gravest cases the temperature remains in the 
region of 100° to 103° with exacerbations corresponding 
to the rigors; in milder and more chronic cases the 
pyrexia is hectic and irregular. 

There is usually painful swelling of the glands 
below the maxillary angle usually on one side only, 
occasionally on both; there is slight local cdema 
and tenderness on pressure and on movement of the 
head ; this occurs on the lateral aspects of the neck, 
parallel to the sternomastoid muscle, and extends 
from the angle of the jaw to the clavicle ; suppuration 
sometimes occurs at this site. 

The’ B. funduliformis septicemias observed by 
myself have never been pure septicemias, they have 
always been accompanied by the formation of distant 
metastatic abscesses. Amongst: such secondary 
localisations the most frequent are those in the lungs. 
They occur early and may be present from the 
first day. They are in the nature of septic infarcts 
leading almost invariably to multiple abscess forma- 
tion which is announced by intense thoracic pain of 
sudden onset, by dyspncea, sometimes by blood- 
stained or rusty sputum, by pleural frictions, and by 
localised areas of subcrepitant rales. Very frequently 
these pulmonary infarcts are complicated by purulent 
pleural effusions containing B. funduliformis, but in 

N , 


702 THE LANCET] 


rare cases such effusions may be serofibrinous and 
aseptic. These purulent effusions occasionally open 
spontaneously into a bronchus, giving rise to a 
pyopneumothorax. 

Articular lesions are also extremely frequent ; 
they range from simple pains in the joints, sometimes 
of great severity, to suppurative arthritis occurring 
especially in the shoulders, elbows, knees, sterno- 
clavicular or sacroiliac articulations. 

Icterus and subicterus have often been noted and 
urobilin is invariably present in considerable quantities 
in the urine. 

Renal lesions are manifested by albuminuria, some- 
times accompanied by a slight or considerable increase 
in the blood-urea. I have also had occasion to 
observe thyroiditis, suppurative peritonitis, abscess 
formation in the psoas muscle or in the deep muscles 
of the buttock originating from sacroiliac arthritis. 
During the course of the disease there is usually a 
leucocytosis ranging from 13,000 to 30,000 white cells 
and in the more chronic cases the red cells are some- 
times reduced to 2 or 3 millions. 

These septicemias may progress rapidly and end 
fatally in from 7 to 15 days; in such cases the 
temperature remains constantly high, the patient is 
in a state of extreme prostration with the aspect of 
a case of typhus, and dies in coma. In other cases 
the repeated recurrence of attacks of extreme high 
temperature may in a few days bring about fatal 
collapse. Again the fatal termination may be 
delayed to the end of the third week, or even a month 
or six weeks may pass before it occurs. In such 
examples the temperature becomes irregular and 
oscillating ; in accordance with the recurrence of 
excessive febrile attacks one sees the usual phenomena 
appear; pulmonary infarcts, pleural effusions, and 
arthritic phenomena; the patient wastes, the colour 
becomes pale and earthy, and there are profuse 
sweats; finally delirium occurs and death follows 
in a condition of cachexia. It may be hastened by 
the sudden bursting of an abscess into the bronchus 
followed by syncope. 


Diagnosis 


The most characteristic lesions found at autopsy 
are those in the respiratory tract. The lungs are the 
site of necrotic infarcts, both centrally and peri- 
pherally, usually about the size of a pigeon’s egg and 
circumscribed. Some are seen as yellow masses 
surrounded by a hemorrhagic zone, others in the 
form of cavities containing pus. From these lesions 
B. funduliformis can usually be recovered in pure 
culture, but occasionally it is associated with an 
anaerobic streptococcus. In a case recorded by 
Prof. Tessier and his co-workers, which was 
accompanied by deep jaundice and purpura, the liver 
was greatly enlarged and was studded with necrotic 
abscesses from which the organism was isolated in 
pure state. 

From this it is clear that these septicemias carry 
an extremely grave prognosis. Of the 20 cases 
observed by the writer and certain of his colleagues 
in Paris only two have recovered. These two were, 
however, amongst those appearing most ill and were 
complicated by pulmonary and arthritic manifesta- 
tions ; further, the number of organisms in the blood, 
- estimated after the examinations of cultures, appeared 
as great in these as in the fatal cases. In these 
Survivors cure occurred spontaneously and treatment 
had been of purely symptomatic character. 

It is therefore understandable that certain German 
observers have been led, as soon as the clinical 
diagnosis was possible, and without awaiting the 


PROF. A. LEMIERRE : SEPTICASMIAS AND ANAEROBIC ORGANISMS 


‘described above. 


[MARCH 28, 1936 


results of bacteriological examination, to perform 
ligation of the internal jugular vein on the side of the 
affected tonsil. They claim that thanks to this 
intervention the mortality has been diminished. 
I have personally had recourse to this treatment in a 
recent case but unhappily without success in 
preventing a fatal termination. 

To anyone instructed as to the nature of these 
septicemias it becomes relatively easy to make a 
diagnosis on the simple clinical findings. The 
appearance and repetition several days after the onset 
of a sore-throat (and particularly of a tonsillar abscess) 
of severe pyrexial attacks with an initial rigor, or 
still more certainly the occurrence of pulmonary 
infarcts and arthritic manifestations, constitute a 
syndrome so characteristic that mistake is almost 
impossible. 

Certain diagnosis is established by bacteriological 
examination. B. funduliformis is easy to discover in 
the purulent effusions, but it is blood culture on 
anaerobic media which gives the earliest definite 
information, and this is particularly sure if the 
blood is taken during a rigor. 


The culture medium employed at the Claude Bernard 
Hospital by J. Reilly, which can be particularly recom- 
mended, consists of 10 c.cm. of the glucose agar of Veillon 
to which is added 40 c.cm. of peptonised bouillon and 
2 c.cm. of a 20 per cent. solution of glucose. This medium 
divided in glass tubes 25 cm. long and 25 mm. wide, is 
liquefied by heat at the moment of employment and 
kept at a temperature of 40°C. After 2 to 4 c.cm. of 
blood have been added the tubes are immediately cooled 
under the tap. The colonies appear in it after two to 
four days’ incubation at 37°. 

B. funduliformis in pus smears appears in the form of 
a fine bacillus of 2 to 3 u in length, Gram-negative, and 
exhibiting at each end a well-coloured mass, ‘whilst. the 
centre of the microbe remains clear. In cultures it pre- 
sents, and this is a very important point, a remarkable 
polymorphic appearance. It occurs in preparations 
simultaneously as a fine bacillus, as long filaments, more 
or less voluminous, and sometimes as spherical elements 
Some of these spherical bodies, of a diameter of about 
2 to 4u, are intensely susceptible to basic stains. Others 
achieve greater dimensions, as much as 12 to l4u. Their 
protoplasm is clear but they contain coloured nuclei of 
various shapes sometimes resembling the nuclei of poly- 
nuclear leucocytes. The spherical elements are quite 
characteristic and permit absolute identification of 
B. funduliformis. The polymorphic character of the 
microbic elements may be observed in the first cultures 
obtained from the blood but is much more obvious in 
subcultures. In individual cases sometimes the forms 
with filaments and sometimes the spherical forms pre- 
dominate. 


One further characteristic of the bacillus may be 
mentioned—namely, that it is constantly hemolytic. 
Finally, J. Reilly has demonstrated that, on injection 
of cultures into the rabbit, septicemia with metastatic 
abscess formation in the lungs, liver, and joints, 
exactly comparable to what is seen in man, is 
produced. 

Various Sites of Infection 


THROAT AND EAR 


The B. funduliformis is the commonest pathogenic 
agent in post-anginal septiceemias such as have been 
But other bacilli of the same group 
may also be the causal agents. Allusion has already 
been made to the B. symbiophiles of Schottmiuller ; 
recently Grumbach and Verdan (of Zürich) have in 
three instances found in the blood a “‘ fuso-bacterium 
nucleatum ” which is perhaps identical with B. funduli- 
formis. There is, on the other hand, an anaerobic 
organism very definitely distinct from B. funduliformis 
—namely, B. fragilis—which is occasionally 


THE LANCET] 


responsible, as the present writer, with Guy and 
Rudolph, has demonstrated ; a similar infection has 
been observed by Richon, Kissel, and Lepoire. 

The infections described above are marked by 
rigors and embolic phenomena, but it occasionally 
happens that somewhat similar fevers are observed 
which get well without any such complications 
although blood culture has revealed anaerobic 
organisms ; we have, for example, observed cases of 
this sort from which B. ramosus has been recovered 
and another due to an anaerobic staphylococcus. 
Such cases are exceptional and are not due to a true 
septicemia but to simple momentary and benign 
bacteremia. These observations are nevertheless 
instructive; the transient discharge of organisms 
into the blood stream during a pharyngeal infection 
is certainly capable, occasionally, of producing 
embolic phenomena which may take on the appearance 
of a local disease in which the original cause is 
not clear. Such septic emboli may be the origin of 
certain cases of pulmonary suppuration or of empyema 
or arthritis, clinically resembling that which has been 
described in this paper but of lesser gravity because 
a true septicemia is not present. 

On the other hand, the reason why the complica- 
tions heretofore described have been straightforward 
suppuration, but not of a putrefactive character, is 
that they have been due to pure infection by 
B. funduliformis or at most to this organism associated 
with an anaerobic streptococcus. The fetid pus of 
tonsillar abscesses contains many species of anaerobic 
organisms, and it is surprising that only one or two 
of them usually pass into the blood stream. It does, 
however, occasionally occur that others of these 
anaerobes may take this course and give rise to 
septicemias of mixed origin with putrid embolic foci. 
I have, for example, described with P. de Font- 
Réaulx, a case with the usual blood picture but com- 
plicated by gangrenous osteoperibstitis of the pubis 
and gangrenous pulmonary abscesses containing 
many different species of anaerobic organisms. 

The description given of the post-anginal septi- 
csemias is sufficient to allow review of those arising 
from other primary foci to be very brief. Such are 
observed in the course of otitis and mastoiditis parti- 
cularly when fetid otorrhcea has been present, such 
foetor being due to infection with anaerobes. 
of this type is very frequently complicated by lateral 
sinus thrombosis and is the cause of pulmonary emboli. 

Anaerobic septicemia arising from otitis and proved 
by blood culture has been described particularly by 
Guillemot (B. fragilis and B. radiiformis), by Boez, 
Keller, and Kehlstadt (B. fragilis), by Boez, Keller, 
and Schreiber (B. ramosus), by Langeron (anaerobic 
staphylococcus), and by Franklin and Camb (Gram- 
negative B. fusiformis). 

The clinical manifestations of such septicæmias are 
very closely similar to the picture given of the post- 
anginal septicæmias. The same picture has been 
observed by us in connexion with buccal suppuration 
following the extraction of heavily infected teeth. 


UTERUS AND PELVIC ORGANS 


Anaerobic septicæmias are well known as compli- 
cations of postpartum uterine sepsis. The clinical 
similarity of these to the post-anginal septicæmias 
has recently been emphasised by A. Schneider. The 
normal presence of B. funduliformis and other 
anaerobic organisms in the vagina was noted in 1898 
by J. Hallé, and in 1902 Jeannin called attention to 
the proliferation of these anaerobes in the uterine 
cavity after any severe case of suppurative puerperal 
endometritis. 


PROF. A. LEMIERRE : SEPTICÆMIAŞY AND ANAEROBIC ORGANISMS 


Otitis. 


[MARCH 28, 1936 703 


In a series of publications since 1910, Schottmüller 
has given a full description of these septicemias 
which are always linked with the presence of peri- 
uterine thrombophlebitis; fever, repeated rigors, 
pulmonary metastases, and occasional icterus are the 
outstanding -clinical features. He gives as the 
commonest cause an anaerobic streptococcus, the 
Streptococcus putridus, which may be associated with 
other organisms including the B. symbiophiles. 
Similar cases have been observed by myself and by 
Boez, Keller, and Kehlstadt. In the uterine septi- 
cæmias, as in the post-anginal ones, the metastatic 
abscesses are only fostid when the infection includes 
a number of different species of anaerobes. 

It has further been noted that similar phenomena 
may occur after surgical operations on the uterus 
and pelvic organs, and that apart from septicemia a 
simple bacteremia may occur producing distant 
abscesses the primary focus of which may be 
overlooked. 

OTHER LOCI 


Gangrenous appendicitis is known to arise fre- 
quently from anaerobic infections; such cases are 
sometimes complicated by thrombophlebitis of the 
mesenteric veins, by pylephebitis, by liver abscess, 
and by fotid subphrenic abscess. In such cases 
Schottmiller has isolated from the blood strepto- 
cocci, anaerobic staphylococci, and the B. symbiophiles. 
Nedelmann has recently isolated the last-named from 
such a casein pureculture. The site of the thrombo- 
phlebitis in such cases prohibits the formation of 
pulmonary infarcts, but gangrene of the lung and 
purulent pleurisy are occasional complications. The 
usual high fever and rigors characterise such cases. 

In 1899 Cottet noted the presence of organisms of 
this type, notably B. funduliformis, in certain cases 
of peri-urethral suppuration. Thomson and Beaver 
have reported a case of septicemia due to B. fragilis 
in a patient suffering from cancer of the bladder, and 
another of septicemia due to B. funduliformis follow- 
ing prostatectomy, this last case being complicated 
by iliac phlebitis and pulmonary metastases. 


Summary 


No attempt has been made to review completely 
the literature of the subject, but sufficient has been 
said to demonstrate that, whatever their primary 
focus, the septicemias produced by the anaerobic 
organisms which occur as saprophytes in the natural- 
cavities of the human body display remarkable 
clinical similarities. They commence by suppuration 
in the local site and this is followed by local thrombo- 
phlebitis. Considerable fever and intense rigors are 
the next feature, and these are followed very frequently 
by septic pulmonary emboli. The syndrome is so 
characteristic that it permits of diagnosis before 
bacteriological examination, including blood culture, 
has provided conclusive proof. The post-anginal 
septicemias due to B. funduliformis have been 
specially described, but the same phenomena are 
observed when such septicemias of anaerobic origin 
arise from other initial causes. 


KEY REFERENCES 
Claus, H.: Uber 100 Fälle von Septico-Pyamie nach Angina, 
Med. Klin 12 


. 1931, 
Kissling, K.: Uber post- -anginöse Sepsis, Münch. med. Woch., 
1929, ixxvi., 1163. 
Lemierre, A. : Sur un cas de septico-pyohémie à bacillus funduli- 


ormi Maladies infectieuses, Paris, 

Pham, C.: Les septicémies dues au bacillus funduliformis 
ERES de Paris, 1935 (containing the fullest existing Dien? 
graphy on the subject). 

Teissier, P., Reilly, J., Rivalier, E., et Stefanesco, V : Les septi- 
cémies primitives åues au bacillus funduliformis, Ann. de 
méd., 1931, xxx., 97 


electrolytic osmotic pressure. 


704 THE LANCET] 


DR. E. A. MOCANCE: MEDICAL PROBLEMS IN MINERAL METABOLISM 


[magcon 28, 1936 


MEDICAL PROBLEMS IN MINERAL 
METABOLISM * 


By R. A. McCancez, M.D., Ph.D. Camb., 
¥.R.C.P. Lond. 


ASSISTANT PHYSICIAN IN CHARGE OF BIOCHEMICAL RESEARCH, 
KING’S COLLEGE HOSPITAL, LONDON 


II.—_SODIUM DEFICIENCIES IN CLINICAL 
MEDICINE 


The Body Fluids 


AT the outset of this lecture I wish to say some- 
thing of the formation and composition of the body 
fluids, a number of which are set out in diagrammatic 
fashion in the accompanying Figure. The upper half 
of each rectangle represents, in milli-equivalents per 
litre, the concentrations of the bases in that fluid, 
and the lower half indicates the concentrations of 
the acids. For any given fluid the two must obviously 
be equal. It will be noticed that the composition of 
the cell fluid differs radically from that of all extra- 
cellular fluids, for the former contains chiefly potas- 
sium phosphate whereas the latter characteristically 
contain sodium chloride .and bicarbonate. There is 
practically no interchange of basic ions between the 
cells and the fluids surrounding them. 

The substances dissolved in these fluids cause 
them to have a considerable osmotic pressure which 
amounts to about 8 atmospheres.?*”? The pressure 
is due (a) to the non-electrolytes. In man these 
contribute only a small quota to the total osmotic 
pressure and are not indicated in the diagram. They 
are, generally speaking, equally distributed between 
cells and plasma, and so merely raise or lower the 
general level of osmotic pressure of the whole body 
without affecting the water distribution between the 
cells and plasma. In the dogfish non-electrolytes are 
present throughout the body in large amounts and 
so raise its osmotic pressure above that of the sur- 
rounding sea water. We were chiefly concerned with 
this total osmotic pressure of the body in the dis- 
cussion of the water regulation of the marine fish 
(Lecture I.). (b) To the electrolytes. These consist 
of the inorganic and organic (protein) ions, but the 
inorganic ions give rise to nearly the whole of the 
The protein ions con- 
tribute so little towards it that they may almost 
be neglected, and therefore the electrolytic osmotic 
pressure taken to be the sum of the osmotic pressures 
due to the inorganic basic and acidic ions. Since the 
-basic ions of the extracellular and cellular fluids are 
not interchangeable, their concentrations control the 
electrolytic osmotic pressure of their respective 
fluids, and hence the water distribution between the 
‘cells and plasma. It is the electrolytic rather than 
the total osmotic pressure with which we are chiefly 
concerned in man. 

` The rectangles in the diagram are not all of the 
same length. The greater length of some of them 
(serum, cell fluid, semen, and bile) is due to the 
proteins or colloidal bile acids which they contain, 
„and does not indicate a greater osmotic pressure.?°? 
Actually the total osmotic pressure of the serum, 
‘the other internal extracellular fluids, and of the cells 
“arè all the same. This is an important poińt, and 


indeed it is fairly certain that no fluid could remain 


* The Goulstonian lectures for 1936, delivered Bre the 
- Royal College of Physicians of London on March Toth, 
‘and 12th. Lecture I. was published on March eF the 
remainder of Lecture II. and Lecture III. will appear in 
forthcoming issues. 


different. 


long in contact with the internal body cells without 
coming into osmotic equilibrium with them by the 
passage of water in one direction or the other, Even 
the bile in the gall-bladder, which may contain much 
more sodium than the serum,®® seems to have the 
same osmotic pressure as the other body fiuids.** 
There is practically no protein in any of the secreted 
fluids, and the short rectangles (saliva and sweat) 
indicate real differences of osmotic pressure. These 
fluids which are secreted on to an impermeable strati- 
fied epithelium need not have the same osmotic 
pressure as the internal fluids. 

With two exceptions sodium forms about 94 per 
cent. of the total base of the extracellular fluids. 
The first exception is the gastric juice, where, as is 
well known, hydrogen forms between 60 and 70 per 
cent. of the total base. The second exception is the 
semen, in which potassium forms 17 per cent. of the 
total base instead of the usual 3 per cent. ‘The two 
important acid radicles of serum, œdema, cerebro- 
spinal fluids, and of the gastro-intestinal secretions 
are chlorides and bicarbonates, but they differ very 
greatly in their relative concentrations, and it is 
these differences which impart some of the peculiar 
characteristics to each fluid. Semen has a most 
interesting and unusual composition for an extra- 
cellular fluid, for it contains a large amount of 
phosphoric acid. The main acid radicle of sweat 
is chloride, but some bicarbonate, lactate, and other 
ions are also present. 

A glance at the diagram is sufficient to show that, 
although the gastro-intestinal fluids and semen have 
the same osmotic pressure as the serum,*®® 100 101 they 
are true secretions in that their ionic pattern is 


TABLE I 


Composition of Serum, Serum Ultrafiltrates, Hiffusions, and 
luid 


Cerebro-spinal Fl 
Mg. per 100 c.cm. 


Serum 
— Serum. ultra- Effusion C.S.F. 
filtrate 
Sodium 330 334 334 334 
Potassium .. 17 18 17-5 10-6 
Calcium 10-3 5°54 5°9 5°33 
Magnesium .. 2°5 1-8 ste 3°3 
Chloride 365 387 390 436 
Bicarbonate.. 151 — 150 105 
Phosphorus .. 3 3:0 3 1°8 
Sulphur tig 1:9 2-0 2'2 0-6 
Sources of Information 
Sodium : 62 97 167 255 
Potassium : 39 97 167 177 179 191 334 
Calcium ; 41 59 70 73 125 166 175 179 189 191 226 232 235 255 265 285 
298 300 303 332 | 
Magnesium : 51 97 166 189 190 191 300 333 
Chloride : 97 151 281 255 317 


64 75 97 125 231 
73 97 125 166 179 255 301 


General ; 82 97 166 


Bicarbonate : 
Phosphorus : 
Sulphur; 335 


The same is true of saliva and sweat, 
which differ obviously from serum not only in com- 
position but also in osmotic pressure. It is impos- 
sible to draw any accurate conclusions about the 
cerebro-spinal fluid from the rough diagram shown here,’ 
but its composition, together with that of serum, serum’ 


‘ultrafiltrates, and cedema fluids, is set out in Table I. 


The osmotic pressure of serum .and cerebro-spina>- 
fluid is the same.** The relative concentrations 0:4 


| 


TABLE IT 


Average Volus aes of Digestive Fluids Secreted by an Adult 
Man in 24 Hours 


(After Rowntree 275) 


Volume c.cm. 


von. in 24 hours. Authority. 
Saliva .. T 1500 \ Bidder and 
Gastricjuiod ..  .. 2000-3000: |J Schmidt. 
Bile sa sá 300-500 Pfaff and Balch. 
| Pancreatic ju ice zi 500-800 Wohlgemuth. 
| Succus enter} cus 3000 Pregl. 
) 8000 = 


| Approximate total `. 


magnesium, /potassium, chloride, bicarbonate, phos- 
a sulphate in effusions, ultrafiltrates, and 

cjerebro-spinal fluid show however that while effusions 

cind cedema fluids are probably formed by simple 

-Ultrafiltration, the cerebro-spinal fluid is a secretion. 

If further evidence were required, it has been shown 

that large pathological variations in 

the serum calcium are not reflected 

in the cerebro-spinal fluid.®5 106 144 


of calcium per 100 c.cm. The cerebro- 
Spinal fluids contained 5:07 and 4:36 
mg. per 100 c.cm. respectively— 
normal amounts, and one of them 
actually higher than the correspond- 
ing serum.8? Again, induced changes 
in the plasma bicarbonate only 
appear in the cerebro-spinal fluid if 
- vue DYntrges are inflamed.*!®8 Non- 
electrolytes hve not the distribution 
between the| two fluids that one 
would expect |were the cerebro-spinal 
fluid an ultra trate. 46 50 60 75 266 278 327 
| The concenfration of magnesium? 
| and possiblyfof chlorides 178 181 has 
been found fto fall in tuberculous 
meningitis with no corresponding 
change in tHe serum. Lastly, the 
way in whidh the flow of cerebro- 
spinal fluid jesponds to changes of 
oxygen andy CO, tension strongly 
suggests secretion rather than filtra- 
tion.? I hajve perhaps over-stressed 
the way in phich the cerebro-spinal 
fluid is formé¢d, but it is not generally 
appreciated fin this country and I 
think it is helpful to bring this fluid 
into line with others which are 

j the body spaces. 


216 326 333 I have, for example, 
} recently seen two cases of severe . 
C long drawn out tetany, in which SERUM 
the s tained 5-81 and 3-78 mg. 
E 5: ULTRAFILTRATE 
\ 


CEREBRO-SPINAL 
FLUID 


tot see 


GASTRIC JUICE 


ILEAL JUICE 
HEPATIC BILE 
SEMEN 
SWEAT 


SALIVA 


about 5 littes, of which say 2-5 are 
plasma. rom this plasma all the 
extracellulgr secretions of the body 
are derived j| and the volume of these is 
very large, j Table II., which is copied 
from Rowy tree 273 and McQuarrie,!98 
sives an indication of the large 


Serum ; 15%, &c. 


EFFUSIONS, LYMPH. F- 


GLOMERULAR FLUID CHLORIDE 


CELL (MUSCLE) [St 
FLUID 


Composition of the body fluids : 


(] DB. R.A. MCOANCE: MEDICAL PROBLEMS IN MINERAL METABOLISM [MARCH 28, 1936 705 


obtained figures of the same order from patients from 
whom continuous removal of gastric juice was being 
practised for therapeutic reasons. It is obvious that 
secretion into the gut at this rate is only made pos- 
sible by an equally rapid reabsorption at a lower 
level, and that the continuous loss of any one of 
the gastro-intestinal fluids must have very serious 
consequences because of the loss of sodium and water 
which it entails. I wish now to consider this subject 
in more detail, with special reference to the resulting 
sodium deficiencies. : 


Forced Loss of the Extracellular Fluids 


(a) Loss of the intestinal secretions.—This is a common 
cause of sodium deficiency and water loss which 
operates in continuous vomiting,?!® 219 263 312 parti- 
cularly in pregnancy, ®§ 113 126 127 163 168 247 284 325 or 
the so-called cyclical vomiting of children,?® 140 165 
pyloric stenosis 38 148 280 246 260 and intestinal obstruc- 
tion,?24 117 168 202 203 214 240 258 gastro-enteritis, diar- 
rhea and cholera,!76 217 260 269 270 281 282 286 287 and 
especially perhaps in the acute diarrhwa and vomit- 
ing of children.*5 52131 A typical sodium chloride 


MILLI 
I0 20 30 40 


EQUIVALENTS PER LITRE 
60 70 80 90 100110 120 130 140 ISO 160 170 


POL AE PB NNS 
See oe pes 


MILLI 
10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 


X = unnamed basic radicles. 
Y = ry) acidic ry) 


Sources of Information 


Cerebro-spina] fluid, exudates, ultrafiltrates, and glomerular fluids: see Table I., 
also 31 32 95 96 328 233 327 328 


Gastric and pancreatic juices, bile: 8° 90 


volumes gf digestive juices which 
nay be se¢reted by an adult man in Jejunal juice ; 16 145 150 
14 hours, J I do not, however, think Ileal Juice : 16 


hese fizuyes unreasonably large, for 
satsch apd Mellinghoff 157215 have .:. Saliva : 1749137 


Swent: 187 200 201 227 229 340 


706 THE LANCET] DR. R. A. MCCANCE: MEDICAL PROBLEMS IN MINERAL METABOLISM 


deficiency has been produced by draining a gall-bladder 
which contained a salt-secreting papilloma.!® Our 
present knowledge of the subject is the result of a 
great deal of research and investigation commencing 
over one hundred years ago into the nature of the 
fluids lost and the resulting acid-base-water balance 
of the organism.?* 242 286 287 Intestinal obstruction, 
710 58 79 84 91 92 107 111 112 115 116 118 119 120 121 122 142 152 186 
805 331 336 337 339 the continuous loss of gastric,* 64 72 89 
° 107 136 157 180 215 329 341 pancreatic, *4 77 90 136 duodenal, 
34 89 90 330 and intestinal juices 1° 145 150 have all been 
experimentally produced and the blood chemistry 
fully investigated. The subject has been reviewed 
by a number of writers.?5 58 88 94168 196 204 283 339 

(b) Loss of sweat.—This is not nearly such a com- 
mon cause of sodium chloride deficiency in this 
country, but it may give rise to unrecognised ill- 
health in hot climates,}®* 194 and may be most serious 
164195 314 or fatal. Some remarkable escapes have 
been recorded.?®°5 Sweating is an essential step in 
the production of stoker’s or miner’s cramp,®’ 22° and 
some aspects of the subject have been investigated 
experimentally in man.?5 30 69 170 200 201 209 229 313 340 
Small laboratory animals do not sweat. The horse 
does, freely, but I am not aware of any experiments 
on this animal. 

(c) Loss of other extracellular fluids.—Porges and 
Mach have described an unusual cause of salt defi- 
ciency—namely, repeated tapping of collections of 
ascitic fluid in a patient who was on a low salt diet. 
This must be rare, but a similar method has been 
employed experimentally.® 93 161 245 291 344 Large 
injections of a glucose solution were made into the 
peritoneal cavity. The injected fluid rapidly came 
into equilibrium with the plasma electrolytes. By 
tapping the abdomen after this had taken place and 
before the fluid was absorbed a large part of the 
body’s extracellular ions was removed. 


Changes in the Blood and Cells Caused by the 
Loss of the Extracellular Fluids 


Let us once more consider for a moment the com- 
position of the body fluids and consider what will be 
the effect of their removal upon the fluids left behind. 
Take, for example, a mixture of the jejunal and ileal] 
juices and let us suppose that 500 c.cm. have been 
secreted and removed from 2500 c.cm. of plasma. 
The mixed juices resemble plasma in composition 
(see Figure) except that they contain less protein, 
and we may consider for this purpose that 500 c.cm. 
of protein-free plasma have been removed. The 
results will be (a) a reduction in plasma volume from 
2500 to 2000 c.cın.; (b) a reduction in the blood 
volume from say 5000 c.cm. to 4500 c.cm. and a 
corresponding rise in the cell count; (c) a concen- 
tration of the plasma proteins by 20 per cent. and 
a rise therefore in the colloidal osmotic pressure ; 
(d) no change in the concentration of serum electro- 
lytes—i.e., little or no change in the total osmotic 
pressure. 

The removal of a similar volume of pancreatic 
juice would have brought about the same hæmo- 
concentration, but in other ways the results would 
have been different, for much more bicarbonate than 
chloride would have been removed. An excess of 
the latter therefore would have been left behind and 
this would have led to an acidosis. With the removal 
of gastric juice a still further complication would be 
introduced, for this juice is not only acid but contains 
far less sodium and more chloride than the plasma. 
The removal of 500 c.cm., therefore, would leave the 
remaining 2000 c.cm. of plasma with a deficiency of 
chloride but with an excess of sodium. This would 


[MAROH 28, 1936 1 


make the plasma hypertonic, but this might not be 
appreciable because water would move in compensa- 
tion from the cells to the plasma. There would, how- 
ever, be an alkalosis. 500 c.cm. of sweat contain 
very much less sodium chloride and bicarbonate than 
a similar amount of plasma. It is obvious that their 
removal from 2500 c.cm. of plasma would raise the 
concentration of sodium salts in the remaining 
2000 c.cm. 

In practice the removal of 500 c.cm. of one of the 
extracellular fluids would not greatly alter the com- 
position of the plasma, for there are small accumula- 
tions of extracellular fluid in various parts of the 
body which may be drawn upon to maintain the 
composition of the plasma relatively unaltered. 
Indeed, the total amount of extracellular fluids in 
the body is thought to be as much as 20 per cent. of 
the body-weight.®* 173 Moreover, changes in the acid- 
base balance may be masked by the kidney, which 
always tends to counteract such abnormalities. 
Further, water may be taken by mouth and some 
or all of it absorbed. After moderate loss of gastric 
juice or sweat this is wholly beneficial, for the water 
is used to restore the hypertonic plasma to normal 
and at the same time to make up the plasma volume. 
When water is absorbed after large amounts of other 
body fluids have been lost, or if the loss of base 
(however brought about) has been sufficiently severe, 
the osmotic pressure of the plasma is no longer 
strictly maintained. A compromise is struck between 
the volume of the plasma and its osmotic pressure, 


TABLE III 
= w e e . b 
q “> “| O72 ae 
: a LS r . é 2j e 
32] $3] ¢|g8 58) GE 
ou >| a8 a: 5159152 Bd Acid-base 
an} as! os Ee fo =9| 92] balance 
38| $5) 2s | 3| 52/35) 85 
P| OE) |a| a Je FA ap 
SIA 8| 8iSel E 
Normal 5-0 | 7:0 |5000 | 330 | 370 | 60 | 30 Normal 
Pyloric stenosis | 5-5 | 7-6 | 4500 | 315 | 300 | 90 | 50 | Alkalosis 
Diarrhea 
(severe) |6:0 | 8-2 | 4000 | 300 | 330 | 15 {120 | Acidosis. 
Intestinal ob- 
struction .. | 5:8 |7°3 | 4200 | 290 | 320; 40 | 80 
Sweating with- 
out drinking | 8-0 |9-0 | 3800 | 380 | 410 | 70 | so |} Generally 
Sweating with 
drinking (see eas 
Lecture III.) | 6-5 | 7-9 | 4200 | 290 | 322 | 59 | 70 
so that we find them both to be reduced. In clinical 
medicine, and experimental work dealing with intes- 


omplicated 
en lost, so 


tinal obstruction, the matter is further 
by the fact that mixed secretions are oj 
that the final blood picture may be mo: ; confused. 
Table III. shows the sort of changes that one might 
expect to find clinically in the blood. ' he figures. 
which are shown in relation to a stand: id normal, 


were not taken from particular instance but com- 
piled from the literature and correspond : the text- 
book disease rather than the bedside cas © lt must 
be emphasised that the normal itself is  ubject to 
some variation, and that patients may 1 we had a 
secondary anzemia or a subnormal per mtage ol 
proteins in their plasma before the on ft of the 
acute intestinal disaster. Disregarding, however, 
these complications it will be observed— | 

(a) That there is always a reduction of blo ` volume. 
This is of course entirely due to a reduction ine plasma 


volume which is also reflected in— 


d 


po E 


THE LANCET] 


(b) the rise of the red cell count and 

(c) the rise in the plasma proteins. 

(d) There is a fall in the serum sodium, except when 
sweating has been severe and water has not been taken 
by mouth. It is not invariable in pyloric stenosis, for 
reasons which I have just given, but usual. In assessing 
the total loss of sodium from the body, both the reduction 
in the extracellular fluid volume and in the concentration 
of sodium in these fluids must be considered. 

(e) There is a fall of chloride and rise of bicarbonate 
in pyloric stenosis due to the loss of hydrochloric acid 
in the vomit. In diarrhea, in which the alkaline pancreatic 
juices are lost, the fall in bicarbonate exceeds the fall in 
chloride. 

(f) In intestinal obstruction there may be a simultaneous 
loss of pancreatic and gastric juices so that there may be 
little or no change in the acid-base balance of the plasma. 

(g) A rise in the blood-urea always accompanies these 
changes. This will be referred to later.. 


Since the osmotic pressure of the cells is always 
close to that of the plasma, you will appreciate that 
these departures from the normal electrolyte pattern 
of the plasma must affect the cells. A rise or fall in 
the concentration of sodium alters the electrolytic 
osmotic pressure of the plasma, and the cells of the 
solid tissue conform to this by varying their water 
content. They do not lose potassium 224 248 or take 
up sodium. The red blood-cells of man behave like 
the tissue cells. The erythrocytes of the dog, on the 
other hand, which contain sodium but not potassium 
respond to osmotic changes in their environment 
by changing their base rather than their water 
content,*4¢4 i 


The Chemical Pathology of Addison’s Disease 


I turn now to other causes of sodium and water 
deficiency and say something of Addison’s disease. 
Clinically, the progressive destruction of the supra- 
renal is accompanied by widespread symptoms 
and signs,}29 274 275 292 but notably by a low blood 
pressure, wasting, asthenia, pigmentation, urea reten- 
tion, anorexia, and often vomiting. The serum 
sodium is abnormally low, but this is not the result 
of the vomiting. The chemical pathology of this 
disease has been enormously advanced by the experi- 
mental suprarenalectomies which have been carried 
out extensively on rats, cats, and dogs in the last 
few years. Blood pressures have been found to fall 
in rats 74 and dogs,?45 311 and the animals become 
very weak and die before long unless treatment is 
administered. The blood changes have been studied 
13 14 37 38 183 185 208 291 305 308 320 345 346 on numerous 
occasions, and it has been established that the blood 
volumes fall and the red cell counts increase. Poly- 
cythemia is not a feature of the clinical disease 
because it may be obscured by a secondary anemia, 
274 275 or a compensatory reduction of red cells.12° 211 
The disease is so chronic that there is ample time for 
such secondary adjustments to take place. The 
hæmoglobin, however, has been observed to fall with 
the administration of sodium chloride and to rise 
again when salt was withheld.14® The serum proteins 
rise,185 308 hut curiously enough Silvette and Britton 2% 
did not find this in cats and I think the matter should 
be further investigated. The only patient with 
Addison’s disease whose serum I have had the oppor- 
tunity of examining had over 7 per cent. of serum 
proteins. This is normal, but in my experience it is 
higher than one would expect in a chronic wasting 
disease. The explanation is to be found in the work of 
Greene et al. 1°8 on the clinical disease. These authors 
have found that the serum proteins may be normal 
when the patients are in good condition, but that in 
the periods of crisis they are raised. All are agreed 
that after bilateral suprarenalectomy the serum 


DR. R. A. MCOANCE : MEDICAL PROBLEMS IN MINERAL METABOLISM [MARCH 28, 1936 707 


sodium falls and with it the chloride 185 345 and, to 
some extent, the alkali reserve.1§* These changes 
reduce the electrolytic osmotic pressure of the plasma. 
Hence the normal distribution of water between the 
cells and plasma is upset, for the muscles, which do 
not lose their electrolytes, take up water 289 29° till 
osmotic equilibrium is restored. Marafion and 
Collazo ?°8 have not confirmed this over-hydration 
of the muscles on clinical material, but their evidence 
on this point is unsatisfactory because it is not clear 
how they obtained their controls. The blood-sugar 
falls,37 38 289 the serum potassium rises,?98 320 346 and. 
there may be some interference with the absorption 
of fat from the intestine.*?5 334 The blood-urea rises. 
It will be seen that the changes in plasma volume, 
blood volume, cell count, serum sodium, chloride and 
urea are the same as those which occur when sweating 
is severe and accompanied by the ingestion of large 
amounts of water—i.e., in sodium chloride deficiency 
without water deprivation (Table III.)—and the 
primary cause I consider to be the same—namely, 
the loss of sodium 18? (see Lecture III.). This is entirely 
supported by the beneficial effects of sodium chloride 
in the treatment of the experimental 13 93 128 210 271 
276 310 and clinical disease.?2 149 The sodium appears 
to be the controlling ion,?!° and indeed Blankenhorn 
and Hayman have claimed that a mixture of sodium 
sulphate, phosphate, and bicarbonate was as 
effective as sodium chloride for 17 days in maintain- 
ing the health of a patient. This requires confirma- 
tion, a8 remissions are common enough in Addison’s 
disease, and sodium sulphate and. phosphate are not 
very efficacious in sodium deficiencies of intestinal 
origin. . 

In the absence of any over-activity of the sweat 
glands or any obvious loss of the bodily secretions, 


one naturally turns to the urine in search of the 


channel through which the sodium is lost. Increased 
excretion has been demonstrated, and the simplest 
if not the most “intelligent ” 248 view to adopt is 
that in the absence of cortical hormone the renal 
threshold for sodium falls. Sodium salts therefore 
are excreted in excessive amounts even when the 
plasma levels are normal or subnormal. In the 
absence of an exaggerated intake this must inevitably 
lead to a sodium deficiency. 


Diabetic Coma and Chronic Interstitial 
Nephritis 

There is one other clinical cause of sodium deficiency, 
but I have left it to the end because it is, I think, 
the most difficult to understand. We know from the 
experiments of Haldane 124 and Dennig et al. ®* that 
a severe experimental acidosis induces at first. a 
large loss of fixed base (mostly sodium), concentra- 
tion of the plasma proteins, and hemoglobin." The 
acidosis must be pronounced to bring about these 
effects,155 and even under Dennig’s severe experi- 
mental conditions the loss of base did not continue 
for more than a few days. There was, in fact, some 
retention of sodium in the later stages,®* and removal 
of the acidosis led to an immediate swing back to 
normal.66 206 The body’s chief protection against 
such a loss of fixed base is the ability of the kidney 
to form and excrete ammonia. 

The blood picture in diabetes and diabetic coma has 
been very fully studied, and is in keeping with a salt 
deficiency. There is no doubt for instance that in coma- 
tose patients 135 250 262 or depancreatised animals 146 
the plasma proteins tend to be raised and the red 
cells concentrated. These findings may be due solely 
to the water loss caused by the high blood-sugars 


and forced diuresis,?5! but are to be expected also 


N2 


` 


"08 THE LANCET] DR. R. A. MCCANCE: MEDICAL PROBLEMS IN MINERAL METABOLISM 


with a salt deficiency. Reverse changes take place 
during recovery.!71174 Plasma chlorides tend to 
move inversely with the blood-sugar in experimental 
and clinical diabetes of all grades of severity,}% 220 221 
234 307? and even in non-diabetic animals.4® There 
may be a great reduction in the plasma chlorides in 
coma,”® 27 43 87 169 249 which indicates a deficiency of 
extracellular electrolytes. The urinary chlorides are 
commonly very much diminished.4* 87 188 It has even 
been suggested that the fall in serum chlorides is the 
cause of the insulin resistance of coma 257 but this is 
not a very satisfactory hypothesis, and in any case, 
in spite of their absence from the urine, the plasma 
= chlorides may be normal or even high in coma.® 188 251 
Diabetic tissues take up the chloride ion with abnormal 
avidity.2, A fall of serum chlorides must not be con- 
sidered to be proof of a salt deficiency, and the only 
reliable index of this is a fall in the serum sodium. 
Such a fall has been demonstrated in coma and pre- 
coma,235 171 188 249 and it is natural to regard this as 
the result of the acidosis.?7 239 Atchley et al., more- 
over, have demonstrated by balance experiments that 
a loss of fixed base took place when insulin was with- 
held for some days from severe diabetics in whom 
ketosis developed. On the other hand they also 
observed a small negative sodium balance and a 
small fall in the serum sodium in another patient in 
the absence of ketosis, and according to Sunderman 
et al.9°° there may be a rise in the total base of the 
. serum following a single large dose of insulin to a 
non-ketosed subject. However that may be, the 
published figures for serum sodium, coupled with the 
knowledge that the serum volume is reduced, makes 
it clear that the patient in coma has lost a variable 
and often large fraction of his body sodium. Accord- 
ing to Blum et al. this loss may be very considerable 
and amount to 40 or 50 per cent. of the total sodium 
in the body.?4 28 A loss of this magnitude must mean 
a serious fall in the electrolytic osmotic pressure of 
the intracellular fluids. The total osmotic pressure 
may, however, be high14® due to the very high 
blood-sugars. Assuming the concentration of sugar 
to be the same throughout the body fluids, the water 
distribution between the cells and plasma will be 
unaffected by the sugar, and resemble that of simple 
salt deficiency when the total osmotic pressure of 
the plasma is low. Be that as it may, the total 
osmotic pressure of the body will undoubtedly 
become subnormal under the action of insulin, and 
- this will be accentuated if water without salt is taken 
with the insulin and absorbed.!74 

In diabetes the ability of the kidneys to form 
ammonia is normal 2188 and only an intense acidosis 
will produce a serious loss of fixed base. In chronic 
- interstitial nephritis the power to form ammonia is 
impaired,?% 243 295 and in my opinion this is why a 
normal production of acids can bring about the loss 
of fixed base.?!? In this disease some of the general 
signs, which I have tried to show you are generally 
associated with sodium deficiency, are absent. 
There is no hemo-concentration for instance. I 
think the explanation must lie in the secondary 
changes which have time to develop in such a chronic 
disease. You will remember that I explained the 
differences between the blood pictures of clinical and 
experimental Addison’s disease in a similar way. 

As is usual, however, when the serum sodium is 
reduced there are generally signs of dehydration and 
a diminished volume of the extracellular fluids.?53 
As in diabetic coma the total plasma osmotic pressure 
may not be reduced in spite of the reduction of plasma 
electrolytes. This is due to the very great rise of 
blood-urea which has usually taken place. This 


[maRcH 28, 1936 


urea (more certainly than glucose) is equally distri- 
buted over both cells and plasma and therefore will 
not affect the distribution of water between the 
plasma and the cells. The latter consequently are likely 
to be swollen up with water which they do not want 
and cannot get rid of, and which prevents them 
from functioning normally. 

These then are the clinical conditions associated 
with a loss of extracellular electrolytes. I have 
attempted to give you some idea of the way in which 
the losses are brought about and the resulting blood 
changes. I have also tried to show you how these 
changes in turn affect the body cells. You will 
remember that the losses may be accompanied or 
followed by an acidosis, or an alkalosis—or neither, 


and that they are often associated with a forced loss 


of water. Owing to these complications and the 
other pathological processes which are going on at 
the same time, it is difficult to decide how much of 
the various clinical syndromes may be attributed 
to the electrolyte deficiency. It is indeed difficult to 
form a picture of the real effects of a loss of neutral 
sodium salts, but I shall return to this later. I 
propose now to discuss other aspects of these diseases 
and to review them in the light of the blood and 
tissue changes which I have already mentioned. 


The Arterial Blood Pressure in Salt Deficiency 


. A very low blood pressure is usual in Addison’s 
disease. It is also the rule in diabetic coma. I am 
not aware of any published observations on the 
blood pressure in the earlier stages of simple intes- 
tinal obstruction, but the later stages are accom- 
panied by shock, collapse, and a lowered blood 
pressure. Claims have been made that a high salt 
intake may produce a high blood pressure,*4® and a 
low salt diet is believed by some to benefit hyper- 
piesis. There is then a suggestion that the lowered 
blood pressure of the diseases under discussion may 
be a reflection of the reduction of blood volume, 
brought about by the loss of salt or other cause of 
anhydremia. I do not think this is the case, but I 
must defer giving you some of my reasons for saying 
so till my last lecture. Meantime let me remind you 
that in chronic interstitial nephritis, in which a low 
serum sodium is quite common, the blood pressure 
is characteristically high. 


The Nitrogen Balance 


There is a little clinical and experimental evidence 
which suggests that sodium deficiency (or dehydra- 
tion) may produce a breakdown of body tissues and 
set up a negative nitrogen balance. The evidence is 
at best rather unsatisfactory, but I wish to put it 
before you because of its bearing on what I shall 
have to say subsequently. In the first place Addison’s 
is unquestionably a wasting disease, but in the absence 
of accurate balance experiments one can make little 
of this evidence owing to the coincident nausea and 
anorexia. Diabetic coma is invariably accompanied 
by an extravagant and unbalanced nitrogen break- 
down, but the uncontrolled diabetes provides an 
adequate explanation for it. Some of the earlier 
work on water deprivation is most unconvincing,?&° 299 
but evidence has accumulated 1°? 211 that thirst or 
severe dehydration from diarrhoa,”?? with or without 
salt deficiency,!° may produce excessive breakdown 
of body protein. Hartwell and Hoguet 14° and 
Haden and Orr,}2° 122 249 jn their experimental work 
on dogs, showed that intestinal obstruction caused 
a much greater breakdown and excretion of nitrogen 
than starvation alone, and they made some con- 
firmatory observations on patients.!!4 They showed 


THE LANCET] 


DR. R. A. MCCANCE : MEDICAL PROBLEMS IN MINERAL METABOLISM 


[magcon 28, 1936 709 


that the administration of saline prevented this 
increased nitrogen excretion, and suggested 12? finally 
that it was due to a loss of chlorides, but it must be 
remembered that Whipple and his collaborators 
57 336 337 338 considered that the breakdown of body 
protein observed under similar circumstances was 


the result of a proteose intoxication. 


The two 


views have been reconciled to some extent by the 
suggestion that the “‘ toxin ”’ is endogenous histamine 
produced by the injured intestinal cells, and that its 
action is to accentuate the loss of chloride by 


its stimulation of the gastric glands.’ 


There is, 


therefore, uncertainty as to the cause of the tissue 


disintegration, 


and it must be admitted that 


experimental interference with the continuity of the 
alimentary canal does not provide ideal conditions for 
a study of the nitrogen balance, and in clinical practice 
it will always be negative because of the diminished 


intake. 
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Psychiat., 1932, cxxxviii., 446. 
47. Chabapier, H., Lobo-Onell, C Licutaud, P., and Lelu, E.: 
Presse méd., 1934, xlii., 844 
48. Chaikelis, A. Si: Jour. Fist i 1934, cv., 767. 
49. Clark, G. W., and Levine, L. ; Amer, Jour. Physiol, 192 a 


INxxj, ., 264, 


50. 


51. 
52. 


65. DeGowin, E. L., and rage, C. W.: Amer. Jour.. Med. 
Sci., 1934, cixxxviil., 

66. Dennig, H., Dill, D. B., ai Talbott, I. H.: Arch. f. exp. 
Path. u. Pharm., 1929, exliv., 297. 

67. Derrick, E. H.: Med. Jour. Australia, 1934, fi., 612. 

68. Dieckmann, W. J., and Crossen, R. J.: Amer. Jour. 
Obst. and Gyn., 1927, xiv., 3. 

69. Dill, D. B., Bock, A. V., and Edwards, H. T.: Amer, 
Jour. Physiol., 1933, civ., 36. 

70. Dilman, L. M., and Visscher, M. B.: Jour. Biol. Chem., 
1933, on ‘791. 

71. Dixon, C. F : Jour. Amer. Med. Assoc., 1924, Ixxxil., 1492. 

72. Dragstedt, L. R., and Ellis, J. C.: Amer. Jour. Physiol., 
1930, aoe 407. 

73. Dulière, W. L., and Minne, R.: Compt. rend. Soc. de 
biol., 1935, cxviii., 1262. 

74. urant, R. : Amer, aoe Physiol., 1927, lxxxi., 679 ; 
“ibid, 1928, Ixxxv., 

75. Egerer-Scham, G., a Nixon, C. E.: Arch. Internal Med., 
1921, xxviii., 561. 

76. Elis, L. B., „and Weiss, S.: Jour. Amer. Med. Assoc., 1932, 
C. og e 

77. Banann i and Hartmann, A. F,: Arch. of Surg., 193C. 
XX 

78. v . Farkas, G.: Zeits. f. klin. ree 1933, cxxili., 111. 

79. Felty, A; aa and Murray, H. A : Jour. Biol. Chem., 1923, 
vV 

80. Ferro-Luzzi, G.: Zeits. f. d. ges. exp. Med., 1933-34, 
xe 

81. Ferro-Luzzi, G.: Ibid., 1934, xciv., 708. 

82. Flexner, L. B.: Physiol. Rev., 1934, xiv., 161. 

83. Folling, A.: Acta Med. Scand., 1929, lxxi., 221. 

84. Foster, W. C., and Hausler, R. W.: Arch. Internal Med., 
1925, xxxvi., 31. 

85. Frank, E.: Med. klin., 1932, xxviii., 1451 

86. Freemont- Smith, F., Dailey, M. o Mernitt, H. H., Carroll, 


. Colin : 
. Collip, J. 


. Cooke, 
. Cooke, J. V., Rodenbaugh, F. 


. Cooke, J. V., 
. Cooper, H. S. F.: Arch. of Surg., ' 1928, xvii., 
. Critchley, M., and O’Flynn, E.: B 

. Curtis, G. M. : Calif 


- Dalley, M. 
- Darrow, D. 


; Fullerton, H. W., 


. Gamble, J. L.: 
. Gamble, J. 


. Same authors : 
. Gamble, J. L., 


. Gaunt, R., Tobin, C. E., 


. Gilligan, D. 
. Gilligan, D. R., 
- Same authors: 


. Gilman, A.: 
3 Gilman, A., 


. Glass, J.: 
3. Glass, J., and Beiless, I.: 
; Goldblatt, M. W. 
i Gollwitzer-Meier, K.: 


xl., 83. 
; Goodwin, G. M., and Shelley, H. I.: 


. Grünwald, H. F.: Z 
1x., 360 
. Guest, G. 


Xi. 
2, Habler, C.: 
3. Haden, R. T 


. Same authors : 


ee J. R.: Arch. Neurol. and Paychiat., 1931, xxv., 


Cohen, H.: Quart. Jour. Med., 1926-27, Xx., 173. 
Cohen, H. Miller, P. R., and Kramer, B.: 
Pediat., 1933, iii., 299. 
ie pevdomad. de med. et de chir., 
V.s . 
P., and Backus, P. L.: Amer. Jour. Physiol., 
1920, li.. 551. 


A. M.: Quart. Jour. Med 1932, xxv., n.s. i., 527. 
H., and Whipple, G. H.: 


” tii., 1918, xxviii., 223. 
918. 


Jour. of 


1868, 
Bér. 2, 


Jour. Exper. Med., 1916, zzii. 
and Whipple, G.H 


1924, xlvii., 337. 
Cumings, J. N., and Carmichael, E. A.: Ibid., 1934, lvii., 338. 
. and West. Med., 1930, xxxiii., 625 
Jour. Biol. COEM 1931, xciil., 

and Yannet, H : J our. Clin. feck: 1935, 
xiv., 266. 


Davis, H. A., and Dragstedt, L. R.: Amer. Jour. Physiol., 
1935, exiil., 93. 


E.: 
C., 


P., and Thomas, G. W.: Arch. Neurol, and Psychiat., 


1931, xxv., 1271. 
Lyall, A., and Davidson, L. S. P.: THE 
LANCET, 1932, 1, 558. 
'New Eng. Jour. Med., 1929, cci., 909. 
L., and McIver, M. A.: 'Jour. Exper. Med., 
xlviii., 837. ' 
Ibid., 1928, xlviii., 849. 
and. Ross, S. G.: Jour. Clin. Invest., 
1924-25, i., 403. 


Gatch, W. D., Trusler, H. M., and Ayers, K. D.: Amer. 
Jour. Med. Sci. ., 1927, elxxiii. ., 649. 

and Gaunt, J. H.: Amer. 

1935, exi., 321, 

Wien. med. Woch., 1932, lxxxi., 107. 

R., Volk, M. C., and Altschule, M. D.: 

Biol. Chem., 1933, ciii. , 145, 

, M. C., and Blumgart, H. L. 

Clin. Invest., ar xiii., 365. 


1928, 


Jour. 
Physiol., 
Gigon, A. ï 
our. 


Jour. 


6 
and Cowgill, G. RS ai ao xcix., 172. 
: Ibid., 1933, ciii., 
: Ibid., 1933, civ., ae. 
Zeits. f. d. "ges. exp. Med., 1932, Ixxxii., 176. 
Ibid., 1930, lxxiii., 
Biochem. Jour., 1935, XXIX., 1346. 
Zeits. f. d. ges. exp. Med., 1924, 


Arch, Internal Med., 
1925, xxxv., 24: 
Gosset, "A., Binet, L., and Petit-Dutailis, D.: Presse méd., 
1928, xxxvi. - 1593. 
Gin’ C. H., Rowntree, L. G., Swingle, W. W., and 
finer, J. J. : Amer. Jour. Med. Sci., 1932, arr N 1. 


ent. f. Physiol., 1908, 
Arch. f. exp. Path. u. Pharm., 1909, 


ers Andrus, W. D.: Jour. Clin. Invest., 
” Zeits. f. d. ges. exp. Med., 1927, liv., 524. 

and Guffey, D. C.: Amer. Jour. Obst. and 
Gyn., 1924, viii., 486. 


29 EE 


9» 39 


M. 
1932, 


. Haden, R. L., and Orr, T. G.: Bull. Johns Hopkins Họsp., 


1923, XXxiv., 26. 

Jour. Exper. Med., 1923, xxxvii., 365, 377. 
: Ibid., 1923, xxxviii., 55 and 477. 
: Jour. ‘Amer. Med. Assoc., 1924, Ixxxii., 1515, 
A ee Jour. Exper. Med., 1924, XYYİX., 321, 

a n Ibid., 1926, xliv., 419 
: i : > Ibid., 1927, xlv., 427, 433. 


os >” 
39 39 


710 THE LANCET] 


DRS. ARCHER & GRAHAM: ON THH EXCRETION OF ASCORBIC ACID 


[marca 28, 1936 


121. Same authors: Ibid., 1927, xlvi., 709. 

122. 99 ” : Ibid., 1928, xlviii., 591, 627. 
123. Haldane, J. B. S.: Jour. of Physiol., 1921, iv., 265. 

124. Haldane, vi B. S., Hill, R.,and Luck, J. M. : Ibid., 1922-23, 


lvii., 
125. Hamilton, B Jour. Biol. Chem., 1925, lxv., 101. 
126. Harding, V. J and Drew, K.: Jour. Obst. and Gyn. 
. Brit. Emp. , 1923, xxx., 507. 
127. Harding, V. J., and van Wyck, H. B.: Amer. Jour. Obst. 
and Gyn., 1926, xi., 

128. Harrop, G. A., Soffer, L. J., Nicholson, Wa a and 
Strauss, M.: Jour. aber. Med., 1935, lxi., 839. 

129. Harrop, G. A., Weinstein, A , Soffer, L. J., and Trescher, 
J. H.: Jour. Amer. Med. “Assoc. .» 1933, c., 1850. 

130. Hartman, F. A., Griffith, F. R., and Artal. W. E.: 
Amer, Jour. Physiol., 1928, Ixxxvi., 


131. Hartmann, A. F.: Amer. Jour. Dis. Child., 1928, xxxv., 557. 
132. ae »  : Southern Med. Jour., 1929, xxii., 517. 
133. eS »»  : Colorado Maed., 1929, xxvi., 373. 

134 : Jour. Amer, Med. Assoc., 1934, cili., 1349. 


135. Hartmann, A. F., and Darrow, D. C.: 


Jour. Clin. Invest., 
1928, vi., 257. 


136. Hartmann, Ay F., and Elman, R.: Jour. Exper. Med., 

137. Hartmann, A. F., and Senn, M. J. E.: Jour. Clin. Invest., 
1932, xi., 327. 

138. Same authors : Ibid., 1932, xi., 337. 

139. : Ibid., 1932, xi. » 345. 


140. Hartmann, A. F., and Smyth, e S.: Amer. Jour. Dis. 
Child., 1926, xxxii., 1: 

141. Hartwell, J. A., and ’ Hoguet, J. P.: Jour. Amer. Med. 
Assoc., 1912, lix., 82. 

142. Hastings. A. B., Murray, C. D., and Murray, H. A.: Jour. 
Biol, Chem., 1921, xlvi., 22 3. 

143. Helwig, F. C., Schutz, C. B., and Cury, D. E.: 

Amer. Med. ” Assoc., 1935, civ., 1569. 

- Herbert, F. K.: Biochem. Jour., 1933, xxvii., 1978. 

. Herrin, R. C.: Jour. Biol. Chem., 1935, eviii., "547. 

- Himwich, H. E.: Bull. N.Y. Acad. Med., 1934, x., 16. 

. Hober, R.: pee Arch, f. d. ges. Physiol’, 1933-34, 


cexxxiii., 1 

. Hoff, F.: Deut. med. Woch., 1932, lviii., 1869. 

š Howell, C. M. H.: THE LANCET, 1934, i., 1116. 

. Ikeda, G.: Jour. Biochem. (Japan), 1934, xx., 253. 

. Ingraham, R. C., Lombard, C., and Visscher, M. B.: 
Jour. Gen. Physiol., 1932-33, xvi., 637. 

. Ingvaldsen, T., Whipple, A. O., Bauman, L., and Smith, 
B. C.: Jour. Exper. Med., 1924, Xxxix., 117. 

3 Jezler, A.: Klin. Woch., 1932, xi., "370. 

154. Johlin, J. M., and Moreland, F. B.: Jour. Biol. Chem., 
1933, ciii., "107, 

155. Joos, G., and Mecke, W.: Arch. f. exp. Path. u. Pharm., 

1934, "clxxiv., 676. 

Jung, G.: Zeits, f. klin. Med., 1931, exviii., 546. 

- Katsch, G., and if oline hort: K.: Ibid., 1933, exxiii., 390. 

. Keith, N. M.: Amer. Jour. Physiol., 1924, lxviii. » 80. 

159. Kerpel- Tee X.: Zeits. f. d. ges. exp. Med., 1932, 


V., 235 
. Kerpel- Fronius, E.: Ibid., 1933, xc., 676. 
: Zeits. f. Kinderheilk., 1935, Ivii., 489. 
162. Kerr, ‘A, B., and ‘Lendrum, A. 0.: Brit, Jour. Surg., 
1935-36, xxiii., 615. 
: P R., and Albers, H.: Zent. f. Gynik., 1933, lvii., 
1878, lxxv., 404, 


164. King, J. HI.: Amer. Jour. Med. Sci., 
. Klinke, K.: Monats. f. Kinderheilk., 1932, liii., 19. 
166. Kral, À., Stary, Z., and Winternitz, R.: Zceits. f. d. ges. 
Neurol. and Paychiat., 1929, cxxii., 08. 
167. Same authors: Zeits. f. d. ges. exp. Med., 1929, lxvi., 691. 


Jour. 


168. ee aan H.: Zeits. f. Geburt. u, Gynäk., 1934, 
cix 

169. Ktihn, R., and oe L.: Klin. Woch., 1931, x., 1616. 

170. Kuno, Y.: Tho Physiology of Human Perspiration, 
andon 1934. 

171. Kydd. D. Jour. Clin, Invest., 1933, xii., 1169. 


172. Langdon Brown, W.: THE LANCET, 1935, i., 1069. 


173. Lavietes, P. H., D *Esopo, L. M., and Harrison, H. E.: 
Jour. Clin. Invest., 1935, xiv., 251. 
174. Lawrence, R. D., Lucas, H? A., and McCance, R. A.: Brit. 


Med. Jour., 1932, ii., 145. 
. Leicher, H.: Deut. ’Arch, f f. klin. Med., 1922—23, oxli., 196. 
. Leitner, N.: Med. Klin., 1931, xxvii., 1789, 
177. Leulier, A.,: Velluz, L., and ‘Griffon, H.: 
Soc. de Diol., 1928, xcix., 1748. 
178. Lickint, F.: Żeits. f. d. ges. Neurol. u. Psychiat., 1928, 


348. 
D. M., and Sage, R. A.: Jour. of Allergy, 1932, 
S., and DL T. G.: Amer. Jour. Physiol., 


Biochem. Jour., 
F., Atchley, D. W., Benedict, E. M., and 
Leland, J.: Jour. Exper. Med., 1933, lvii., 7 
183. Loeb, R. F., Atchley, D. W., and Stahl, J.: Jour. Amer. 
Med. ABSOC., 1935, civ., 2149. 
184. Louria, H. W. Arch, Internal Med., 1921, xxvii., 620. 
. Lucas, G. H. W: Amer. Jour. Physiol., 1926, lxxvii., 114. 
. MacCallum, W. G., Lintz, J., Vermilye, H, N., Leggett, 
T. H., and Boas, E.: Bul. Johns Hopkins Hosp., 
1920, xxxi., 
187. McCance, R. AV: Unpublished observations. 
188, Me auc R. A., and Lawrence, R. D. : Quart. Jour. Med., 
1935, n.s. iv., 53. 
189. McCance, R. A., and Watchorn, E.: Ibid., 1930-31, 
xxiv., 371. 


The remaining references of Lecture II. will appear 
with the concluding part of this lecture next week. 


Compt. rend. 


1928, xxii., 46. 


SOME OBSERVATIONS 
ON THE EXCRETION OF ASCORBIC ACID 


By H. E. ARcHER, M.R.C.S. Eng., F.I.C., Ph.C. 


ASSISTANT CHEMICAL PATHOLOGIST TO ST. BARTHOLOMEW’S 
HOSPITAL; AND 


GEORGE GRAHAM, M.D. Camb., F.R.C.P. Lond. 


PHYSICIAN TO THE HOSPITAL 


THE condition of scurvy in an adult is rarely seen 
in England. The in-patient records of St. Bartholo- 
mew’s Hospital show that such a diagnosis has only 
been made three times in the last 22 years. The 
latest of these cases was diagnosed in July, 1935, 
when a man, aged 63 years, was brought. by the 
police to the hospital because he had fainted in the 
street. The detailed investigation of this case is 
here recorded. 

During the last two years the man had been out 
of work and his health had begun to fail. He was 
only able to walk two miles without getting tired, 
whereas previously he could walk eight miles. For the 
last six months he had tired very easily and his teeth 
were decaying. Four weeks previous to admission 
the patient noticed some difficulty in walking; 
his legs felt weak. For the last fortnight the appetite 
had been very poor. A red patch appeared on the 
ankles; then some pain was felt in the right knee, 
which swelled slightly and became discoloured with 
a bruise, blue at first and then red and yellow. The 
swelling and bruising continued to spread above and 
below the knee, and when he first came to the hospital, 
three days before admission, the legs showed petechial 
hemorrhages about the ankles, and swelling and 
bruising of the subcutaneous tissue about the knees. 
It was not possible to admit him on that day, but 
admission was arranged for three days later. On 
his way to the hospital he felt very tired and sat 
down on a doorstep where he was found by the police 
in a fainting condition and brought up to the hospital. 


Past health—Gonorrhea at 32. Right hydrocele for 
the last ten years. His general health had been very 
good and although he had travelled in many countries 
he had never had any tropical disease. 

Condition on admission.—Well-made elderly man, 
looking rather ill. The eyes showed no abnormality ; 
tongue clean. The teeth were nearly all present, but 
several were decayed and loose. The gums were red, 
soft, and much swollen, especially at the right side of the 
lower jaw; at this point the gum nearly reached the top 
of the teeth and bled easily when touched. The glands 
in the neck were not enlarged. The heart, lungs, and 
abdomen did not show any abnormal physical signs 
apart from the hydrocele. Blood pressure 185/70. The 
lower part of the right thigh was swollen and the skin 
was stained blue, red, and yellow. The right knee was 
swollen and appeared to contain a little fluid. The calves, 
shins, and ankles showed some petechial hemorrhages 
which were almost confluent behind the ankles and heels. 
(idema was present and extended half way up the calf 
of both legs. The tourniquet test did not cause any 
petechial hemorrhages on the arms. The temperature 
was 98°F. on admission, and rose to 99° that night, 
but subsequently remained below 98-4°. The pulse varied 
from 60-80. Respiration 20. The urine did not contain 
any albumin, blood, or sugar. (Three days later a few 
red cells were found in the urine on microscopic examina- 
tion.) The presonce of swollen and bleeding gums 
together with bruising and petechial hemorrhage suggested 
the diagnosis. 


DIET PREVIOUS TO ADMISSION 


The man was out of work and was living alone 
on a sum of only 17s, 6d, a week; he had drawn up 


THE LANCET] 


DRS. ARCHER & GRAHAM : ON THE EXCRETION OF ASCORBIC ACID 


[MARCH 28, 1936 711 


oo budget and allowed 6s. 2d. a week for 
ood. 


Expenditure on food. Other expenses. 

Per Per 

week. week. 

d. s. ad 

Meat or fish at 4d. per Gas (average) .. sa 9 

day .. TOT 4 | Tobacco and matches. 1 6 

Egg, meat, or sardines at Washing Se 9 

2d. per day .. .. 1 2 abe stamps, &c. 3 

Bread .. aya 1 0 | Clothes (set aside) 6 

Tea, cocoa, coffee 6 | Papers and library book 4 

Sugar .. od 44| Amusements .. dr 7 

Condensed milk 24| Beer (Saturday night). 4 

Butter .. le AG 3 | Rent .. Se -- 6 0 
Potatoes, salad, or fruit 4 

6 2 11 0 


Details of diet.—Breakfast: 2 eggs or meat pie or 
sardines, bread and butter, coffee. Dinner: 60z. meat, 
bacon, or fish ; chip potatoes, bread and butter. Supper : 
cocoa, bread and butter. A little salad and some stewed 
fruit was eaten one or two days a week. Fried onions 
and potatoes once a week. Green vegetables were never 
eaten because of the expense of the gas for cooking them. 
A little tinned pineapple had been eaten about four weeks 
before admission. It is difficult to say how much salad 
was eaten, but probably a very small amount as only 
4d. a week was spent on potatoes, salad, and fruit. The 
vitamin content of the diet was thus very small. 

Mr. G. T. Hankey examined the gums the day after 
admission and reported that the “ swollen, hemorrhagic 


appearance of the gums is probably scorbutic.”’ / 
Blood count. Differential count. 
Heemoglobin .. .. 54 percent. Polynuclear 
Red cells .. 2,680,000 perc.mm. cells . 4224 perc.mm. 
Colour-index.. .. 1- 3 Lympho- 
Leucocytes .. 6400 s cytes - 1792 ib 
Large mono- 
nuclears. 320 S9 
Eosinophils 40 5 


Bleeding time, 14 mins.; 
Wassermann reaction negative. 

X ray examination of the legs did not show any sub- 
periosteal hæmorrhage. 


platelet count, 190,000 ; 


THE DIAGNOSIS 


The absence of fever and a raised pulse-rate was 
against the diagnosis of a septicæmia or a subacute 
bacterial endocarditis. The white count of 6400 


and the absence of any abnormal cells excluded ` 


leukæmia and the number of platelets and the normal 
bleeding time a thrombocytopenia. 

In order to determine the excretion of ascorbic 
acid, we kept the patient, who had eaten some 
potatoes and green vegetables for dinner, and some 
orange juice at tea-time on the day of admission, 
for the next six days on a diet containing practically 
no ascorbic acid; the amount excreted in the urine 
was estimated each day except on Saturday and 
Sunday. 


The titration of specimens of urine for their ascorbic 
acid content was carried out by the Tillmans’ reduction 
indicator 2-6 dichlorophenol indophenol modified as 
suggested by Harris and Ray.! Before titration, acetic 
acid was added to the dye solution in such amount that the 
concentration of acetic acid at the end of the titration 
was in the region of 10 per cent., a preliminary titration 
giving the clue to the amount of acetic acid required. 
The solution of dye was standardised against freshly 
prepared solutions of ascorbic acid, the check being 
repeated at intervals of three days. The ascorbic acid 
solutions were checked by titration against 0-01 N iodine. 
All forms of ascorbic acid administered during the tests 
were titrated against the dye solutions used for the urinary 
estimations. As far as possible fresh specimens of urine 
were titrated but where this was found difficult, as in the 
examination of the night material, the ascorbic acid that 
had undergone reversible oxidation was recovered by 
reduction with H,S as described by Emmeric and Van 
Eckelen.?, Grace Medes* has shown that the pH of the 
urine is of great importance in this process, Experiments 


in this laboratory with urines allowed to undergo partial 


oxidation on standing showed that if the initial pH of 
the urine was in the region of 6 to 6-5 treatment by H,S 
resulted in a 95 per cent. recovery after the specimen had 
been standing for 18 hours. The results in estimating 
urines of very low ascorbic acid content by this method 
are certainly too high owing to some reduction by other 
constituents of the urine, but as in these investigations the 
substantial quantitative variations in excretion on scorbic 
and ascorbic diets were of moment, the errors which 
must be considered in estimating very small amounts 
could be ignored. 


The amount of ascorbic acid excreted in the urine 
was very small and varied from 6-18mg. on the 
first six days (Fig. 1). On the seventh day 300 c.cm. 


ASCORBIC ACID Mg. 
in 
© 


29 32 


l S 9 B 17 2l 25 
DAYS 


* 1870 mg. 
t 3550 ,, 
® 4950 ,, 


(a) Intake of 187 mg. fof ascorbic acid each day 
(b in the form of orange juice. 
of ascorbic acid. 


Total amount l 
ingested at 


39 ?9 1 o> 


(C) 4, » 210 ,, 


FIG. 1.—Showing the amount of ascorbic acid excreted (diagonal 
shading) in relation to the amount ingested (stippling) over 
& period of 32 days in a scorbutic patient. When a total of 
4950 mg. had been ingested the excretion amounted to an 
average of 53 per cent. of the intake. 


of orange juice was added to the diet; the amount 
of ascorbic acid in this amount of juice was estimated 
by the dye test at 187 mg. The excretion of ascorbic 
acid in the next ten days was slightly larger and 
varied from 10 to 19mg. a day (average 15 mg.). 
If it is assumed that the dye test is accurate when 
such small amounts are being excreted, 150 mg. 
were excreted out of a total of 1870 mg.—that is, 
a difference of 1720 mg. On the seventeenth day the 
dose was increased to 281 mg. which was contained 
in 450 c.cm. of orange juice. On the first day of the 
new diet—i.e., the seventeenth day—the excretion 
rose to 42mg. The ascorbic acid was not estimated 
during the next four days as the laboratory was closed 
for the August Bank Holiday and the ascorbic acid 
could not be preserved more than 24 hours. From 
the twenty-first to twenty-sixth day the excretion 
of ascorbic acid varied between 115 mg. and 190 mg. 
and the average excretion was 126mg. a day; as 
the daily intake was 281 mg., 46-6 per cent. was 
excreted with urine. During the next five days 
210 mg. of pure ascorbic acid was given each day 
instead of orange juice. The average excretion for 
the five days was 110mg. and 51 per cent. was 
excreted. This shows that the pure ascorbic acid 
behaved in the same way as that contained in the 
orange juice. 
THE THERAPEUTIC TEST 

During the first six days after his admission to 

hospital the patient definitely improved in health. 


All the oedema subsided and the bruising of the 
thighs was slightly less ; the fluid in the right knee- 
N3 


712 THE LANCET] DRS. ARCHER & GRAHAM: ON THE EXCRETION OF ASCORBIC ACID 


joint disappeared. The teeth had been scaled by 
Mr. Hankey and the gums, touched with silver 
nitrate 10 per cent., showed a definite improve- 
ment, but the gums were still much swollen and bled 
easily. Though a little vitamin C had been given at 
dinner and tea on the day of admission, the improve- 
ment was probably due mainly to the rest in bed. 
Very rapid improvement followed the administration 
of the orange juice; after three days it was noted 
that the bruising was passing off and that the gums 
were retracting very quickly ; after eight days there 
was still a little bruising round the left heel. The 
teeth presented a remarkable appearance; the 
retraction of the gums had exposed a broad band of 
white tooth which was in striking contrast to the 
stained crown. The improvement in the blood 
picture was also interesting :— 


Date. 


Hb. 
(1935) (per cent.) Red cells. C.I. 
July 22nd si 63 . 2,800,000 .. 1-1 
» 26th s 67 3,300,000 .. 1:0 
Aug. 9th ae 66 3,700,000 .. 09 
»» 21st s 79 4,500,000 .. 08 


During this period no iron or liver was administered. 
The colour-index of 1:1 had raised some doubt as to 
the nature of the anzmia, especially as it is stated by 
Vaughan * that the anemia of scurvy is a hypo- 
chromic one, but Parsons and Smallwood > have 
pointed out that even in children the anemia may 
be ortho- or hypochromic in character. The rapid 
recovery of the patient confirmed the clinical diagnosis 
of scurvy. 

The excretion of ascorbic acid was estimated in 
two other cases to see how soon the excretion of 


400 
350 
00 


N Gl 
0n 
oO 


ASCORBIC ACID M9. 


100 


50 


* 1200 mg. 
Total amount 
ingested at ES n 


FIG. 2.—Showing the amount of ascorbic acid excreted in 
relation to the amount ingested over a period of 17 days by 
a man on a diet deficient in ascorbic acid but with no symptoms 
of scurvy. No rise in the excretion occurred until 1200 mg. 
had been taken. The excretion rose to an average of 48 por 
cent. of the intake after 1600 mg. had been ingested, and to 
75 por cent. after 3200 mg. had been ingested. 


ascorbic acid increased and what percentage of the 
dose was excreted. 


k~ Case 2.—A man was brought to hospital because he 
had fainted in the street. On examination he seemed ill 
with a temperature of 100° F. and was admitted to hospital. 
Although there were no symptoms of scurvy, the diet 
which he had been eating seemed as deficient in ascorbic 
acid as that of the man with scurvy (Fig. 2). The 
opportunity was taken to estimate the amount of ascorbic 


acid excreted first on an ascorbic diet, and then after a, 


daily dose of 400 mg. of pure ascorbic acid. The amount 


[MarcH 28, 1936 
of ascorbic acid excreted was small (10-16 mg.) and no rise 
in the excretion occurred until 1200 mg. had been taken. 
The percentage output excreted after 1600 mg. had been 
eaten was 48 per cent., and after 3200 mg. 75 per cent. 


Case 3.—A healthy man who eats plenty of fruit was 
examined for comparison. A mixed diet was taken which 
contained potatoes and vegetables together with 125 c.cm. 
of tinned grape 
fruit and 70 c.cm. 
of tomato juice. 
The ascorbic acid 
content of this diet — 
was 63 mg., not 
including that in 
the potatoes and 
vegetables. The ex- 
cretion of ascorbic 
acid was 43 mg. 
and 54 mg. on the 
first and second 
day of the experi- 
ment. The diet was 
then changed to 


ASCORBIC ACID M9. 
Nm 
© 
© 


ANN 


one containing no 100 
potatoes, vege- Uy 
tables, or fruit, but 50 


400 mg. of ascorbic 


acid were taken 7 GWM 


W 
each day for ten i 3 5 7 9 li 


days (Fig. 3). The DAYS 


excretion rose to : 
262 mg. on the FIG. 3.—Showing the rapid rise in the 
i excretion of ascorbic acid in a healthy 
first day and to man whose previous diet con- 
418 mg. and 403 tained much Tni t to Phom 400 mg. 
of ascorbic acid was given over a 
mg. on the second period of six days. In two days the 
and third days. excretion had amounted to more 
The urine was not than the known intake, showing the 
collected on the high previous content of the diet. 
fourth and fifth 


days, but on the sixth day 416 mg. were excreted. 
During the next four days the same diet was taken without 
the addition of the ascorbic acid. The excretion decreased 
to 92 mg. on the first day and to 23 mg. on the fourth day. 
The total ascorbic acid excreted on the second, third, and 
sixth days was 1236 mg. and the known intake was 1200 mg. 
This apparent discrepancy is explained by the high intake 
of the previous diet. It is impossible to say what per- 
centage of the intake was excreted, but it must have been 
over 90 per cent. 


SSS 
SSS 


DISCUSSION 


Abbasy, Harris, Ray, and Marrack ê have recently 
published some very interesting experiments on the 
excretion of ascorbic acid. They suggest that the 
estimation of ascorbic acid excreted after a single 
test dose is of great value in demonstrating the 
presence of vitamin-C subnutrition. When a healthy 
adult, whose habitual level of excretion was 33 mg. 
of ascorbic acid, was given 600mg. he excreted 
161 mg., or 27 per cent., of the dose; whereas when 
the level was only 14 mg., 35 mg., or 6 per cent. of 
the 600 mg. administered, were excreted, and when 
the level was 8 mg. the excretion rose only to 17 mg., 
that is, 3 per cent. of the amount taken in. Wood ? 
has performed this test on a woman with mild scurvy. 
No ascorbic acid had been detected in the urine on 
the day before the test and only 1:7 mg., or 0-3 per 
cent. of the 600 mg. ingested, was excreted in the 
urine. These observations after a single test dose 
undoubtedly show that a deficiency of ascorbic acid 
exists, but they do not, in our opinion, give such full 
information as the observation of the amount of 
ascorbic acid which must be given before the per- 
centage output rises above 75 per cent. In our 
case of scurvy (Case 1) the significant rise in the 
excretion occurred when 1700 mg. had been given 
in comparison with 600 mg. in Johnson and Zilva’s 8 
man, and with 1200 mg. in Case 2, and 1400 mg. 


THB LANCET] MR. A. BREWS: 
in Harris and Ray’s case.® This is a very small 
difference, and it would be difficult to know where 
to draw a line between scurvy and a potential case 
of scurvy, and a case of vitamin-C subnutrition. The 
percentage outputin Johnson and Zilva’s case rose 
to 56 per cent. after 1360 mg. and to 87 per cent. 
after 1480 mg. had been taken; and in Harris and 
Ray’s case it rose to 77 per cent. after only 1480 mg. 
had been taken, and in our Case 2, although it 
reached 48 per cent. after 1600 mg. had been in- 
gested, it did not reach 75 per cent. until 3200 mg. 
had been eaten. In Case 1 of our series the percent- 
age output did not exceed 53 per cent. even after 
4950 mg. had been eaten. 

The observation on our single case of scurvy 
suggests that the percentage output is much more 
valuable evidence that a patient has scurvy than the 
amount of ascorbic acid taken before the excretion 
increased, or the amount excreted after a test dose. 


We have to thank Miss J. Marks, M.P.S., for much 

assistance in the estimation of the ascorbic acid, and 

_ Miss Cambell, the sister of the ward,for her care in supervis- 
ing the diet and collecting the urine. 


REFERENCES 

1. Biochemical Journal, apes xxvii., 303. 

2 » 1934, xxviii., 

3 Ibid., 1935, xxix., bot. 

4. Vaughan, J.: The Anemias, London, 1934, p. 106. 

5 FATON; L. a oy and Smallwood, W. C rea Dis. Child., 

p X., 

6. Abbasy, M. A., Harris, L. J., Ray, S. N., and Marrack, J. R.: 
Ibid., 1935, ii, a 

7. Wood, P.: Ibid., 1405. 

8. Johnson, S. W vaca Zilva, S. S.: Biochem. Jour., 1934, 
xxviii., 1393.” 

9. Harris, L J., and Ray, S. N.: THE LANCET, 1935, i., 71. 


THE TREATMENT OF 
CARCINOMA OF THE CERVIX UTERI 


BY THE STOCKHOLM TECHNIQUE AT THE 
LONDON HOSPITAL 


1929 AND 1930 


By Atan Brews, M.D., M.S. Lond., F.R.C.S. Eng., 
M.R.C.P. Lond., M.C.0.G. 


HON. ASSISTANT OBSTETRIO AND GYNECOLOGICAL SURGEON 
TO THE LONDON HOSPITAL 


DURING the two years 1929 and 1930, 71 cases of 
carcinoma of the cervix uteri were referred to the 
obstetric and gynecological department of the 
London Hospital for treatment. No case, however 
advanced, was refused treatment. 

Four early cases were treated by Wertheim’s 
hysterectomy (2 of these were complicated by preg- 
nancy and the other 2 were considered exceptionally 
good subjects for a major surgical operation). The 
subsequent history of these 4 cases is as follows :— 


One died of recurrence 1 year and 5 months after 
operation. 

One was dying of recurrence when last seen 2 years 
and 8 months after operation. 

One was alive and well when last seen 1l year and 
9 months after operation. 

One is alive and well more than 5 years after operation. 


The remaining 67 cases were treated with radium 
by a technique as similar as possible to that pub- 
lished by Forssel and Heyman from Radiumhemmet, 
Stockholm. In brief, the treatment has consisted of 
three applications of radium, with intervals of 7 and 
21 days, each application consisting of about 120 mg. 
of radium element, partly intra-uterine and partly 


CARCINOMA OF THE CERVIX UTERI 


[Maron 28, 1936 713 


vaginal. The duration of each application has been 
22-24 hours, and a heavy screenage—equivalent to 
2 mm. of lead in 1929 and to 3 mm. of lead in 1930— 
has been employed. 

For various reasons 14 of the cases did not receive 
the complete treatment (9 cases received two appli- 
cations only and 5 cases one application only). 
Three of these patients died in hospital before treat- 
ment could be completed; 7 other cases were so 
advanced (Stage III. or IV.) and their reaction to 
radium was so unsatisfactory that it was deemed 
inadvisable to proceed with treatment ; the remaining 
4 were Stage II. cases and failed to come in for further 
treatment although advised to do so. All these 
14 patients are now dead. 

Until the autumn of 1930 no really effective deep 
X ray therapy was available for the treatment of 
these cases, and in this series it has been used only 
for the treatment of definite clinical recurrence in 
the pelvis arising some time after the original radium 
application. : 
DIAGNOSIS 

Although some authorities are of the opinion that - 
there is some danger of disseminating malignant 
cells by removing a fragment of a malignant growth 
for histological examination, we have felt that the 
advantage of confirming the macroscopic diagnosis 
by this means outweighs this debatable objection. 
In this series the diagnosis has been confirmed histo- 
logically in all 4 cases treated by Wertheim’s hysterec- 
tomy, and in addition the uteri removed at operation 
have been preserved. In the 67 cases treated with 
radium the diagnosis has been confirmed histolo- 
gically in 59 cases; in the remaining 8 cases in which 
the nature of the growth was unproved histologically, 
6 have died of recurrence, 1 is untraced, and 1 only 
is alive and well more than five years after treatment. 


RESULTS 


The results of treatment with radium are set out 
in Table I. 


TABLE I 
Cases. 

Died in hospital urls treatment Eaety moray 

4°5 per cent.) 3 
Died within first year ‘after ‘treatment (4 “had secondary 

medium X ray therapy) .. 19 
Died within second year after treatment G bad secondary 

deep X ray therapy) : 10 
Died within third year after ‘treatment a had secondary 

deep X ray therapy) ‘ 11 
Died within fourth year after treatment a had secondary 

deep X ray therapy) 2 


Died within fifth year after treatment a had secondary 
deep X ray therapy) . 


Local recurrence in cervix 44 years after treatment. Still 
alive after recent fourth application of radium.. 
Recurrence in bladder 19 months after treatment. 

alive and well 44 years after fourth appheaton s: 
radium to recurrence RS 1 
Recurrence in bladder 14 months after treatment. N ow 
alive and well 53 years after fourth application of 
radium to recurrence ate Es 1 
Alive and well with no clinical evidence of any recurrence 
more than 5 years after treatment (1 had Peronda y 


Now 


deep X ray eee a s% si 15 
Untraced ee iw ane as ea us 1 
67 


It will be seen that there are 16 five-year cures out 
of 67 cases treated with radium—that is, 24 per cent. 

The 59 cases treated with radium and proved histo- 
logically to be carcinoma consisted of 54 in which 
the carcinoma was epidermoid in structure and 5 in 
which it was of glandular columnar-celled type. 
In the former group 14 are alive and well after more 
than 5 years, and in the latter 1 patient is alive and 
well after a similar period. 


714 THE LANCET] 


In Table II. these 67 cases treated with radium 
are grouped into the four stages according to the 
anatomical extent of the growth recommended by 
the Radiological Sub-Commission of the League of 
Nations, Geneva, 1929.1 The following results are 
shown :— 


TABLE II 
Per cent. 
Stage I. .. 15 cases with 6 five-year cures .. 40 
» IL ae 20 45 » 68 Pr wee ane 30 
wee III. .. 25 Ss oa D ye GR 16-6 


so AVe wa (an 


9? 0 99 99 ee —— 


Stages I. and II. constitute cases probably operable, 
and if the results are combined then there are 35 cases 
with 12 five-year cures—34-3 per cent. When Stages ITI. 
and IV., which constitute the cases probably inoper- 
able, are combined then there are 32 cases with 4 
five-year cures—12-5 per cent. — 

Table III. represents an analysis of the effect of 
age-incidence of the disease on the results obtained 
with radium treatment in this series of cases. 


TABLE III 
Five-year 
Age. Cases. Cures. 
20—29 oe oe 2 oe ee 0 
30—39 ea Ss 7 s ci 3 


40—49 ae ae 25 arà Te 3 
50-59 is ats 19 es we 6 
60-69 oe s% 9 oe are 3 
70-79 ee ie 5 a ee 1 


The high primary mortality of 4:5 per cent. is due 
to 3 deaths occurring during treatment in hospital. 


CasE 21.—This patient had a Stage II. carcinoma of 
the cervix, which was treated with one Stockholm appli- 
cation of radium. Under the same anesthetic a primary 
carcinoma of the left breast was treated by the insertion 
of surgical radium needles. The patient died one hour 
after her return to the ward, and a post-mortem revealed 
that the cause of death was hxemopericardium secondary 
to perforation of the heart by a radium needle inserted 
under the left breast penetrating an intercostal space. 
If this case is excluded—and the death cannot reasonably 
be attributed to the Stockholm treatment of carcinoma 
of the cervix—then the primary mortality is 2 cases out 
of 67, that is, 3 per cent. 


Case 31.—A patient, aged 70, with Stage II. growth, 
died eight days after the second application of radium 
with spreading peritonitis. Post-mortem examination 
revealed gangrene and infection of the left half of the 
fundus of the uterus. The growth was scirrhous, con- 
stricting the cervical canal, and associated with pyometra. 
Had the pyometra been drained for a week or ten days 
prior to radium treatment, then in all probability this 
death would not have occurred. 


CasE 53.—A patient, aged 22, with a Stage IV. growth, 
had a marked febrile reaction and recurrent secondary 
hemorrhages following the first application of radium. 
She remained in hospital for twelve weeks and died ten 
days after the second application of radium. This death 
can be more fairly attributed to the final stages of the 
disease than to its treatment with radium. 


TABLE IV 
Percentage of 
Number 
Year. of cases. Dye Toae 
1920 sa es 96 ate 27:1 
1921 as ae 115 23°5 
1922 Bis 24 130 20-0 
1923 105 23:8 
1924 149 s 23:5 
1925 is Së 134 ; 142 
1926 Ia a 143 i 25:9 
1927 3 or 143 os ; 25:9 
1928 ka sa 128 sa Jà 23-4 
1929 a zá 152 es ies 30°3 


An abstract of the results of treatment of carci- 
noma of the cervix uteri with radium at Radium- 


MR. ROMANIS & MR. SELLORS: APICAL THORACOPLASTY 


[MARCH 28, 1936 


O 


hemmet, Stockholm, for the years 1920 to 1929," is 
given in Table IV. 

If these ten years 1920-29 are combined, then 
1295 cases of carcinoma of the cervix were treated 
at Radiumhemmet with 308 five*year cures. This 
gives an average five-year cure per year of 23-8 per 
cent. 

: The treatment of the cases described above has been 
entirely carried out in the obstetric and gynecological 
department at the London Hospital by Mr. Eardley 
Holland, Mr. Victor Lack, and myself. I am immensely 
indebted to my senior colleagues for allowing me to 
organise the treatment, and for allowing me to follow up 
and publish their cases. It is only their consistent adher- 
ence to our agreed technique that has made it possible 
for us to establish the value of this treatment in a con- 
secutive series of cases. I am also indebted to the Yarrow 
research fund of the London Hospital for financial help 
in the initial years of organisation. 

The secondary, medium, and deep X ray therapy, 
when employed, was entirely prescribed and supervised 
by Dr. G. E. Vilvandré and Dr. M. H. Jupe, the honorary 
radiologists to the hospital. 


REFERENCES 


1. League of Nations, C.H. 788, Radiotherapy of Cancer. 
Reports submitted by the Radiological Sub-Commission, 
Geneva, 1929, p. 13. l 

2. Berattelse frán Styrelsen för Cancerföreningen i Stockholm 
över Verksamhetsáret, 1934. Report on cases treated at 
Radiumhemmet, p. 92. 


APICAL THORACOPLASTY 


WITH A DESCRIPTION OF RECENT MODIFICATIONS 
IN TECHNIQUE 


By W. H. C. Romanis, M.Chir. Camb., F.R.C.S. Eng. 


SURGEON TO ST. THOMAS’S HOSPITAL AND THE CITY OF LONDON 
HOSPITAL FOR DISEASES OF THE CHEST, AND 


T. Hotmes SELLORS, D.M., M.Ch. Oxon., 
F.R.C.S. Eng. 


ASSISTANT SURGEON TO THE CITY OF LONDON HOSPITAL FOR 
DISEASES OF THE CHEST, QUEEN MARY’S HOSPITAL, 
AND THE ROYAL WATERLOO HOSPITAL 


THE increasing use and popularity of upper partial 
thoracoplasty in the treatment of tuberculous cavities 
in the lung has led to the development of this operation 
as a specialised procedure aiming at permanent 
collapse of these excavated areas, yet still leaving the 
base and greater part of the lung as a functioning 
organ. In a previous paper we have outlined the 
principles which govern the selection for surgical 
treatment. i 

In the case of an apical thoracoplasty the operation 
has usually been an exaggerated form ofthe upper 
stage of the standard Sauerbruch paravertebral 
operation involving resection of considerable lengths 
of the upper four or five ribs under which the diseased 
area lies. Pulmonary collapse is obtained by (a. 
threefold movement of the divided ribs. The posteripr 
cut ends of these anterior portions fall inwards and 
downwards so that the end of the first rib may le 
in close proximity to the second and third transverse 
process. A certain amount of lateral collapse is also 
obtained by the downward swing of the main curve 
of the ribs—the so-called “ bucket-handle ” action— 
but in the upper chest this effect is not nearly Bo 
noticeable as in the lower part. Whereas the posterior 
part of the lung apex is set free, the remainder is 
held attached to the deep aspect of the first rib and, 
as may be judged from X ray films, undergoes only a 
small descent. The main part of the collapse is effected 
in the transverse rather than in the vertical axis. 


THE LANCET] 


This form of thoracoplasty not infrequently fails 
when the cavity is centrally placed or is lying close 
to the mediastinum. The cavity admittedly becomes 
reduced considerably in size, but may persist in 
part as a pear-shaped slit with the long axis vertically 
placed. The lesion then 
still remains as an open 
source of infection and the 
only remedy for this state 
of affairs is the perform- 
ance of an anterior and/or 
lateral supplementary rib 
resection. (Figs. 1 and 2.) 
The amount of scarring 
produced by the original 
operation precludes the 
successful practice of any | 
form of extrapleural pneu- 
molysis as a subsidiary 
procedure. 

It has been common 
practice in certain hands 
to facilitate the amount of 
collapse obtained by an 
apical thoracoplasty by 
means of extrapleural 
stripping. Semb and Holst 
in a large number of cases 
have carried this dissection 
posteriorly into the para- 
vertebral gutter removing 
the heads of ribs and up- 
wards over the lung dome 
allowing fascia and mus- 
cular bundles to add their 
weight to the collapsing 


VILTIUNIA FANN” pp 


9.1.35 


raised. 


FIG. 
plasty Ribs 2 to 4. 


lung. Radiologically this collapse obtained by 
this “extrafascial apicolysis” is definitely 
superior to that produced by the standard 


operation, but the vertical fall of the apex does 
not always ensure collapse of cavities close to 
the mediastinum. 

Our experiences with extrapleural pneumolysis 
and extensive stripping of the parietal pleura from 
the ribs carried out from in front preparatory to 
filling the cavity with paraffin wax have led us to 


30.11.35 


MR. ROMANIS & MR. SELLORS : 


FIG. 1.—Big right apical cavity. Small pneumothorax space towards apex. 


14.vi.35 


APICAL THORACOPLASTY [marcu 28, 1936 715 


believe that the danger of stripping the pleura from 


the mediastinum is negligible—a fear that has presum- 
ably hindered the common practice of this form of 
mobilisation over a large area. It was consequently 
decided to perform the stripping over the whole 


2 


15.ii.35 . 
Right diaphragm 


2.—After posterior ikoratoplasty of upper five or six ribs followed by anterior thoraco- 
The cavity though greatly 
clavicle at the level of the fourth to fifth vertebra. This illustrates the persistence of a 
cavern in spite of extensive rib-resection. 


inished can still be seen below the 


diseased area of the apex in addition to performing 
the ordinary form of extensive removal of the upper 
ribs. Gravesen has given the name “ cupolaplasty ” 
to this form of operation. A necessary factor in 
performing this type of operation, as with any form 
of extrapleural pneumolysis, is fusion of the pleural 
membranes over the area to be collapsed. This is 
more commonly found than might be expected, for 
most of the cases are of long standing and pneumo- 
thorax treatment has previously been tried and failed, 


aista. 


9.vii.35 


FIG. 3.—Right localised upper zone disease showing fibrosis and cavity formation. 


FIG. 
lung tissue between it and the diaphragm, 


4.—After complete apicolysis and resection of Ribs 1 to 4 fluid level is seen and is extrapleural with dense zone of E 


FIG. 5.—Three weeks later fluid was absorbed and lung has re-expanded, but not above the level of the fourth to fifth transverse 


processes, 


716 THE LANCET] 


or tried and abandoned. The pneumothorax has 
usually been abandoned on account of the presence 
of adhesions over the diseased apical area. Even 
in cases in which we might have had some doubt as 
to whether the pleural cavity was completely adherent 
over the operation field there has been no untoward 


30.x.35 
FIG. 6.—Big infraclavicular cavity on the left. 


FIG. 7.—Film taken ten days after operation showing depression of the apex of the lung below 
phe fou yet tebre and almost complete obliteration of the cavity. Complete closure 
obtained later. 


circumstance such as might be occasioned by tearing 
of the parietal pleura. 


TECHNIQUE 


The operation commences as an ordinary upper thora- 
coplasty, and the muscles attached to the vertebral 
border of the scapula are divided through a J-shaped 
incision made midway between the scapula and spinal 
column. The scapula is lifted off the chest wall and 
the upper ribs are exposed. The periosteum of the 
third and possibly the second ribs is removed and an 
extensive length of both bones removed. Before 
proceeding to do anything to the first rib this stripping 
is done, and it immediately renders the subsequent 
removal of a long length of the first rib considerably 
easier. To effect the stripping the finger is carefully 
worked into the rib-bed until the space normally 
occupied by the endothoracic fascia is found. The 
plane of separation is easily recognised and dissection is 
carried upwards and outwards with the fingers within. 
the rib framework until the whole of the apex js 
freed. Steady and careful pressure enables this 
stripping to be done without difliculty, though 
occasional resistance is encountered in the form of 
firm bands of adhesions. These, however, can be 
overcome safely so long as the finger pressure is kept 
well to the deep surface of the ribs. When the 
apex is free it falls downwards to a marked degree 
and if further depression is required it can be carried 
out beyond the lower limits of the third rib. There 
is slight oozing from the raw bed, but this stops 
readily and the apex can be held down with a swab 
while the remaining part of the rib-resection is per- 
formed. These ribs are now freed of their periosteum 
preparatory to their resection, and one of the chief 
advantages of the preliminary stripping lies in the 
fact that the deep surfaces and even the anterior 
parts of the upper two ribs can be easily reached. 
It is possible to remove the whole of the upper two 
ribs without encountering any of the difficulties 
that occur in other forms of this operation. At times 


MR. ROMANIS & MR. SELLORS: APICAL THORACOPLASTY 


{mancH 28, 1936 


removal of a further length of the anterior part of the 
third rib is carried out, it being recalled that a section 
of this rib had been removed preparatory to stripping. 
Then according to the amount of collapse required 
part of the fourth and/or fifth ribs are resected. 
We have made it customary to grade the collapse 
and prevent a sharp shelf 
being left by removing a 
short piece of bone in the 
rib or two below the major 
part of the resection. 

The operation is com- 
pleted by suture of the 
muscles and skin after 
hemostasis has been 
assured. Originally we 
omitted drainage of the 
wound in the hope that 
the blood-stained serum 
that was bound to collect 
would act as a pad in 
the dead space and would 
help to maintain the col- 
lapse, until such time as 
the soft tissues had time 
to fall in and obliterate 
this space. The risk of 
infection, however, is con- 
siderable and in conse- 
quence we prefer to drain 
the wound for several 
days. 

There is certainly some tendency for the stripped 
apex to re-expand unless the rib-resection has been 
extensive, and to overcome this we have, in a few 
cases, divided the intercostal periosteo-muscular 
bundles either anteriorly or posteriorly and sutured 
them to each other and to the inner aspect of the 
thoracic cage at a lower level so as to form a grid 
or coarse meshwork close over the depressed apex. 
As periosteal regeneration occurs, this forms a rigid 
barrier beyond which the lung cannot re-expand. 


4.11.36 


RESULTS 


The amount of shock produced in an operation of 
this character is very little greater than that produced 
by a rib-resection of the same magnitude; in no 
case have we found it necessary to perform an opera- 
tion involving five or six ribs in two stages. As 
against this it must be admitted that the convalescence 
is rather more disturbed over the first few days— 
the temperature and pulse are raised and if a big 
cavity is present there is usually abundant sputum 
about the third to eighth day, but pain is not 
conspicuous, nor is the deformity any more noticeable 
than with a simple thoracoplasty. The risk of 
infection of the dead space in this type of patient 
has been noted, but such infection occurred only 
in cases that were not drained, and did not lead 
to serious ill-effect. 

X ray films taken shortly after the operation show 
a collection of fluid lying over the lung apex which 
is often depressed almost to the level of the hilum. 
This fluid certainly adds to the collapse actually 
produced by the stripping, but as time goes on the 
fluid is absorbed and the upper limit of the lung edge 
rises to a small extent before becoming stationary. 
In dealing with firm-walled apical cavities there is 
no doubt that the operation produces a radiological 
collapse far superior to that obtained by any other 
procedure that we have employed with the possible 
exception of extrapleural pneumolysis with wax 
implantation, But this latter is accompanied by the 


THE LANCET] 


MR. BURNS & MR. ELLIS: STENOSING TENDOVAGINITIS 


[marnoH 28, 1936 717 


not infrequent complication of extrusion of the wax 
at a very variable period after the operation. 

The following cases illustrate the results obtained 
with the combined pneumolysis and thoracoplasty :— 


l. Woman aged 23. Chronic left apical disease with 
cavity known to be present three years. A.P. (artificial 
pneumothorax) failure. Complete apical stripping with 
resection of upper four ribs. Total length of rib removed, 
22in. Cavity obliterated rapidly. Patient started to 
put on weight a fortnight after operation. No. T.B. 
(tubercle bacilli) in sputum. 


2. Man aged 26. Extensive right upper zone cavitation. 
A.P. failure. Complete apical stripping with resection 
of upper five ribs. Total length of rib removed, 2] in. 
Good apical collapse was obtained. 


3. Woman aged 20. Right apical fibrocavernous 
disease. A.P. failure. T.B.+. Complete mobilisation 
of apex with resection of ribs, 1, 2, 3, and part of 4. Total 
length, 16in. Wound not drained. Thin seropurulent 
fluid collected in the dead space and discharged through 
the wound on the twelfth day. The sinus ultimately 
closed. Patient has put on over 2st. in weight. T.B. 
absent. (Figs. 3-5.) 

4. Man aged 31. Right apical cavities. T.B.++. 
A.P. failure. Complete apical stripping and resection of 
ribs 1, 2, 3, 4, and part of 5. Total length, 18}in. A 
“grid ” of muscle and periosteum. Wound not drained. 
Collection of fluid in dead space compressed lung and 
about three weeks after operation broke through into a 
bronchus. Bloodestained fluid was coughed up for several 
days and the extrapleural cavity emptied. Ultimate 
result good. T.B. absent. 

5. Man aged 34. Large single cavity of left apex. 
T.B.+. Complete apical stripping and resection of 
ribs 1, 2, 3, 4, and 5. Total length 26in. A ” grid” 
was made over the apex. Successful collapse. Highest 
point of lung lies between the levels of the fourth to fifth 
transverse processes. (Figs. 6 and 7.) 


As regards the end-results it is too soon to judge. 
The operation, however, has as its primary aim 
closure of cavities and in this it would appear to be 
rore satisfactory in selected cases of localised apical 
disease than any method that we have previously 
employed. 


STENOSING TENDOVAGINITIS 
AT THE RADIAL STYLOID PROCESS 


By B. H. Burns, B.Chir. Camb., F.R.C.S. Eng. 


ORTHOPAEDIO SURGEON TO ST, GEORGE’S HOSPITAL; AND 


V. H. Ers, B.Chir. Camb., F.R.C.S. Eng. 


ORTHOPÆDIO SURGEON TO ST. MARY’S HOSPITAL ; 
ASSISTANT SURGEON, ROYAL NATIONAL ORTHOP-EDIO 
HOSPITAL 


STENOSING tendovaginitis was first described by 
de Quervain ! in 1895, and subsequently by Hoffmann? 
in 1898. Since that time nearly 200 cases have been 
reported, mostly by continental writers. We are 
aware of only one case recorded in this country °; 
yet the condition is by no means uncommon, and 
it is perhaps almost the only cause, in our experience, 
of pain in the region of the styloid process of the 
radius with disability in movements of the thumb. 
Stenosing tendovaginitis occurs far more often in 
women, but among our 28 cases there were 3 men. 
In this series the ages range from 15 to 49, the com- 
monest age being about 35. There was usually a 
history of some two to four months’ pain, coming 
on insidiously without definite history of trauma. 
The majority of the women were engaged in house- 
hold work, and the commonest complaints were of 


tendon. 


pain on wringing and a tendency to drop things, > 
particularly in movements involving radial abduction, 
as in lifting a kettle. The condition sometimes 
occurs in an acute form in turnip toppers, but this 
occupation being seasonal it seldom becomes chronic 
in these patients. 

The symptoms and signs are typical. Strong active 
abduction of the thumb is painful. There is a visible 
swelling over the styloid process of the radius (Fig. 1), 
which in some cases may partially obliterate the 
anatomical snuffbox. It extends for a short distance 
up the radius, and there is tenderness over the swelling. 


5 dyed e {i 
Se 


m so eean 


FIG. 1.—Drawing showing a particularly well-marked swelling ; 
more commonly the swelling is less definite. 


The diagnosis is certain if, on grasping the patient’s 
thumb and quickly adducting it, there is sharp pain 
over the styloid process. The condition is due to 
obstruction of the free movements of the tendons 
of the extensor ossis metacarpi pollicis and extensor 
brevis pollicis as they pass beneath the dorsal carpal 
ligament. 

Morbid Anatomy.—The fibrous tendon sheath of 
the two tendons is thickened, and in severe cases 
may be as much as four times the normal thickness, 
which is 1/32 in.* The lumen of the sheath is narrowed. 
In mild cases the slight thickening of the tendon 
sheath may be the only finding, but in the more 
severe cases the narrowing of the lumen produces a 
constriction and even flattening of the tendons, 
which may be bulbous beyond the constricted area. 
The thickened sheath may have lost its lustre and 
be brownish in colour; new blood-vessels may be 
observed in it. It may have an almost cartilaginous 
consistency, and frequently appears hyaline or 
cdematous. Occasionally there is a synovial effusion, 
but the synovial membrane is not thickened and 
may be absent, with consequent adhesions to the 
These adhesions, composed of new fibrous 
tissue, appear almost like a pannus, and are not 
readily stripped from the tendon. 

A section of the thickened sheath shows large 
quantities of new fibrous tissue, which is markedly 
cellular. A few new blood-vessels may be observed 
surrounded by lymphocytes and an occasional plasma 
cell. In the more superficial layers, which appear to 
be those of the original sheath, elastic fibrils are 
present. Some of the fibrous tissue shows mucoid 
degeneration. 

Differential Diagnosis.—The only other conditions 
likely to be confused with this one are fractures of 
the scaphoid, in which there is tenderness in the 
anatomical snuffbox with weakness of the wrist. 
But in these cases there is no tumour, and the diag- 
nosis is confirmed by radiography. The more difficult 
differential diagnosis is from sprain of the external 


718 THE LANCET] 


lateral ligament of the wrist, which is a much less 
common condition. Careful examination will show 
that the tenderness is limited to an area distal to 
the radial styloid process, and whereas adduction 
of the whole hand is painful, that of the thumb 
alone is not so. 

Treatment.—Cases have been reported where fixa- 
tion of the thumb in abduction has relieved the 


FIG. 2.—The short extensor tendons are exposed and the 
superficial part of the thickened sheath cut away showing 
this structure in section. 


symptoms (Hoffmann), but in three of our earlier 
cases this method was unsuccessful. de Quervain 
first treated these cases by simple incision of the 
constricting sheath. This manœuvre produces imme- 
diate relief, and in no cases has it failed. It is there- 
fore obviously the method of choice. Local anæs- 
thesia is satisfactory. An incision is made through 
the skin over the swelling and the fibrous sheath 
partially excised (Fig. 2). The free motion of the 
tendons is immediately obvious, and only the skin 
need be sutured. 

We have not considered it necessary to report 
our 28 cases in detail, as they are essentially similar 
and the results of operation are uniformly satis- 
factory. They may be summarised as follows :— 


(16 V.H.E. 12B.H.B.) 


3 males, 25 females, ages 15-49 (Mode. 35). 
22 treated by operation. All cured immediatoly. 
3 treated by plaster, with no permanent relief. 


3 refused treatment. One of these went to another 
hospital, where manipulation was performed with no 
benefit. 


Analysis of 28 Personal Cases. 


With others, we have been struck by the similarity 
of this condition to the thickening of the tendon 
sheath which causes snap fingers and thumb. Similar 
thickenings have been found in other tendons about 
the wrist—namely, the extensor carpi radialis longior, 
the extensor carpi ulnaris, and the flexor carpi 
ulnaris. 

REFERENCES 
1. de Quervain, F.: Corresp.-Blatt. f. Schweiz. Aerzte, 1895. 
XXV., 389 
2. Hoffmann, P.: Trans. Amer. Orthop. Assoc., 1898, xi., 252. 
3. Brown, W. M.: Brit. Med. Jour., 1935, ii., 538. 
4. Finkelstein, H.: Jour. Bone and Joint Surg., 1930, xii., 509. 


DR. F. L. KER: PEMPHIGUS ACUTUS 


[MARCH 28, 1936 


A CASE OF PEMPHIGUS ACUTUS 
By FRANK L. Ker, B.A. Camb., M.B. Edin. 


SENIOR ASSISTANT, LITTLE BROMWICH HOSPITAL, 
BIRMINGHAM 


THE following brief record of a case of pemphigus 
acutus (butcher’s pemphigus) may be of interest on 
account of the rarity of the condition. 


History.—The patient, a man of 21, commenced work 
as a slaughterman five weeks before admission to the 
Little Bromwich Hospital on Nov. 3rd. From Oct. 17th 
to 26th he had been treated for a septic finger—the result 
of a prick at work. On the day before admission he 
noticed some small red papules on his chin, which spread 
rapidly during the ensuing 24 hours, involving his cheeks 
and both upper limbs, many becoming vesiculated. His 
general health was good, but he reported to his doctor 
and was notified as a case of suspected glanders. The 
patient, who had lived in the country all his life, had 
never been vaccinated. Subsequent inquiries at the 
slaughter-house revealed that no animal had been 
slaughtered recently which was suffering from any unusual 
disease. 

Examination on admission showed a well-developed 
youth whose face and upper limbs were the site of 
vesicular and pustular lesions, varying in shape and size, 
the largest being about an inch and a half in the greatest 
diameter. The majority were round,-while some were 
oval and others irregular. All were surrounded by an 
area of inflammation. A few were umbilicated and others 
were discharging a seropurulent fluid. The lesions on the 
face were mainly confined to the chin and cheeks, the 
forehead being almost unaffected. The trunk was clear, 
but the extensor aspects of the thighs showed a few 


papules with some small vesicles. There was a small 
healing scar with a central scab over the first inter- 
phalangeal joint of the ring finger of the left hand. The 


tongue was heavily furred, while the throat was very 
congested and both tonsils were covered with a thin 
film of exudate. The breath was fæœtid. Temperature 
101° F.; pulse-rate 124; respirations 24. No evidence 
of a primary chancre could be found and the Wassermann 
reaction was negative. Fluid aspirated from the lesions 
gave no Bacillus mallei or Streptothrix actinomyces, but a 
good growth of non-hemolytic streptococci was obtained. 


Progress.—Lesions continued to appear for five days 
after admission, the scalp and back becoming involved, 
while the anterior aspect of the trunk remained clear. 
The throat was exceedingly painful and as a result swallow- 
ing was almost impossible, but no vesicles appeared on 
the throat or palate. The temperature remained elevated 
until the rash was fully developed, reaching a maximum 


of 103° F. on the evening after admission. The condition 
gradually subsided and except for a rise in temperature 
ten days after vaccination—which was performed on 
Nov. 4th and produced local pain and inflammation— 
convalescence was uneventful. The lesions slowly crusted 
and when these separated no scar was left. The patient 
was dressed three weeks after admission to liospital 
and discharged a week later. He reported a month after 
discharge when all that could be seen was slight bluish 
staining of the skin where the lesions had been. His 
general health was excellent. 

Treatment.—The larger blisters were removed with 
scissors, leaving raw deeply congested areas, many show- 
ing a clear central vesicle. New vesicles were punctured 
as they appeared. Further treatment was directed 
to relieve the intense discomfort caused by involvement 
of so large an area of the body. A bland ointment consist- 
ing of three parts of lanoline and one part of olive oil with 
3 por cent. carbolic acid was found beneficial when applied 
spread on thin muslin. Antistreptococcal serum (20 c.cm.) 
was given intramuscularly on the third day. When the 
temperature had settled he was given permanganate 
baths. 

All the nursing staff while attending to him wore gowns, 
rubber gloves, masks, and goggles, and their arduous 
task was made very unpleasant by the puitrefiactive 


THE LANCET] 


ROYAL SOCIETY OF MHDICINE: MEDICINE - 


[MARCH 28, 1936 719 


odour which pervaded the room. His recovery is due to 
their untiring energy on his behalf. 


The case is of interest for several reasons, namely : 
(1) The similarity of distribution to that of the lesions 
of small-pox and the rapidity with which they went 
through the same stages as the small-pox lesion. 
(2) The absence of any prodromal symptoms. (3) The 

.slightness of the general disturbance considering what 
large areas of the body were involved. (4) The isola- 


tion of non-hemolytic streptococci from the lesions, 
which are usually attributed to the diplococcus of 
Pernet and Bulloch. (5) The rapid recovery from 
a condition which in its severe forms is usually 
fatal. | 


I am indebted to Dr. J. McGarrity, medical superinten - 
dent of the hospital, for permission to publish this case ; 
also to Dr. H. G. M. Henry, of the City Laboratories, for 
the bacteriological reports. 


MEDICAL SOCIETIES 


ROYAL SOCIETY OF MEDICINE 


SECTION OF MEDICINE 
AT a meeting of this section held on March 24th 
the chair was taken by Sir CHARLTON BRISCOE, the 
president, and Sir WALTER LANGDON-BROWN opened 
a discussion on the 
Medical Aspects of the Menopause 


No one, he said, could doubt the importance or the 
complexity of the subject. The special endocrine 
difficulties of the menopause could be referred to 
two causes: (1) the fact that woman, unlike other 
mammals, had no phase of anestrus; and (2) the 
bisexual activity of the ovary. Woman started at 
the menopause a running-down of a clock which 
had never, since puberty, stopped going; the 
uterine endometrium knew no rest. The inter- 
dependence of pituitary and ovary was now recog- 
nised ; the anterior lobe liberated œstrin. The study 
of basophilism had led to interesting physiological 
deductions. The basophils were inhibitors and the 
eosinophils were stimulators of the ductless glands. 
The medulla of the ovary had been described as male 
and the cortex as female. This bisexuality must 
greatly increase the upset of the organism when the 
female part ceased to function. The endocrine state 
before the menopause had a considerable influence on 
the abnormal conditions produced by this change. 
The stout, lethargic arthritic woman apt to have 
headaches would benefit by thyroid at the menopause ; 
the thin excitable type would not. The obesity of 
the climacteric seemed to be of the pituitary type, 
but some women at this time took on an acromegalic 
appearance. It appeared that when the ovary began 
to fail the pituitary made a temporary effort to 
compensate by producing increased sex hormone, 
and this completely upset the balance. For this 
reason symptoms could often be relieved—though 


only temporarily—by giving œstrin. The adrenals also” 


showed increased activity, and the thyroid was speeded 
up in the direction in which it was already tending. — 

The vascular changes did not include any intrinsic 
cardiac changes but there was temporary or per- 
manent hypertension and vasomotor instability. The 
former might depend on basophilic pituitary activity ; 
these cells often showed hyaline change. The 
instability seemed to be a direct result of lack of 
cestrin and the adrenals played a considerable part 
in its production. Blood pressure rose during 
shivering and fell steeply during the subsequent 
flushing. Cstrin preparations alleviated these symp- 
toms, but in some cases they appeared years after 
oophorectomy ; possibly an undefined cellular change 
accounted for them. The diencephalon was now 
regarded as the head ganglion of the sympathetic 
‘nervous system and the centre for many emotional 
phenomena. It also influenced gastric motility. 
The pituitary was the intermediary between the 
diencephalon and the gonads. 


Purely psychical factors must also be considered 
and the attitude with which a woman approached 
the change was of great importance. Women must 
not feel that their usefulness was ended but must 
make investments of interests to continue after the 
menopause. The hypothyroid type tended to suffer 
from the fibrocytic form of arthritis. The human 
corpus luteum did not produce a hormone to relax 
the pelvic ligaments at parturition—another penalty 
women had to pay for the upright position. Multipare 
often had a recurrence of backache at the menopause. 
Diathermy to the cervix was sometimes useful in 
this trouble, restoring some function to the ovary. 
But endocrine disturbances in most cases did no more 
than provide a suitable soil for joint disturbances. 
Treatment of the menopause was mainly symp- 
tomatic: iodine, liquor sedans, and small doses of 
thyroid were useful in suitable cases. Vasomotor 
symptoms were relieved by cestrin. Suggestion was 
a factor in the use of modern endocrine preparations. 
Menopausal women usually had an excess in the 
blood of the hormone found in the urine of pregnant 
women and this preparation was not, therefore, of 
any use. Valerian had a real sedative influence on 
the autonomic nervous system. The psychological 
part of the treatment must never be forgotten ; 
often a time of retreat was desirable while the 
endocrine system settled down to a new and more 
stable equilibrium. | 

Dr. A. P. THomMSON analysed the cases coming to 
him as a general physician. The neglect of the 
subject in text-books was surprising. The best 
review of the subject was that published by the 
Medical Women’s Federation in 1933. This had 
shown that 15 per cent. of women had no symptoms, 
while 10 per cent. were definitely disabled. The 
most numerous intermediate group presented the 
symptoms of an ordinary anxiety neurosis: the fear 
that their attraction and value would disappear and 
the fear of cancer. Among the poor the menopause 
was often welcomed. In a large group the symptoms 
of thyrotoxicosis threatened and came to nothing ; 
radical treatment should be advised only with very 
great caution. Permanent thyroid changes dated 
from the menopause in rather less than 2 per cent. 
of the women reviewed by the Medical Women’s 
Federation. The results of psycho-analysis in Dr. 
Thomson’s cases had been bad. Women were 
frequently referred to him on the threshold of some 
gynecological intervention to see if the heart would 
stand it. The murmur was usually due to simple 
anzemia and the patients were quite well in a month 
or two, their hemorrhage and other menopausal 
symptoms having disappeared with rest and tonic 
treatment. He suggested that no woman should be 
submitted to operation until simple medical measures 
had been tried. Some doctors had an odd faith in 
insulin for uterine hemorrhage; if insulin really 
inactivated cestrin diabetics would have menorrhagia 
instead of the usual amenorrhea! A simple and 


720 


valuable treatment was bleeding, which had been 
widely used in the sixteenth century, and certainly 
relieved flushing, especially if there was hyperpiesis. 
The most important late symptom was obesity ; it 
occurred twice as often in married women as in 
single ones. This seemed to relate to their greater 
ability to take care of themselves, whereas the single 
woman had to carry on. An arthritis of the knees 
might occur in women at the menopause who became 
fat, owing to wear and tear; but Dr. Thomson had 
never seen a case in a thin woman. The psychotic 
group represented the physician’s failures. Quite a 
large number of alcohol and drug addictions began at 
the menopause. 


THE PITUITARY AND OVARIAN RELATIONSHIP 


Dr. P. M. F. BisHoP said that the gradual decline of 
ovarian activity was undoubtedly the starting-point, 
and a compensatory over-secretion of prolan A 
followed. It seemed logical to treat with cestrin, 
and this had met with some success. The symptoms, 
however, were not due to withdrawal of cestrin but 
to the presence of prolan A; they did not appear 
until four or six weeks after oédphorectomy. The 
prolan A curve ran more or less parallel with the hot 
flushes. @Œstrin damped down the prolan A produc- 
tion. When both prolan A and cstrin were absent 
from the urine, hot flushes never appeared. Prophy- 
actic treatment seemed highly undesirable. The 
object of cstrin administration was not to cut out 
prolan A altogether but to keep it down and let the 
patient become gradually accustomed to higher and 
higher levels of it. There was usually no need for 
high doses or injections, or of cestrin estimations. 
Doses of 500-1000 international units were generally 
sufficient; and the flushes themselves were a good 
enough indication of the imbalance. Patients often 
said they felt well during cstrin treatment; and a 
valuable change of mental attitude was sometimes 
effected thereby. 

Dr, F. STOLKIND thought reassurance was very 
valuable treatment. Endocrine preparations by 
mouth were waste of time and money and the results 
from injections were probably psychological. He 
had not seen any benefit from diathermy to the 
cervix, bleeding, or psycho-analysis. 

Dr. A. H. DouUTHWAITE agreed that menopausal 
arthritis of the knees was simply an osteo-arthritis 
related to the increased weight, but questioned 
whether there were not also a true rheumatoid 
arthritis related to the menopause, less crippling 
than in younger people and very resistant to treat- 
ment. Complete achylia often suggested chronic 
gastritis in these cases and the blood uric acid was 
above normal, though lowering it did not relieve the 
symptoms. Venesection did relieve symptoms if 
hyperpiesia was present. 

Dr. Puitiep ELLMAN mentioned a syndrome of 
obesity, arthritis, and hypertension in women with 
definite hypothyroidism. The disturbance of equilib- 
rium due to excessive fat produced the joint 
changes. Astonishing results were obtained by 
thyroid medication, especially relief of the arthritic 
symptoms. Menopausal acromegaly was another 
syndrome, and in one case had been repeatedly 
relieved by intrapelvic diathermy—possibly for 
psychological reasons. The syndrome of obesity, 
hypertension, and hypothyroidism was not an 
uncommon late sequel of artificial menopause with 
removal of the ovaries. 

Sir WALTER LANGDON-BRowN, in reply, agreed 
that many women looked forward to the menopause 
as a chance of pursuing their intellectual interests 


THE LANCET] NORTH OF ENGLAND OBSTETRICAL AND GYNZSCOLOGICAL SOCIETY 


[MARCH 28, 1936 


without interference. Cancerophobia was one of the 
commonest diseases of the day. The high percentage 
of achlorhydria was probably a factor of increasing 
age. Psychological treatment was of the greatest 
importance but formal psycho-analysis was likely to 
do more harm than good. 


NORTH OF ENGLAND OBSTETRICAL 
AND GYNZCOLOGICAL SOCIETY 


A MEETING of this society was held in Sheffield on 
Feb. 28th, with Dr. Ruru NicHOLson, the president, 
in the chair. A joint communication on 


Radium Treatment of Carcinoma of the Cervix 


was made by Prof. W. FLETCHER SHAW and Prof. 
DANIEL Douaat. They had been struck by the fact 
that although radium treatment of carcinoma of the 
cervix had been practised in this country for many 
years, there had been singularly few reports based on 
five years’ freedom from recurrence. The stafis of 
institutions where radium treatment was carried out 
had stated that they were obtaining good results 
but had not as yet published any figures com- 
parable with those from foreign clinics. On the 
other hand, the results likely to be obtained by the 
Wertheim operation were well known. Unfor- 
tunately this operation entailed both a high immedi- 
ate mortality and a long and trying convalescence, 
and for this reason most gynecologists would 
undoubtedly have been prepared to abandon it if 
convincing evidence had been produced by the 
radiologists that radium treatment could give equally 
good results. Such evidence had not as yet been 
forthcoming in this country and for this reason Prof. 
Shaw and Prof. Dougal had determined in 1928 to 
purchase their own supply of radium and to treat 
their own cases both in private and in hospital. As 
this step was in the nature of an experiment, it was 
decided to treat all cases by the same method and to 
follow up every case with the idea of publishing results 
as soon as a sufficient number had been collected. 

After due consideration the method of Heyman 
of Stockholm had been chosen, with certain modi- 
fications suggested by Dr. Helen Chambers and 
Prof. S. Russ of the Middlesex Hospital. Forty 
milligrammes of radium, suitably screened,was inserted 
into the uterine cavity and 60 mg. in three box 
applicators was applied to the cervix and vaginal 
fornices. Each patient was treated on three occasions 
for 24 hours, with an interval of one week between 
the first and second application and three weeks 
between the second and third application. The 
cases treated up to Jan. Ist, 1931, numbered 94, 
and the results five years later were : 


Alive and well five years peace 
Dead or untraced .. 


39 (41:4 24) 

55 (58-6 %) 
The immediate mortiir was 2-1 per cent., one 
patient having died from peritonitis and one from 
pulmonary embolism. Microscopical confirmation 
had at first not been carried. out in advanced cases, 
because the diagnosis in such cases was deemed to be 
so definite to an experienced clinician that confirma- 
tion was unnecessary. Later, when it was realised 
that readers of the report would not have seen the 
cases, and would have to accept the diagnosis on the 
authors’ unconfirmed statement, a piece of growth 
was excised for laboratory examination as a routine. 
Microscopicalexamination was therefore carried out in 
about half the cases ; but those not so examined were 
so advanced that no error in diagnosis was possible. 


mt 


THE LANCET] 


NORTH OF ENGLAND OBSTETRICAL AND GYNÆCOLOGICAL SOCIETY [mMaRoH 28, 1936 721 


In considering the results with regard to the stage 
of the growth, the classification of the radiological 
subcommittee of the League of Nations Cancer 
Committee had been adopted. 


Stage. Cases Alive Dead. 
I. rar rer be “AL - wiiees TO awaasa 4 
II. zs aa aise BT. - Baines Vo: -esewei 15 

III. ae ae ge, AO asies IT -w0deee 23 
IV. es e 10 scce’ e 1 eeseve 9 


Two patients with cervical stump carcinoma following 
subtotal hysterectomy were included, and both died 
of recurrence. These cases should perhaps have 
been omitted, for it had obviously not been possible 
to follow the full routine as regards application. 

In considering the question of radium versus the 
Wertheim operation, the results in the present series 
(94 cases with 41-4 per cent. of five-year cures) could 
be compared with the surgical results of Bonney 
(384 cases with 39 per cent. five-year cures) and 
Fletcher Shaw (154 cases with 38-3 per cent. five-year 
cures). The operability rate had also to be taken 
into consideration (Bonney 63 per cent.). Prof. 
Shaw and Prof. Dougal considered their series a 
small one; whether the high percentage of freedom 
from recurrence would be maintained when they 
had larger figures remained to be seen. But they 
were convinced that the results with radium were 
better than those with Wertheim’s hysterectomy. 
At the same time they were by no means satisfied 
with figures which showed less than half the patients 
alive after five years. Certain of their patients were 
now having deep X ray therapy after radium treat- 
ment, but this had been done for too short a time 
to allow of any comparison of results. They were 
convinced that the surgical treatment of carcinoma of 
the cervix was a thing of the past. 

The PRESIDENT congratulated Prof. Shaw and 
Prof. Dougal on the excellence of their results. She 
read on behalf of Mr. P. Malpas the figures from the 
Liverpool Radium Centre, of cases treated during 
the years 1929 and 1930, the total five-year survival- 
rate of all cases treated being 33 per cent. The method 
used was that of Heyman, followed by deep X rays. 

Mr. J. W. Burns asked if any of the patients had 
suffered from annular constriction of the rectum 
after treatment. He had observed the condition in 
2 cases. He also expressed the view that radium 
therapy was well worth while even in very advanced 
cases, since it relieved pain and made the end easier. 

Mr. T. F. TODD commented on the excellence of 
the results obtained, which he regarded as far and 
away ahead of anything else so far achieved. Except 
for one single year’s results from the Marie Curie 
Hospital, he knew of nothing comparable in the 
international literature. He considered radiation 
definitely preferable to surgery even in early cases ; 
at least eight of the international radium centres had 
published a five-year survival-rate of over 50 per 
cent. in operable cases—i.e., 10 or more per cent. 
better than surgery. Mr. Todd recalled Beckwith 
Whitehouse’s published figures of 500 cases treated at 
several teaching hospitals in this country, with a 
five-year survival-rate of about 11 per cent. 

Dr. FRANK ELLIS gave figures from the Jessop 
Hospital for Women, Sheflield, showing a 30 per cent. 
five-year survival-rate. It was customary in Sheffield 
to perform Wertheim’s operation on Stage I. cases 
(if fit for operation) after preliminary radiation. If 
the tumour was bulky and infected the patient had 
(1) X ray treatment for two weeks to the whole 
pelvis ; (2) two weeks’ rest with douches ; (3) radium ; 
(4) one day later, Wertheim’s operation; and 


(5) further X ray treatment to the whole pelvis 
if glands were found to be involved. If the tumour 
was small and uninfected, the procedure was: 
(1) single dose of radium; (2) one day later, 


. Wertheim’s operation ; and (3) a full course of X rays 


to the whole pelvis if glands were involved. Cases 
in Stages II., III., and IV. were given X rays, radium, 
and then X rays again. Dr. Ellis showed a series of 
slides, indicating the technique of the methods 
employed ; also a slide to show the type of X ray 
burn of the skin, which while healing perfectly 
might be thought by the uninitiated to indicate an 
overdose—being in reality the dose aimed at. He 
also quoted Ddéderlein’s figures in operable cases 
which showed 80 per cent. five-year cures after 
complete radiation, as compared with 46 per cent. 
after operation. They afforded adequate reason for 
Döderlein having given up the operative procedure. 

Dr. E. A. GERRARD drew attention to the excellence 
of the results in a series of cases which had been 
handled entirely by gynecologists, without resort to 
their radiological colleagues. Was this a point of 
importance—even significance? He thought so, 
particularly as there was a growing tendency in 
certain areas for the general practitioner to refer 
malignant cases directly to the radiologist. Was 
this in the best interests of the patient? The radio- 
logist could hardly be expected to have had a wide 
experience in a special branch like gynecology. 
The diagnosis in carcinoma of the cervix, particu- 
larly of the endocervical type, was not always easy, 
and the correct application of the radium was liable 
to present real difficulty unless the operator was 
regularly engaged in vaginal surgery. 

Mr. J. E. STACEY advocated Wertheim’s operation 
in first-stage and early second-stage cases—along 
with radiation, as this precluded the ill-health from 
cystitis, proctitis, &c., which was liable to follow if 
radiation alone were employed. He believed that 
coöperation between gynecologist and radiologist was 
advisable; the gynecologist should diagnose the 
condition and the radiologist should decide the dose 
and apply the treatment. 

Prof. MILes PuHILuies also advocated the codpera- 
tion of gynecologist and whole-time radiologist. He 
laid stress on the necessity of doing all one could to 
prevent carcinoma by the ruthless removal of the 
cervix whenever it was found in a badly damaged 
or chronically infected condition. The fact that the 
annual mortality-rates showed, for a number of years, 
a steadily falling death-rate from cancer of the 
uterus, whereas that from cancer in all other organs 
was increasing, was at least highly suggestive that 
this method of preventive treatment was becoming 
effective. 

Dr.I. A. B. CATHIE spoke of the grading of tumours 
as an aid to prognosis. He was inclined to disagree with 
the prevalent idea that the columnar-cell type of 
growth was resistant to irradiation. 


Prof. DouGat, in reply, said that Prof. Shaw and 
himself, recognising that their series was a small one, 
realised that they might have been fortunate in their 
results. He agreed with Mr. Todd that there was now 
no justification whatever for the Wertheim operation. 
He had seen one case in which application of radium 
had been followed by a fistula, but the dose given 
had been unduly high—11,000 mg.-hours. He held 
that codperation between surgeon and radiologist 
was undoubtedly desirable, though the dose for 
carcinoma of the cervix was largely standardised. 
He did not think that a radiologist was the best 
person to apply the radium in this region, for even 


T22 THE LANCET] NORTH OF ENGLAND OBSTETRICAL AND GYNECOLOGICAL SOCIETY MARCH 28, 1936 


an experienced operator sometimes found great 
difficulty in advanced cases with the insertion of the 
intra-uterine portion of the dose.—Prof. DOUGAL 
agreed with Dr. Cathie that the columnar-cell type 
of growth was proving to be less resistant to radium 
than had been thought in the past. 


Naegele Pelvis 


Dr. CLancy reported the case of a 6-gravida 
who had had two stillbirths and three live children, 
all by instrumental deliveries. After the first delivery 
there had been paralysis of the left leg. She was 
admitted to hospital at the thirtieth week and on 
vaginal examination the membranes were found to 
have ruptured. The cervix and vaginal vault 
exhibited marked laceration indicating severe trauma 
at previous deliveries, and in view of this fact, it 
was decided to have a radiogram taken. This 
revealed a Naegele pelvis, of which there had been 
no indication by vaginal or other examination. 
The external appearance of the patient was also 
normal, and neither figure, gait, or carriage gave 
any suggestion of deformity. ‘The following measure- 
ments were taken: interspinous, 8} in. ; intercristal, 
9} in. ; external conjugate, 6} in. ; external obliques, 
7 and 74 in; posterior superior spine to symphysis 
on each side, 6} in. ; spine of last lumbar vertebra to 
anterior superior spine, 6} and 6?in. On examina- 
tion of the patient’s back a definite bony lump was 
found over the sacro-iliac joint on the affected side. 
The striking feature of these cases was the difficulty 
in diagnosis ; for apart from the bony lump there was 
nothing to indicate the serious deformity. The 
customary measurements, as stated by Whitridge 
Williams, merely suggested a justo-minor pelvis. 
Dr. Clancy felt that there was much to be said for 
having a radiogram taken wherever there was a 
history of former dystocia. 

The PRESIDENT spoke of the rarity of spontaneous 
delivery in the type of case, also the high mortality 
recorded—Litzmann, 22 deaths in 28 cases. 
Dr. J. W. BRIDE referred to the temporary paralysis of 
the leg from which the patient had suffered after the 
first delivery. It was remarkable that nerve injury 
should be so rare even after difficult instrumentation.— 
Prof. PinLurs said that this case showed the desir- 
ability of all maternity hospitals being provided 
with an X ray apparatus. 


Malignant Ovarian Tumours and 
Hysterectomy 


Mr. C. Il. Wausu showed a specimen of calcified 
fibroids associated with malignant pseudomucinous 
ovarian cyst and adenocarcinoma of the body of the 
uterus with hematometra. 


The pationt was a nullipara, aged 66, who had passed 
the menopause at 52, since when there had been no 
vaginal discharge. She had been perfectly well until 
the day before she was admitted to hospital for severe 
abdominal pain and vomiting. The pulse, respiration, 
and temperature were normal, but abdominal palpation 
revealed a hard mass in the right iliac fossa and a cystic 
tumour in the left side of the abdomen. The cervix 
felt normal and there was no vaginal discharge. In 
view of a possible diagnosis of carcinoma of the colon, 
a barium meal was given, and on radiography a calcified 
mass was seen in the right iliac fossa, which had the 
appearance of a calcified fibroid. The cystic mass was 
thought to be ovarian in origin, and a laparotomy was 
performed. There was no ascites, The uterus contained 
multiple fibroids, and the large calcified tumour seon in 
the radiogram was found to be a pedunculated fibroid, 
arising from the right side of the fundus uteri. The 
swelling on the left side was an ovarian cyst the size of a 


football. Total hysterectomy with bilateral salpingo- 
odphorectomy was performed, and on incising the uterus 
after operation the surgeon was surprised to find it full 
of malignant growth and distended by about 6 oz. of 
blood-stained fluid. The tubes were also found to contain 
severale malignant nodules, but in no instance had the 
growth reached the peritoneal surface. The ovarian 
tumour proved to be a papillary pseudomucinous cyst 
adenocarcinoma. 


Prof. FLETCHER SHAW, in advocating removal of 
the uterus in all cases of malignant disease of the 
ovaries, recalled a case which supported the view 
that the growth in the uterus was secondary to the 
one in the ovaries. The patient, aged 39, had had 


double ovarian carcinomata—each the size of an 
orange and both free from adhesions. These were 
removed and the uterus retained; but after the 


operation the patient had amenorrhea for 18 months, 
succeeded by irregular and increasing bleeding. 
About two years from the first operation, the irregular 
hemorrhage having been present for about six months, 
panhysterectomy was performed and an advanced 
carcinoma was found in the interior of the uterus. 
If the growth had been primarily in the uterus it was 
hardly possible for it to have remained quiescent 
and for the woman to have 18 months’ amenorrhea 
after the removal of the ovaries. If, as seemed 
more likely, the uterine growth was secondary to 
the ovarian, it must have been in an early stage when 
the ovarian growths were removed and have progressed 
slowly, for hemorrhage began only 18 months later. 
The first operation was in 1912 and the second in 
1914, and the patient was alive now, 24 years after 
the first operation. 


Dr. Erus thought it an advantage when operating 
on these cases to leave the uterus with a view to 
subsequent radium therapy. He quoted a recent 
paper by Schroeder giving results of treatment of a 
relatively large number of cases of proved malignant 
disease of the ovary treated by radiation. Schroeder 
divided his cases into three groups: (1) those in 
which he was able to remove all visible growth ; 
(2) those in which most of the visible growth was 


removed; and (3) those in which only a portion 
of the growth was removed for biopsy. The five- 


year cures were 66 per cent. in Group 1 and 16 per 
cent. in Group 2. The latter was, however, sub- 
divided into two sub-groups. In first of these the 
uterus was not removed, so that it was used afterwards 
for intrapelvic application of radium in addition to 
the X ray treatment which all the patients received ; 
the five-year survival-rate was 25 per cent. In the 
second, in which the uterus was not left and therefore 
radium was not applied, there were no five-year 
survivals, These figures indicaged the advisability 
of supplementing operation with radium as well as 
X ray treatment, with the corollary that it was 
advisable to leave the uterus in position if all obvious 
growth was removed. 


Mr. Burns referred to a case in which a malignant 
ovarian tumour, the size of an orange, was removed 
and the patient had no symptoms for two years. 
After this time, uterine hemorrhage occurred, and 
curettage showed a growth similar to that of the 
ovary. A dose of 2000 mg. hours of radium was given, 
and the patient had no further symptoms. Curettage 
18 months later revealed merely fibrous tissue. 


Mr. C. R. Macponatp showed a specimen of acute 
torsion of a hydrosalpinx in pregnancy. 


Dr. BRIDE reported two cases of unusual Ectopic 
Pregnancy. 


THE LANCET] 


[MARCE 28, 1936 723 


REVIEWS AND NOTICES OF BOOKS 


An Enquiry into Prognosis in the Neuroses 


By T. A. Ross, M.D., F.R.C.P., sometime Medical 
Director, Cassel Hospital for Functional Nervous 
Disorders. London: Cambridge University Press. 
1936. Pp. 194. 10s. 6d. 


THIS book presents a serious attempt to find out 
what really happens to patients who have been 
treated for neuroses. The after-histories of nearly 
1200 patients treated at the Cassel Hospital have 
been investigated, and, as the first cases were treated 
in 1921, many have now been followed up for over 
ten years. Forty-five per cent. of all the cases were 
well one year after discharge; 25 per cent. were 
improved; 19 per cent. had not benefited, while 
the remaining 11 per cent. were lost sight of. Of 
850 patients, investigated five years after discharge, 
502 were lost sight of, 290 were well, and 58 were 
improved. In 1934, only 134 of the 1186 patients 
were known to have relapsed. Dr. Ross states 
that many patients who reported themselves as 
improved in the earlier years after leaving hospital 
reported themselves later as being well. The average 
duration of stay in hospital increased gradually 
from 2-3 months in 1921 to 7-2 months in 1933. 
The best results were obtained in 1930 when the 
average duration of stay in hospital was 4:4 months. 
In this year 63 per cent. of the patients were well a 
year after discharge. Dr. Ross also reports his 
investigations into the prognosis as regards suicide 
and insanity. Patients known to have committed 
suicide numbered 7; and 23 patients were known 
to have become psychotics. The names of the “ lost ”’ 
patients were sent to the proper authority, and it 
was found that 10 had been certified and 16 had been 
received into mental hospitals as voluntary patients. 
From these figures Dr. Ross concludes that the 
prognosis with regard to becoming insane is good. 

Dr. Ross’s writings on the neuroses make a general 
appeal, for he uses simple language which all can 
understand. His methods of treatment are also 
simple and can easily be made use of by the practi- 
tioner. He is strongly critical of the Freudian school 
in their insistence on the need for prolonged analysis ; 
whereas the Freudian analysts maintain that simple 
methods, such as Dr. Ross advocates, only cause 
temporary relief. 

The good results here reported suggest that the 
methods Dr. Ross advises result in permanent cures 
in a high proportion of cases of neurosis ; they should 
be studied with care. 


Pathology of Internal Diseases 


Second edition. By WILLIAM Borb, M.D., M.R.C.P. 
Edin., Professor of Pathology in the University of 
Manitoba; Pathologist to the Winnipeg General 
Hospital, Canada. London: Henry Kimpton. 
1935. Pp. 904. 45s. 


To bring this book up to date has involved 25 
additions to the text, though only four years have 
elapsed since the first issue, and the revision or com- 
plete rewriting of 13 sections. The descriptions of 
the anemias, the diseases of the endocrine system, 
and pulmonary disease, among others, have had to 
be considerably altered. In spite of all this new 
material the volume has been increased by only 
16 pages. This feat has been accomplished by the 
introduction of small type for some of the less com- 
mon conditions and by shortening the chapter sub- 


headings. We have here an attempt to bridge the 
gap which often exists between medicine and patho- 
logy, and the book should certainly help the student. 
The post-graduate student in particular will appre- 
ciate the references to recent work, which are now 
arranged under subject headings. A surprisingly 
large store of sound, well-balanced teaching is to be 
found in readable form in these pages. 


1. Foundations of Short Wave Therapy 


By Dr. Wotreanc HOLZER, Assistant in 
the Physiological Institute of the University 
of Vienna; and Dr. EUGEN WEISSENBERG, 
Medical Superintendent of the Short Wave Section 
of the University Clinic for Nervous and Mental 
Diseases in Vienna. Translated by JUSTINA WILSON, 
F.R.C.P. Edin., D.M.R.E.Cantab., and C. M. 
DowsE, B.Sc. Lond., A.M.I.E.E. London : 
Hutchinson’s Scientific and Technical Publications. 
1935. Pp. 228. 12s. 6d. 


2. Short Wave Therapy and General Electro- 
therapy 


Illustrated. By HEINRICH F. Wor, M.D., 
Consultant, Department of Physical Therapy, 
Mt. Sinai Hospital. New York: Modern Medical 
Press. 1935. Pp. 96. $2.50. 


3. Néodiathermie à ondes courtes 


By Dr. HENRY BORDIER and Dr. T. KOFMAN. 
Paris: J. B. Bailliére et Fils. 1936. Pp. 139. 
Fr.24. l 


1. IN our review (THE LANCET, 1935, ii., 1125) 
of the German original we noted that here is to be 
found the best presentation of the technical aspect 
of ultra-short waves available in book form. The 
translator of this section has kept closely to the text— 
a highly desirable feature where physical facts and 
theories are detailed, even though it leads him to 
speak of the principles of electric circuits as 
“ connexion theory.” Accuracy has been maintained 
throughout and the rare misprints lead to no confusion. 

The second section, devoted to therapy, is relatively 
short. The translator has expanded it by printing 
the descriptions of cases in the same type as the 
general text, whereas in the original smaller type 
was used for clinicalexamples. Some redundancies 
have crept in: an “adipose”? woman is translated 
as a “stout corpulent’’ woman, but the fact that 
the translation is more free has made it also more 
readable. This therapeutic section would have been 
improved if Dr. Wilson had felt free to make some 
additions from her own experience of the method. 
Every practical worker in short-wave therapy should 
possess a copy of this book. 


2. Dr. Wolf’s book of drawings show types of 
electrodes and methods of application to the various 
diseased organs. Practical hints are interspersed, 
some of which are aimed, wisely, at preventing further 
damage to the patient. The author continues to 
maintain a preference for the diathermy machine 
for treating whole limbs, while the valve apparatus 
is appropriate for the treatment of selected cases of 
acute local inflammation. 


3. It was in France that the therapeutic applica- 
tion of high-frequency currents originated, for it was 
d’Arsonval, in 1891, who made possible the use of 
diathermy. This little book gives an account of the 
theory and practice of diathermy and of ultra-short 


724 THE LANOET] 


waves which is well balanced, concise, and yet very 
readable. French machines of commercial type are 
included and some space is devoted to the biological 
effects of high-frequency currents. 


A Synopsis of Physiology 


Second edition. By A. RENDLE SHortT, M.D., 
F.R.C.8., Professor of Surgery, University of 
Bristol; and C. I. Ham, M.B., F.R.C.S. Edin., late 
Demonstrator in Physiology in the University of 
Bristol. Edited by C. L. G. Pratt, M.Sc., M.D., 
Lecturer in Physiology, St. Thomas’s Hospital 
Medical School. Bristol: John Wright and Sons 
Ltd.; London: Simpkin Marshall Ltd. 1936. 
Pp. 312. 10s. 6d. 


Tus book should be an excellent tonic for students 
who complain that physiology is ‘‘ so indefinite.” It 
is crammed with facts from beginning to end, and 
even the reasoning is tabular. It is not, of course, 
intended by the authors to be used alone as a text- 
book, although it contains more information than 
many text-books; it is a present to the student 
rather than a contribution to physiology. A dangerous 
present, perhaps, for it would be a peril to any student 
into whose hands it fell more than three months 
before his examination. The reason for this is that 
the authors have done their work surpassingly well, 
so that the reader of the book does not require to 
think at all: this has all been done for him. If he 
has not done his own thinking previously he will 
inevitably bend all his energies to memorisation and 
his knowledge will be sterile. Physiology is a subject 
‘to be understood rather than learnt ; it is the medical 
student’s training in how to reason about the human 
body, a pursuit which will occupy him for the rest of 
his active life. Nevertheless, examinations must be 
passed, and there could be no better form of revision 
than reading through this book. It is an exhaustive 
summary, accurate in the main details, and the sub- 
ject is not “simplified.”” The sub-headings of the 
various sections provide what no larger book can— 
namely, a bird’s-eye view of the subject matter and 
a gratifying illusion of finality. It is strongly to be 
recommended to those who feel their confidence 
ebbing before an examination. It should prove even 
more useful to teachers of physiology, not because 
they will learn very much from it, but because it 
will help them to present their lectures in an orderly 
fashion by suggesting a plan. Knowledge does not 
always go hand in hand with the power of exposition, 
and no teacher need be ashamed of making use of 
the painstaking analysis whose results are presented 
in this synopsis. 


Lectures on Diseases of Children 


Seventh edition. By Rosrert Hutcuison, M.D., 
LL.D., F.R.C.P., Consulting Physician to the 
London Hospital and to the Hospital for Sick 
Children, Great Ormond-street. London: Edward 
Arnold and Co. 1936. Pp. 452. 21s. 


THERE can be few text-books that have provided 
generations of medical students with more agreeable 
or serviceable reading than Dr. Hutchison’s famous 
lectures. The seventh edition of a volume so well 
known requires little comment. The lecture dealing 
with chronic constipation in infancy and childhood, 
and part of that concerned with pink disease, have 
been rewritten, but apart from this there have been 
only minor alterations. The style conveys a peculiarly 
personal quality, and the matter is compact of sound 


REVIEWS AND NOTICES OF BOOKS 


[MARCH 28, 1936 


judgment. The author specifically disclaims any 
intention of writing an exhaustive treatise on children’s 
diseases, and the student must seek elsewhere for 
detailed descriptions of modern methods of diagnosis 
and treatment. For a wholesome reminder of the 
outstanding importance of clinical observation, the 
student can do no better than study Dr. Hutchison’s 
lectures. 


British Journal of Children’s Diseases 


(Vol. XXXIII., January-March.}—In an address 
entitled Farrago Pyretologica: a Medley on Fevers, 
recently delivered before the Nottingham Medico- 
Chirurgical Society, Dr. J. D. Rolleston stated that 
the study of fevers was so full of interest and import- 
ance that he had ventured to revive the term used 
in its Greek form by Richard Morton in 1692 for the 
title of his work on fevers. During the 35 years 
that Dr. Rolleston had been in fever practice he had 
witnessed a remarkable change in the incidence and 
severity of certain diseases, such as scarlet fever, 
small-pox, and enteric, as well as the appearance of 
new diseases such as encephalitis lethargica, encepha- 
litis following measles and varicella, and summer 
typhus. New specific methods of diagnosis and 
treatment had been introduced, while others, especi- 
ally the therapeutic use of alcohol, had been super- 
seded or largely replaced. After discussing the 
Dick and Schultz-Charlton tests, and active and 
passive immunisation against scarlet fever as well 
as the antitoxin treatment, he maintained that 
four weeks’ isolation was amply sufficient for an 
uncomplicated case, as had been recommended in 
a Ministry of Health report in 1927, though this 
recommendation did not seem to be generally known 
to the profession or the public. Chicken-pox was not 
always a trivial disease as it might give rise to serious 
and even fatal complications, and he had seen 6 deaths 
from it. He had never seen two attacks of measles 
in the same individual, nor a severe attack of rubella 
apart from one complicated by appendicitis and 
another by purpura hemorrhagica. Like most 
observers with a long and intimate knowledge of 
the acute exanthemata, he had never encountered 
“ the fourth disease,” and declared that this term 
was more applicable to erythema infectiosum, 
sometimes known as “the fifth disease.” It was 
still necessary to insist on making the diagnosis of 
diphtheria on clinical grounds, for he was constantly 
seeing cases in which valuable time had been lost, 
often with fatal results, because the practitioner did 
not send the child to hospital or inject antitoxin 
before he had received the report on the throat 
swab.—In a paper on the Mantoux Test in Children 
with Special Reference to Home Contacts, Dr. 
G. Gregory Kayne stresses the importance of some 
simple rules to guide the clinician in the use of the 
Mantoux test, and describes some points in the 
technique, routine procedure, and reading of the 
test. The significance of a positive and negative 
reaction in children is also described. Lastly, the 
usefulness of the test in the examination and handling 
of home contacts is considered.—Dr. A‘nir Chand, 
professor of medicine at the Amritsar medical school, 
contributes a paper on Chronic Jaundice in Three 
Brothers with Hypertrophic Cirrhosis of the Liver 
and Infantilism. The clinical features tallied in 
almost all respects with those of Hanot’s cirrhosis. 
In the first case, that of a man aged 24, who died, 
signs and symptoms of portal cirrhosis appeared in 
addition to those of biliary cirrhosis a few months 
before death. No biopsy nor necropsy could be 
obtained. The other two brothers aged 16 and 12 
were still alive—In a paper entitled A Seventeenth 
Century Cure for Rickets, Dr. W. J. Rutherfurd 
comments on Sir Thomas Browne’s statement in 
his Account of the Birds Found in Norfolk that 
about Norwich the livers of rooks were used for the 
cure of rickets.—The abstracts from current litera- 
ture are devoted to treatment. 


THE LANCET] 


THE LANCET 


LONDON : SATURDAY, MARCH 28, 1936 


THE MIDWIVES BILL 


At the opening of the Parliamentary session 
last December the Speech from the Throne referred 
to the need of improving the maternity services 
and promised legislation whereby local authorities, 
in coöperation with voluntary associations, would 
provide an organised service of salaried midwives. 
The pledge is redeemed by the Midwives Bill 
which the Minister of Health has now presented. 
It embodies the main points recommended by the 
Joint Council on Midwifery—the principle that 
every maternity case should be nursed by a 
qualified midwife, the prohibition on unqualified 
persons nursing maternity cases for gain, the 
establishment by local authorities of a salaried 
service in all areas not already served by salaried 
midwives, and the grant of compensation or 
pension to all midwives who either are not accepted 
for salaried service or are found unfitted by reason 
of age or infirmity. County and county borough 
councils (and in some cases county district councils) 
are by statute the “local supervising authorities.” 
It is to be their duty to secure within their areas 
a sufficiency of certified midwives to attend on 
the parturient woman in her own home and to 
act as maternity nurse for at least ten days after 
childbirth. The authorities are to arrange with 
welfare councils and voluntary associations for the 
whole-time service of the necessary personnel or 
else to employ midwives direct. They are to 
formulate proposals in consultation with local 
organisations of medical practitioners and of mid- 
wives and with welfare councils and voluntary 
associations, and the resultant scheme is to be 
submitted to the Minister within six months of 
the Bill passing into law. Before a local authority 
first engages midwives for employment, it must 
advertise the prospective appointments and the 
proposed salaries and conditions. As every prac- 
tising midwife in the district must receive this 
information, there is reasonable hope that as 
many as possible of the salaried posts will be filled 
by local midwives previously in independent 
practice—a course which will simplify the tran- 
sition and alleviate hardship. Each authority is 
to fix scales of fees for the services of midwives 
and maternity nurses, and it will be charged 
with the duty of recovering the fees from the 
patient or her husband, subject to a discretionary 
power to remit in view of the financial circum- 
stances of the particular household. The additional 
cost of the scheme to the ratepayers will be borne 
in part by the Exchequer through the mysterious 
but efficient formula of the block grant adjusted 
to local needs and population. As the Minister 
` has power to reduce the grant in case of inefficiency, 


THE MIDWIVES BILL 


[marcu 28, 1936 725 


the local supervising authority itself comes under 
supervision. | 

While the general standards of midwifery are 
being thus improved to the national advantage, 
it would be a pity if the national conscience had 
cause to feel uneasy over the fate of the midwives 
at whose expense the change is made. With the 
goodwill of the local authorities existing midwives 
can be absorbed in the new scheme, but there will 
remain a residue for whom the future holds 
anxiety. It is said that there are about 60,000 
midwives on the roll and that only about a quarter 
of these are in actual practice; of this quarter 
roughly half are in salaried posts under voluntary 
nursing associations or otherwise, while the other 
half are practising independently. What with 
financial stringency, the fall in the birth-rate, and 
the increasing readiness of women to go into 
hospitals for their confinements, the midwife’s 
calling is overcrowded, although as in other 
callings there is room for women of the best type. 
The Bill proposes to remedy this superfluity by 
the double process of buying out and weeding out. 
Under Clause 5 the midwife who surrenders her 
certificate within three years will be compensated 
with a sum equal to three times her average net 
annual emoluments ; a midwife deemed incapable 
of efficient service by reason of age or infirmity of 
mind or body will be required to surrender her 
certificate (subject to a right of appeal to the 
Minister) and, on surrender, will be entitled to 
receive a sum equal to five times her average net 
annual emoluments. The number of women who, 
under these two processes, will be eliminated from 
practice is officially estimated at less than 3500. 
When due allowance has been made for a frugal 
reluctance to subsidise the so-called inefficients 
out of the public purse, the fact remains that most 
of these women paid for their own training and all 
have played their modest part in serving genera- 
tions past, present, and future. The women who 
disappear from practice under Clause 5 can never 
be restored to the rol] ; they will commit a criminal 
offence if in future they act as midwives or maternity 
nurses. Section 3 of the Dentists Act was far 
more tender to the existing practitioner. Statistics, 
so far as available, indicate that a large majority 
of midwives have been earning less than £100 a 
year; one-third of them earn £50 or less; only 
one in seven earns £200 or more. When bad debts 
and professional expenses, food, and rent are 
deducted from these gross totals, the net annual 
sum (on which the compensation will be computed) 
is exiguous. Some 550 midwives in independent 
practice, it is believed, are over 60 years of age. 
They cannot have put by much against a rainy 
day. The Bill not ungenerously accepts the 
principle of compensation for this disappearing 
class of workers ; its individual application will be 
scrutinised anxiously by those concerned. 

As for the rest of the Bill, there is an excellent 
proposal that rules framed by the Central Mid- 
wives Board may require midwives to attend 
periodical courses of instruction arranged by the 
local authority of the district, and may also permit 


‘the Board to grant diplomas to midwives presenting 


926 THE LANCET] 


themselves for examination in the teaching of 
midwifery. The Minister of Health may prescribe 
the qualifications of persons appointed by a local 
authority to supervise the midwives practising 
within the area; nobody is to be appointed who 
does not possess the prescribed qualifications. 
Lastly there is a significant little clause which will 
give the Minister a power denied to him by the 
Court of Appeal last year. Under Section 14 of 
the Midwives Act of 1918 a midwife in cases of 
emergency can call to her assistance a medical 
practitioner. The Act says the local authority 
shall pay the medical practitioner a fee on a scale 
fixed by the Minister. In the Monmouthshire 
County Council case it appeared that not only 
did the Minister fix the scale of fees as Parliament 
said he might, but he also added conditions. The 
conditions involved the possibility that a doctor 
might do the work and yet not get the fee. The 
Court of Appeal found no power in the section for 
the Minister to do anything but fix a scale. Four 
doctors, advised by the two medical defence 
societies of which they were members, successfully 
claimed their fees in spite of the Minister’s con- 
ditions. There was talk of the Minister taking 
the case to the House of Lords; he has found a 
simpler method of getting his way. 


HYPERPYREXIA IN THE TREATMENT OF 
GONOCOCCAL INFECTIONS 


DurincG the past few years much experimental 
work has been done, chiefly in the United States, 
on the treatment of certain infections by physical 
methods which produce an increase in the general 
body temperature over a period of hours. Some 
have modified the old radiant heat bath, while 
others induce pyrexia by means of diathermy, 
short (wireless) waves, or inductothermy. It was 
evident from the views expressed at the Conference 
on Fever Therapy held at Dayton, Ohio, last year, 
that opinions differ greatly about the best type 
of apparatus, the most effective methods of apply- 
ing the treatment, and the pathological conditions 
in which benefit may be expected. Nevertheless 
on some points there is a remarkable unanimity, 
and reports from many quarters show that the 
results in gonococcal arthritis may be excellent 
and even spectacular. Dr. NEYMANN, of Chicago, 
speaking at the Royal Society of Medicine last 
April, said he could find no exception to the wide- 
spread belief that electropyrexia is the treatment 
of choice in such cases, and the same phrase is 
used by KENDELL, WEBB, and Spmweson,? who 
report good results in 31 cases of gonococcal 
arthritis treated in the Kettering hypertherm— 
an air-conditioned cabinet in which the humidity 
can be controlled. 

Among the forms of therapy now adopted is 
the combination of general hyperpyrexia with 
local application of the diathermy current to the 
pelvic focus of infection; and BIERMAN and 


1 Neymann, C. A.: Proc. Roy. Soc. Mod., 1935, xxix., 1513 
see THE LANCET, 1935, i., 1102. 

3 Kendell, li. W., Webb, W. W., and Simpson, W. M.: 
Amer. Jour. Surg., 1935, xxix., 428, 


(HYPERPYREXIA IN THE TREATMENT OF GONOCOCCAL INFECTIONS 


[maRcH 28, 1936 


LEVENSON ? regard this mixture of old and new 
methods as a definite advance. Their practice is 
to place the patient in a water bath at 100—102° F. 
and gradually raise the temperature to 107—108°. 
By this means it is possible, within an hour, to 
bring the rectal temperature up to about 105° F., 
after which pyrexia of about 105-5° can be kept up 
without difficulty for five or six hours by trans- 
ference to a bed covered with a hood made of 
insulating material and containing a battery of 
60-watt electric light bulbs. Additional pelvic 
heating is obtained by the diathermy current, 
the active electrode (water-cooled if necessary) 
being inserted into rectum or vagina and the dis- 
persive electrode being applied in four sections 
covering a wide area of skin. In this way, it is 
found, a temperature of 111° can be maintained 
in the pelvis for as long as 34 hours. Of 16 patients 
treated (8 male and 8 female), 13, it is stated, 
had complete restoration of function, and in the 
other 3, who had already suffered irreversible 
joint changes, some improvement was recorded. 
The women required an average of 2-1 treatments 
the men 3:5, and the intervals between treatments 
varied from two to thirteen days. The best results 
were obtained in early acute cases. 

The use of heat in the treatment of metastatic 
complications of gonorrhcea is by no means new, 
and has been practised in various forms for many 
years. Hence the conservative may argue with 
some reason that hyperpyrexia is merely a varia- 
tion on an old theme; and there is no doubt 
that excellent results are commonly obtained by 
well-tried methods, without the additional dis- 
comforts and risks involved in exposure to high 
temperatures for a long period. Nevertheless 
there is at least one feature of these recent 
investigations which deserves close attention 
—namely, the frequent reference made to the 
rapidity with which gonococci disappear from 
the discharges and purulent secretions themselves 
subside when these more drastic methods are 
employed. STUHLER t says that urethral discharge 
sometimes ceases, and smears are often negative 
for the gonococcus, after the first session of fever 
therapy, and he makes the remarkable claim that 
fever therapy for gonococcal infections is one of 
the greatest advances made in the last fifty years— 
an advance “of even greater importance to the 
clinician than was the discovery of the gonococcus by 
Neisser in 1879.” In their latest paper 5 StUHLER 
and his colleagues review the results of treating 
gonorrhea with the Kettering hypertherm during 
a period of nearly two years, and are able to say 
that of 76 patients who completed the treatment 
68 were cured and 7 were improved, while only 
1 failed to respond. The condition was in 36 cases 
an uncomplicated urethritis; in the remaining 
40 there was a complication in addition; but 
the infection never spread in consequence of 
treatment. Two-day intervals were allowed between 
sessions of fever therapy, and as a precautionary 


è? Bierman, W., Fra Levenson, C.: Amer. Jour. Med. Sci., 


January, 1936, p 
*S5tuhler, L. GP: : Proc. Staff Meot: Mayo Clinic, 1935, X., 207. 
è Desjardins, ‘A. U., Stubler, L. G., and Popp, W. OR Jour. 


Amer. Med. Assoc., Feb. 29th, 1936, p. 690. 


THE LANCET] 


measure the treatment was always twice repeated 
after the signs and symptoms had disappeared ; 


but most of the patients required only five or six 


sessions for cure. Better results were obtained 
as technique improved and these latest data in 
no way modify the optimism of earlier reports. 
If the claims put forward are justified—if means 
can really be found to reduce the weeks of mental 
stress, incapacity, and danger associated with 
the acute stages of gonorrhea to days or even 
hours—then STUHLER’S words are certainly not 
an overstatement. Meanwhile in this country, 
so far as we know, there has not yet been any 
organised attempt at investigation on similar 
lines. An inquiry of this kind might well commend 
itself to public health authorities and those 
engaged in the systematic treatment of venereal 
diseases in clinics throughout the country. 


ACADEMIC FREEDOM 


WE print elsewhere (p. 739) Lord RuTHERFORD’S 
account of the work done by the Academic 
Assistance Council and of how it is proposed to 
carry on such part of the work as seems likely to 
require to be done in the future. 

The Academic Assistance Council consists of 
36 men and women eminent in various fields of 


scholarship and science; 13 of them are fellows | 


of the Royal Society (including the president 
and two past-presidents) and 6 are either members 
of the medical profession or research workers in 
the medical sciences. “ Intellectuals ” and “ pro- 
fessors”’ are sometimes accused of showing little 
ability in practical organisation ; the work done 
by this body of “ intellectuals ” is an instructive 
commentary upon that popular opinion. From 
the beginning they had to deal with a problem 
which stirred popular feeling, exciting generous 
and selfish emotions in about equal proportions. 
On the one hand a tale of cruelty and oppression 


ACADEMIC FREEDOM.—-MEASLES IN LONDON 


[maron 28, 1936 727 ` 


in foreign countries never fails to arouse sympathy. 
Less literary ability than was at the command 
of the Council would have produced a story fit 
to be adorned with headlines in the daily and 
evening press. It would have been a convenient 
safety valve for emotion, and, by wounding 
foreign susceptibilities, have postponed for ever 
any hope of reconciliation. On the other hand, 
the pecuniary rewards of learning and science in 
this country are not so abundant that the provision 
of opportunities for foreigners, who may be 
competitors for posts to which home-bred scholars 
looked forward, can be examined with complete 
impartiality. The dangers could have been 
avoided by the issue of completely colourless state- 
ments and emphasis upon the temporary character 
of much help given. The result would have been 
general indifference. The Council have had the 
wisdom and skill to avoid wholly the dangers 
without lapsing into a policy of mere hand-to- 
mouth charity. They have, without using language 
which could give reasonable offence to foreign 
governments or nationals, made plain the tragic 
circumstances of many who have deserved well 
of all who value intellectual liberty, and in their 
practical policy have given no grounds for local 
jealousy. An organisation has now been created 
fit to cope with the difficulties of the future and all 
will wish success to the proposal to put it upon a 
permanent basis. 

All will hope, not least the members of the 
Council, that the time will come when the interest 
of the Society for the Protection of Science and 
Learning will be purely historical. Unfortunately 
the state of the world holds little prospect that 
the hope will be realised in the near future, and 
we trust that the new society will be generously 
supported by members of a learned profession | 
which in its long history has too often suffered 
from the want of intellectual freedom. 


ANNOTATIONS 


MEASLES IN LONDON 

ATTENTION was drawn on p. 692 of our last issue 
to the rapid increase in the number of cases of 
measles under treatment in the fever hospitals 
of the London County Council. The total number of 
patients in the measles wards is now over 3000. 
During the week ended March 24th 964 fresh cases of 
measles were admitted, and on one day (March 23rd) 
as many as 178 cases. The number under treat- 
ment at one time has not yet reached the maximum 


of the last epidemic when, on a day in April, 1934, ~ 


3696 measles patients were being cared for in these 
hospitals. In that epidemic, notable prevalence, as 
reflected in the occupied beds, commenced a fortnight 
earlier than upon this occasion, and although the 
epidemic must be approaching its climax, it is not 
possible to say that this has in fact been reached. 
The later start is all to the good, because it implies 
more favourable seasonal conditions during the phase 
of maximum prevalence ; we learn that the incidence 
of broncho-pneumonia is not notably high, and that 
in this respect the epidemic compares well with the 
last. In 1933-34, concurrently with measles, diph- 
theria and scarlet fever were also very prevalent. 
There is at the present time no undue prevalence of 


these other common infections of childhood, and this 
is fortunate because, although the London County’ 
Council possess ample reserves of accommodation, 
there is a shortage of nursing and domestic personnel. 
Now that the need for temporary additional assistance 
has been made known in the press it will doubtless 
be met, although this authority is not alone in 
experiencing difficulty in obtaining nursing and 
domestic staff at the present time. 


VITAMIN B, BY INJECTION IN TREATMENT OF 
NERVOUS DISEASES 


AT a meeting of the Edinburgh Pathological Club 
last week Dr. W. Ritchie Russell read a paper! on 
the parenteral administration of vitamin B, in poly- 
neuritis and other conditions. He obtained supplies 
of the vitamin from Messrs. Hoffmann-La Roche for 
clinical trial and used them in the treatment of 
diseases in which there was evidence of degeneration 
of the peripheral nerves. Cases of chronic progressive 
polyneuritis, alcoholic neuritis, and subacute com- 
bined degeneration of the cord were treated. All 
of them showed peripheral sensory loss of the glove 


1To appear in May issue of the Edinburgh Medical Journal. 


728 THE LANOET] 


and stocking type, and Dr. Russell found that 
injection was followed within a day or two by 
shrinkage of the area of sensory loss. As the treat- 
ment was continued the anesthesia and weakness in 
the limbs quickly diminished, and he believes that 
the improvement occurring rapidly in the nerves 
that were least degenerated is similar to the rapid 
recovery obtained by injecting the vitamin in animals 
suffering from B,-deficiency. The longer nerves, 
which are severely degenerated, can of course recover 
only gradually. In some of the cases reported the 
patients had been taking vitamin B, by the mouth 
previously without any good effect, and the striking 
improvement after parenteral administration suggests 
that in such persons the vitamin is destroyed in the 
alimentary canal or is for some other reason not 
absorbed. The two advantages of injection to 
which Dr. Russell drew attention are (1) that it 
overcomes this possible ‘‘ conditioned deficiency ” 
due to failure in absorption, and (2) that it produces 
a quick response which is of value in diagnosis 
because it demonstrates that the patient is really 
suffering from a lack of the vitamin. Anorexia of 
long standing sometimes responded to a single dose. 


INCAPACITY AND LIGHT WORK 


THE insurance doctor is constantly called on to 
decide when a patient who has been in receipt of 
sickness or disablement benefit should no longer 
be certified as incapable of work. It would of course 
be impracticable to place upon the expression 
“incapable of work ” so narrow a construction as 
total inability to carry out any of the physical or 
mental processes that constitute work, and in the 
handbook for the guidance of approved societies 
the advice is given that an insured person should 
properly be regarded as satisfying the statutory 
condition of being ‘‘incapable of work ” if he is in 
such a condition, through some specific disease 
or bodily or mental disablement, that an attempt 
to work would be seriously prejudicial to his health. 
Further, although a person who is admittedly unable 
for the time being to follow his ordinary occupation 
may not necessarily be rendered unfit for some other 
and less exacting form of work, he may properly be 
regarded as incapable of work if it appears probable 
that he will soon be able to resume his former work, 
and it would therefore be unreasonable to expect 
-him to undertake any other form of work in the mean- 
time. But if it becomes clear in the course of the 
illness that there is no reasonable prospect of his 
becoming fit for his ordinary occupation the society 
are advised to consider whether the man’s physical 
and mental condition is such that he is capable of 
performing other remunerative work of such a 
character as a man of his training, education, and 
experience could reasonably be expected to under- 
take. If the man (or woman) can be so regarded 
benefit should not continue to be paid after the 
insured person has had a reasonable time in which 
to adapt himself for a new form of employment. 

Here enters the problem of “light work.” It 
is one thing to say the insured person is fit for light 
work, but it is another thing for him to be able to 
obtain it. And, as Dr. J. P. Steel points out in 
relation to compensation cases, the difficulty is greater 
when the labour market is overstocked. At the last 
panel conference the Insurance Acts Committee 
put forward a recommendation that where an insured 
person is considered by his doctor to be fit for work, 
but not fit for his former occupation, the doctor 
might give an indication to this effect in his next 
certificate by the insertion in the remarks column 


INCAPACITY AND LIGHT WORK 


‘pituitary extracts. 


— 


[MARCH 28, 1936 


of the words ‘‘(?) alternative employment.’ It 
had previously been proposed that when a patient 
was likely to be fit for some employment but was not 
likely ever, or for a long period, to resume his previous 


‘occupation, this fact might be indicated to the 


society in the form of an inquiry as to what action the 
society proposed to take in the particular case. This 
was regarded as open to objection as a possible 
infringement of professional secrecy. One difficulty 
in dealing with this type of case is that, when an 
insured person is permanently incapacitated for his 
ordinary work although no longer completely dis- 
abled, certain approved societies are apt to stop 
payment of benefit the moment the practitioner 
indicates his fitness for some kind of work. Other 
societies willing enough to deal with cases more 
liberally are met with the difficulty that in many 
areas there may be no alternative employment. An 
entry on a certificate, as was remarked at the 
conference, does not turn:‘a blacksmith into a waiter. 
Dr. Steel is dealing specially with persons in the 
transitionary stages between incapacity following 
an accident and complete recovery therefrom. But 
the provision of light work, or of alternative employ- 
ment, is common to both problems. 


REPEATED ABORTION 


DURING the luteal phase of the ovarian cycle the 
uterine muscle loses its spontaneous contractility 
and becomes relatively insensitive to posterior 
From this it is deduced that the 
corpus luteum maintains the uterine quiescence 
that is essential for retention of the developing 
embryo during early pregnancy. Assuming that 
habitual and threatened abortion sometimes results 
from undue uterine motility various workers! have 
advocated the prophylactic or therapeutic use of 
the corpus luteum hormone progestin in such cases. 
Tinding that 1 rabbit unit of progestin can inhibit 
human uterine contractions on the seventh day 
post partum, Falls, Lackner, and Krohn ? have been 
giving l rabbit unit twice daily in cases of threatened 
abortion until the symptoms subsided or the patient 
aborted, and a similar dose twice weekly from the 
time of diagnosis of pregnancy until the 32nd week 
in cases of habitual abortion. In a series of 41 cases 
they report only 7 failures, and these results are in 
general agreement with those of other workers, 
though there is elsewhere a tendency to give more 
frequent doses, in the habitual abortion group, 
during the early months of pregnancy when this 
type of abortion is commonest. 

Despite the success claimed for this treatment, 
however, there may well be other factors—excluding 
such organic causes as syphilis—responsible for 
habitual abortion; and of these a deficiency of 
vitamin E is possibly the most important. Attention 
was first drawn to this stable, fat-soluble vitamin, 
present in high concentration in wheat-germ oil, 
by H. M. Evans and K. S. Bishop in 1922. Lack 
of this factor in the diet of male rats results in 
irreparable degeneration of the germinal epithelium 
of the testis ; in pregnant females it leads to death of 
the fœtus; and though in non-pregnant females no 
degenerative changes have been found in the ovaries 
such animals are said to suffer from a transient, 
relative sterility. The interesting observation has 
also been made, by Hill and Burdet in 1932, that 


Saeed 


1 Wolfsohn, H.: Med. Wolt., 1932, vi., 1616 ; Weinzierl, E. : 
Med. Klin., 1933, xxix., 563 ; Bishop, P. M. F., Cook, F., and 
Hampson, A. C.: THE LANCET, 1935, i., 139. 

3? Kalls, F. H., Lackner, J. E., and Krohn, L.: Jour. Amer, 
Med. Assoc., Jan. 25th, 1936, p. 271. 


THE LANCET] 


SCURVY: OVERT AND LATENT 


[marncH 28, 1936 729 


the ‘“‘royal jelly,” the food juice of the future queen 
bee, is an abundant source of vitamin E, whereas 
the food of the sterile working bee is lacking in it. 
In 1929, investigating the diets of 206 sterile women, 
D. Macomber found them lacking in fat-soluble 
factors, and ‘noted that when this deficiency was 
rectified 40 of the women became pregnant. In this 
country Dr. Evan Shute? has lately reported that 
the blood-sera of 70 per cent. of women aborting 
spontaneously displayed an abnormal resistance to 
proteolysis when exposed to tryptic solutions, and 
states that administration of vitamin E restored 
the normal proteolytic action of trypsin. In Canada 
Watson 4 has succeeded in bringing pregnancy to 
term in 75 per cent. of a series of 43 cases of threatened 
or habitual abortion by treatment with vitamin E. 
And others report similar experiences. 

What part this factor plays in the maintenance 
of pregnancy has not yet been explained. Apparently 
it has no direct influence on ovarian activity, for 
there are no demonstrable degenerative changes in 
the ovaries in its absence, nor, as has been shown by 
Saphir,® will it produce cornification of the vagina 
if injected into castrated adult rats, or activation 
of the ovaries of infantile rats, or luteinisation of 
the ovaries of infantile rats previously sensitised 
with a follicle-stimulating extract. On the other 
hand, by injecting into cestrous rabbits extracts 
derived from vitamin E-deficient pregnant and non- 
pregnant rats, Rowlands and Singer ê have shown 
that such extracts are less able to cause ovulation 
than pituitary extracts from normal rats. This 
suggests that vitamin E helps to maintain the normal 
activity of the corpus luteum during early pregnancy, 
not by direct action on the ovary, but by stimulating 
the gonadotropic function of the pituitary. If this 
is so, then the essential cause of habitual abortion 
is relative deficiency of the corpus luteum hormone— 
a deficiency which might be rectified either directly 
by injecting progestin or indirectly by giving vitamin E 
to encourage the pituitary to produce its luteinising 
factor, or by administering the luteinising hormone 
(prolan) of pregnancy urine. 


SCURVY: OVERT AND LATENT 


ADULT scurvy is so rarely seen in this country 
that there are few opportunities for its investigation. 
Such cases as occur are usually in food faddists or 
men living alone, and a typical example of the latter 
class is described by Drs. Archer and Graham in a paper 
we publish this week. The patient, an unemployed 
man, was living by himself on the tiny income of 
17s. 6d. a week. He budgeted very carefully, but 
his. total weekly expenditure on fruit, salads, and 
potatoes was only 4d. The potatoes were bought as 
chips and there was very little of them. Doubtless 
it was at this point that the “living alone” factor 
just tipped the scales; a larger amount of potatoes 
boiled at home would have saved the situation. 
The man was taken into St. Bartholomew’s Hospital 
where a diagnosis of undoubted scurvy was made, 
and, in the course of his treatment, his misfortune 
was turned to good scientific account, the urinary 
excretion of ascorbic acid, before and after treatment, 
being studied by means of titration. The excretion 
before treatment was low (6-18 mg. daily), and 
addition of a daily dose of 187 mg. of ascorbic acid 


3 Shute, E.: Jour. Obst. and Gyn. Brit. Emp., February, 


1936, p. 74. 
s Watson. E. M.: Canad. Med. Assoc. Jour., February, 1936, 
1 ry 


š Saphir, W.: Endocrinol., 1936, xx., 107.. 
* Rowlands, I. W., and Singer, E.: Jour. of Physiol., 1936, 
Ixxxvi., 323. 


as orange juice led to little rise in it during the next 
10 days. In other words the patient’s tissues were 
not yet ‘‘saturated.’’ After 17 days the dose was 
increased to 281 mg. and the result was an immediate 
Tise in excretion to 42mg.; by the 2lst it had 
exceeded 100 mg. Study of a second case confirmed 
these results and a comparison was also made with 
the values given by a healthy man eating plenty of 
fruit. The daily urinary excretion in the latter case 
was 40-50 mg., and administration of 400 mg. of 
ascorbic acid daily for 10 days produced an immediate 
rise in excretion to 262 mg. on the first day and to 
over 400 mg. on the second day—an excretion of 
over 90 per cent. In agreement with the results of 
this work is a study from the Vanderbilt University 
medical school in America. Here the subjects of 
investigation were not suffering from scurvy, but 
were consuming diets of very varying vitamin-C 
content. Some showed urinary excretion of under 
10 mg. daily and a number of under 20, while very 
few rose above 30. The percentage retention after a 
single large dose of about 600 mg. of ascorbic acid 
tended to vary inversely with the size of the previously 
observed urinary excretion, the majority retaining 
80 to 90 per cent. The only three subjects who 
retained less than 60 per cent. and who could be 
regarded as ‘‘ saturated ’’ were the only three showing 
a previous daily excretion of over 40mg. The 
contrast is very conspicuous, as illustrated by both 
these studies, and it is increasingly clear that know- 
ledge of the daily urinary excretion of ascorbic acid, 
and of the response to a large test dose of the vitamin, 
is a valuable diagnostic datum in latent or overt 
scurvy. 
MODERN VIEWS ON EVOLUTION 


THERE are many grades of opinion among biologists 
on the question of the mechanism of evolution, 
ranging from that of the neo-Lamarckians whose 
faith in the inheritance of acquired characters remains 
unshaken in spite of the paucity of evidence in its 
favour, to that of the gene mutationists whose theory 
has been erected upon an imposing mass of experi- 
mental evidence from genetics and cytology. Prof. 
Walker attempts,? in a recent publication, to reconcile 
conflicting points of view and facts which have 
hitherto been difficult to fit into a single theory. 
After disposing of the Lamarckian theories he ranges 
himself on the side of the selectionists, but denies 
the wide application of the chromosome theory of 
heredity. The most important characters of orga- 
nisms, he says, are not inherited alternatively and 
are therefore not borne on the chromosomes, which 
are responsible for the transmission of relatively 
insignificant features. The major characteristics 
must be represented in some other part of the cell. 


~The original suggestion is made that changes may 


originate in the chromosomes and later be impressed 
upon the rest of the cell. ‘‘ Mendelian ” characters 
are thus the recently acquired ones, while older 
and more basic characters are those which show 
‘ blending inheritance.” Prof. Walker is justifiably 
sceptical of the Mendelian explanation of blending 
inheritance by the postulation of a large number of 
factors, a procedure which could explain almost 
anything. He is not, however, always just to the 
opposing view, and has ignored recent work which 
tends to show that many ‘‘ Mendelian ” characters 
are only outward signs of more important physio- 


1 Youmans, J. B., Corlette, M. B., Akeroyd, J. H., and 
Frank, H.: Amer. Jour. Med. Sci., March, 1936, p. 319. 

* Evolution and Heredity. By Charles Edward Walker, D.Sc., 
M.R.C.S., Associate Professor of Cytology in the University of 
Liverpool. London: A. and C. Black Ltd. 1936. Pp. 222. 6s. 


| 


730 THE LANCET] 


logical characteristics, that the action of a gene is 
by no means fixed but depends upon the nature of 
the rest of the “‘ gene complex,” and that the chromo- 
some theory of sex determination can be reconciled 
(at least theoretically) with the occurrence of the 
sex reversal. Many of the difficulties in accepting 
the complete chromosome theory, particularly those 
derived from a study of the protozoa, are well stated 
in this monograph, which is, however, too discursive 
for easy reading. 

Dr. Hurst makes a contribution of a different 
kind. His book? is written in a lucid style and is 
so well planned that no one can fail to follow the 
arguments. The gene and mutation theories are 
clearly presented with no mention of any facts 
which might lead to confusion or to doubt that the 
theories as at present conceived may apply to all 
aspects of heredity and evolution. The origin of 
life in ‘‘ progenes ” is discussed in a manner which 
almost gives the impression that the matter has 
already been proved whatever may be meant by 
the term ‘‘progene.” That naturally occurring 
short-wave radiations give rise to mutations which 
are the basis of evolutionary change is suggested 
and later assumed in spite of much contrary evidence. 
This is a readable and entertaining book, but which 
might, however, mislead the ordinary reader by giving 
an impression that the basis of the mechanism of 
evolution is thoroughly understood, and that it is 
now only a matter of working out the details. 
Few biologists would claim such finality for the 
theories of to-day. 


THE PERCENTAGE OF OXYGEN IN OXYGEN 
TENTS 


In order to raise the oxygen-content of the 
atmosphere of an oxygen tent it is customary to 
begin by turning on the by-pass so as to obtain a 
brisk flow from the cylinder. When the required 
percentage has been reached the stream is adjusted so 
that it covers the relatively small amount used by 
the patient, and also the loss by leakage—which 
varies according to the airtightness of the tent. In 
many oxygen tents it is intended that the leak shall 
be sufficient to give egress to the carbon dioxide 
produced by the patient, making the use of soda- 
lime unnecessary. It is not practicable to blow away 
all the carbon dioxide in this way, for the loss of 
oxygen would be excessive ; but an accumulation up 
to 2 per cent. or more is often considered permissible. 
On the other hand, in the type of tent where soda- 
lime is used the absorption of carbon dioxide is so 
efficient, and the tent can be made so airtight, that 
the oxygen flow can be cut down to 3 or 2 or even 
14 litres per minute. Recently A. L. Barach ‘ has 
pointed to a possible disadvantage in the more open 
type of tent. He was called to see a child 9 years 
old in one of these tents suffering from broncho- 
pneumonia. The child was as “‘blue as a serge 
coat’’; the pulse-rate was 160 and the temperature 
108°F. The oxygen concentration in the tent was 
28 per cent. (the oxygen in the atmosphere being 
21 per cent.). Using a second cylinder Barach 
increased the oxygen flow by 32 litres a minute until 
the percentage rose to 60. The child’s colour immedi- 
ately began to improve, the pulse-rate came down to 
120, and the temperature gradually fell to 101°. 
The child, whose eyes had previously rolled upwards, 


3 Heredity and the Ascent of Man. By C. C. Hurst, Ph.D., 
Sc.D., sometime Fellow Commoner and Research Student of 
Trinity College, Cambridge. London: Cambridge University 
Press. 1935. Pp. 138. 3s. 6d. 

Jour. Amor. Med. Assoc., Feb. 29th, 1936, p. 725. 


THE PERCENTAGE OF OXYGEN IN OXYGEN TENTS 


[MARCH 28, 1936 


became conscious, and the breathing which had 
appeared terminal and very shallow took on a deeper 
and more vigorous character. In another hospital 
disappointment with oxygen therapy could be traced 
to the practice of giving 7 litres of oxygen a minute 
in a tent that “leaked like a sieve.” In three other 
instances in New York Barach found that a flow of 
30 to 40 litres was required to keep the concentration 
between 50 and 60 per cent. Somewhat similar 
observations in this country were described by 
Dr. E. P. Poulton in last week’s British Medical 
Journal. In a tent of the more open type he found 
that the maximum value was 35 per cent., and some- 
times a value as low as 25 per cent. was obtained. 

The problem remains whether the advantage of 
doing away with soda-lime is counterbalanced by the 
extra consumption of oxygen necessary or whether 
the certainty of being able to reach an adequate 
percentage of oxygen with quite a small flow is 
worth the expense of the soda-lime used. Barach 
inclines towards a large flow of oxygen (6 to 8 litres) 
and an increased leak, while Poulton has emphasised 
the value of an airtight tent with a small flow of 
oxygen and the addition of soda-lime. But both 
concur in the importance of analysing the atmosphere 
of the tent; and the practice of certain manu- 
facturers in saying that it is unnecessary to test 
the oxygen concentration if a certain flow (between 
12 and 7 litres) is run in, is to be condemned. 


TRIGEMINAL TIC 


Dr. Wilfred Harris’s experience! of the treatment 
of trigeminal neuralgia by alcoholic injection must be 
unique. He has notes of 1140 cases which he has 
treated in this way and has recently examined this 
material for the purpose of summarising some of the 
lessons to be learnt from it. He suggests that, in 
order to avoid confusion with other forms of facial 
neuralgia, the terms trigeminal tic and glosso- 
pharyngeal tic should be used for the paroxysmal 
form of neuralgia which affects these nerves. 
Analysis of the cases brings out the greater liability 
of the female sex to trigeminal tic, which Dr. Harris 
believes to be due to an irritative process at the 
periphery of the nerve concerned. Of the total 
number of cases, 748 occurred in women and 392 
in men. In 61 per cent. the mght side of the face 
was involved and in 39 per cent. the left side. Of 
the 60 bilateral cases (over 5 per cent. of the total) 
80 per cent. were in women. The author’s technique 
for the injection of the Gasserian ganglion is described 
in detail, and the importance of proceeding step by 
step, patiently waiting for the manifestation of 
the signs appropriate to each stage of the operation 
before going on to the next stage, is emphasised. 
Those who have watched Dr. Harris at work will 
remember that he prefers local anæsthesia in cases 
where the intelligent coöperation of the patient can 
be anticipated. Any motor paralysis which results 
from the injection generally passes off gradually after 
a period of three months, and even in bilateral cases 
there is little loss of the power of mastication. 
Dr. Harris’s method of injecting the inner two- 
thirds of the ganglion where it is unnecessary to 
destroy sensation over the distribution of the third 
division of the nerve is well worth noting; it must 
require .considerable practice before any operator 
can expect to achieve the same measure of success 
with this delicate manœuvre as its originator can 
claim. Since 1926, when Dr. Harris drew attention 
to the occurrence of trigeminal tic as a complication 


1 Ann, of Surg., 1936, ciii., 161. 


THE LANCET] 
of disseminated sclerosis, he has several times observed 
the occurrence of trigeminal tic and disseminated 
sclerosis in members of the same family. In some 
families there had been a familial tendency to 
trigeminal tic; in one no less than nine members 
in three generations suffered from the disease. 


PROLONGED ANALGESIA 


THE relief of intractable pain is always a major 
medical problem, and when the pain is chronic it is 
one that tests the resources of the practitioner to the 
utmost. Sometimes, of course, the pain depends on 
a local cause which is accessible to local remedies ; 
for instance, the pain folowing many rectal opera- 
tions is often of this description. Here much can be 
done by strict cleanliness at the actual operation to 
diminish the suffering which used to be regarded as 
an inevitable sequel to any operation on the rectum. 
Nevertheless, operations in this region are more often 
than not followed by pain, more or less severe, even 
to-day. Frequently opiates are employed to control 
it, but since the symptom is of purely local origin it 
ought if possible to be controlled by local measures. 
Some rectal operations are satisfactorily performed 
under local anesthetics, but the analgesic action of 
these is usually brief, and they cannot readily be 
applied again to the wound. A local analgesic with 
prolonged action would therefore be a great gain, 
but it is no easy task to find one which is both 
effective and innocuous. Quinine and urea chloride, 
for example, though excellent for its lasting effect, 
is liable to produce sloughing. N. J. Kilburne + 
describes the investigation, experimental as well as 
clinical, of a number of analgesics, with the object 
of finding one which could be used locally and could 
produce long-lasting effects. This he claims to have 
found in Eucupin, a modification of quinine hydro- 
chloride with urethane. This is also bactericidal, 
and is said both to relieve pain and keep down 
infection. It is applied by soaking cotton in a 0-75 
per cent. solution and pressing it into the wound. 
Kilburne’s experiments with oily substances have 
not led him to regard these with favour for prolonged 
action, but we believe that trials now in progress at 
a London hospital are giving more encouraging results. 


THE GOAL OF EUGENICS 


AN attempt to portray in simple but accurate 
language the main principles of eugenics and their 
application to social problems has been made by 
Mr. Huntington in conjunction with the directors of 
the American Eugenics Society. It is an outgrowth 
of an original report of a committee of the American 
Eugenics Society, prepared under the direction of 
Prof. Irving Fisher, and it is intended for intelligent 
people who make no claim to scientific knowledge 
concerning eugenics. Ina preface the author informs 
us that he has done his best to express the general 
sentiment of the group of directors as a whole, but 
modestly adds that he has doubtless given too much 
weight to his own views. It is questionable whether 
the book will be found of much service to medical 
readers. It is prepared in the form of a catechism 
containing 371- questions and answers. Many of 
these are worded in such a way as to apply primarily 
to American conditions. Much the most difficult 
task which to-day confronts writers on eugenics js to 
give a satisfactory account of the aims and methods 
of ‘‘positive’’ eugenics; of how, in other words, 


1 Surg., Gyn., and Obst., March, 1936, p. 590. 
3 To-morrow’s Children : The Goal of Eugenics. By Ellsworth 
Huntington. New York: John Wiley and Sons, Inc. ; London: 
Chapman and Hall Ltd. 1936. Pp. 139. 6s. 


THE GOAL OF EUGENICS.—ARTHUR SHADWELL 


‘biologically well-endowed. 


[maron 28, 1936 731 


to encourage the fertility of persons regarded as 
The fact having been 
noted that rural communities have a higher fertility 
than urban, American eugenists advocate a back-to- 
the-land movement which they hope may be 
organised on a sufficient scale to affect the country’s 
birth-rate. Such proposals are hardly applicable to 
this country. Like most eugenists, Mr. Hunt- 
ington is concerned lest schemes for promoting 
fertility should act dysgenically by encouraging the 
reproduction of biologically inferior strains at the 
expense of biologically superior. In this connexion 
the reader will frequently encounter throughout the 
book phrases such as a “ well-matured plan of eugenic 
selection ” or ‘‘ an adequate basis of selection ” which 
will enable us to distinguish eugenically superior from 
inferior stocks. A 372nd question which many medical 
readers would like to ask the author is whether 
anyone has yet devised a workable and scientifically 
valid scheme of eugenic selection applicable to the 
average citizen; and if not, why the American 
Eugenics Society does not try to do so. Most people 
admit that a small proportion of grossly unfit persons 
can be distinguished, of whom it can be definitely said 
that they should not become parents. But in view 
of the limitless variety of physical, moral, and mental 
qualities which combine to constitute good and bad 
citizenship, it is far from obvious how we are to 
recognise the person who embodies these various 
qualities in such a way as to enable us to regard him 
as representing a eugenically average type. If an 
average type cannot be recognised, how are we to 
devise well-matured plans, and establish adequate 
bases, of eugenic selection designed to encourage 
the fertility of persons above that average and to 
discourage that of persons below it ? 


ARTHUR SHADWELL 


THE death of Dr. Arthur Shadwell which occurred 
on Saturday last at a nursing-home at Richmond 
has removed from among us a distinguished authority 
on many social questions and an effective writer on 
social matters of the first importance. The son of 
a Yorkshire clergyman, he was educated at Uppingham 
where he acquired under Paul David a knowledge of 
and taste for music which never left him. He went 
to Oxford as an exhibitioner at Keble, was a student 
at St. Bartholomew’s Hospital, and having graduated 
in medicine practised for a time in Brighton, where 
he became assistant physician to the Sussex County 
Hospital. He proceeded to the Oxford M.D. and was 
elected F.R.C.P., but he soon retired from the active 
practice of his profession to use his academic and 
practical training to fine advantage in dealing with 
such great subjects as the temperance question, 
epidemiology, urban water-supplies—especially the 
London water-supply—the arguments for and against 
socialism, and the application of economics to political 
activities. As a special correspondent of the Times 
he made investigations into epidemics of cholera in 
Germany and Russia, and in 1909 he published under 
the title of Industrial Efficiency a large volume in 
which he recorded the results of his personal study of 
economic conditions in this country, on the Con- 
tinent, and in the United States, a work which gained 
him the degree of LL.D. Birmingham.. Ten years ago 
he wrote an excellent handbook entitled the Socialist 
Movement, in which he was able to display his first- 
hand familiarity with much of what he discussed, 
his singularly fair attitude of mind, and his wide 
acquaintance with social history. The FitzPatrick 
lectures delivered before the Royal College of 


132 


Physicians of London in 1925 and 1926 proved his 
classical learning. He was opposed to the State 
management of industry as advanced by the 
advocates of socialism, but he was able to give 
the authority for his arguments, either derived from 
his own work or that of others, and his appeals for 
reforms gained added force from his reasonableness. 
Through his long and distinguished connexion with 
the Times and the historic and literary value of his 
books, Shadwell became an authority in many 
provinces of political economy. If he wrote more 
as a philosopher than a doctor his medical training 
was always at the back of his arguments. 


THE POSITION OF CHIROPODY 


Tue prosperity of the Incorporated Society of 
Chiropodists was emphasised at the recent annual 
dinner of the society noticed in another column; and 
from the mouths of the speakers it could be gathered 
how wise the attitude of the medical profession had 
been in regarding the therapeutics of the foot as a 
definite branch of ancillary medicine which ought 
to be in the hands of an organised body of workers. 
When the movement for the recognition of chiropody 
in this manner first took shape many members of the 
medical profession viewed it with but qualified 
approval. But with the spread of scientific know- 
ledge a too exclusive attitude has long been found 
illogical. As medicine in the development of its own 
work has had to call for aid from other sciences, the 
necessity for proper coöperation in medical work 
with workers outside the professional roll became 
clear and the increasing importance attributed in 
the medical curriculum to the preliminary subjects 
may be mentioned in obvious proof. But the 
spirit thus shown in the scheme of general medical 
education has not stopped there but has ex- 
tended to various fields of practice, and the 
Society of Chiropodists forms a good example of 
this. When the movement for professional collabora- 
tion with the society originated there were found in 
opposition those who held that the absence of full 
medical training made professional union a dangerous 
course, but those who desired to see professional 
coöperation occur were able to counter by saying 
that as a matter of fact the fully qualified medical 
man had not, save in the instance of a few specialists, 
cultivated that field of therapeutics. The treatment 
of the foot, apart from definite surgical treatment, 
had been left to the charge of chiropodists and the 
advocates of proper collaboration held that it 
was a duty of the medical profession to assist the 
chiropodists to become an organised and standardised 
body, with whom regular medical consultation could 
take place. The liberal view was taken with the 
approval of the Royal Colleges and the British Medical 
Association, and the effect has been successful. The 
society, in association with its Foot Hospital, is doing 
valuable work and extending its activities throughout 
the country. 


A PANORAMA OF CURRENT THERAPEUTICS 


Tus week the first 35 articles of the series on 
treatment in general practice now running in the 
British Medical Journal have been issued together 
in the form of an attractive book.! The contributions 
include those on diseases of the respiratory tract (14), 
acute specific fevers (6), and cardiovascular diseases 
(15); the other group of articles published in 1935— 
referring to the nervous system—and those on the 


THE LANCET] 


Articles from the British 
1936. 


1 Treatment in General Practice. 
Medical Journal, London: H. K. Lewis and Co., Ltd. 
Pp. 250. 8s. 6d. 


THE POSITION OF CHIROPODY 


[marcu 28, 1936 


treatment of digestive disorders appearing this year 
week by week, with their successors, will be collected 
in subsequent volumes. The whole will form, as the 
editor of the British Medical Journal says in his 
preface, a panorama of current therapeutics, a com- 
posite picture of the art and science of medicine 
to-day none the less valuable because parts of it 
will need touching up and perhaps even repainting 
to-morrow. All the contributors are teachers of 
clinical medicine in various schools, and the practical 
simplicity of the methods of treatment outlined 
refutes once again the calumny that the outlook of 
the modern specialist is too academic or his arma- 
mentarium too dependent on diagnostic aids to make 
his advice of much use outside the great cities. At 
the same time some of the credit for the practical, 
even occasionally dogmatic, nature of the teaching 
is due to editorial vigilance. The volume is slender 
enough to be pleasant to handle and the type is 
easy to read. 


WE regret to learn the sudden death at Farncombe 
on Sunday last of Sir James Smith Whitaker, late 
senior medical officer to the Ministry of Health. 


Dr. A. Rupert Hallam, lecturer on dermatology in 
the University of Sheffield, has been appointed by 
the National Radium Trust to be a member of the 
Radium Commission, in succession to Sir Arthur 
Hall. 


THE Lister memorial lecture will be delivered by 
Sir Robert Muir, F.R.S., at the Royal College of 
Surgeons of England on Tuesday, April 7th, at 
5 o’clock. He will speak on malignancy with 
illustrations from the pathology of the mammal. 


THE SERVICES 


ROYAL NAVAL MEDICAL SERVICE 


Surg. Capt. E. MacEwan to Barham (on transfer of flag). 

Surg. Lt.-Comdr. J. H. Nicolson to Woolwich. 

Surg. Lt.-Comdr. (D.) L. R. Armstrong to Pembroke 
for R.N.B. 

Surg. Lts. J. G. Slimon to Challenger ; A. H. O'Malley 
Rad for R.N.B.; and C. J. Mullen to Pembroke for 

.N.B. 

Surg. Lt. (D.) R. S. Jenkins to Woolwich. 

The following have received appointments as Surg. Lts. 
for short service: B. M. Goldsworthy, St. Thomas’s 
Hospital; T. J. Harkin, Royal College of Surgeons in 
Ireland; M. G. H. Heugh, London Hospital; L. Merrill, 
Guy’s Hospital; E. H. Murchison, Glasgow University ; 
and G. A. Maxwell Smith, Edinburgh University. 


ROYAL NAVAL VOLUNTEER RESERVE 
Surg. Lt. S. C. Suggitt to Pembroke for R.N.B. 


ROYAL ARMY MEDICAL CORPS 
Lt.-Cols. E. G. R. Lithgow and P. C. Field retire on 


ret. pay. 
Majs. L. M. Routh and F. D. Annesley, M.C., 
to be Lt.-Cols. 


TERRITORIAL ARMY 
Supernumerary for service with O.T.C.—Lt. N. J. Logie 
(empld. Aberdeen Univ. Contgt. (Med. Unit), Sen. Div., 
O.T.C.) to be Capt. 
ROYAL AIR FORCE 


Group Capt. F. N. B. Smartt to Headquarters, R.A.F., 
Iraq, Hinaidi. 

Flying Offrs. A. S. Amsden to No. 3 Armament Training 
Cargp, Sutton Bridge, and H. E. Bellringer to No. 1 Arma- 
ment Training Camp, Catfoss. 

Dental Branch.—Flight Lt. W. D. Guyler to R.A.F. 
Record Office, Ruislip. Flying Offrs. I. St. C. Alderdice, 
O. F. Brown, J. H. G. Fensom, S. Hill, R. A. Pepper, 
and W. A. H. Smith to Medical Training Depôt, Halton, 
on appointment to non-permanent commissions, 


THE. LANCET | 


PROGNOSIS 


[Maron 28, 1936 733 


A Series of Signed Articles contributed by invitation 


XCIV.—PROGNOSIS IN FRACTURES OF 


THE OS CALCIS : 


A MAN who fractures his os calcis wants to know 
first how long it will be before it has recovered, and 
next, whether there will be any permanent disability. 
The prognosis in both respects depends primarily 
on two essential factors : early and accurate diagnosis 
and efficient treatment. The diagnosis may be 
obvious, as with a man who lands on his feet from 
a height and has great pain and broadening of his 
heel, but in other cases it may be overlooked unless 
an X rayistaken. Indeed an X ray is essential not 
only for diagnosis but for determining the exact 
variety of fracture. An ordinary but true lateral 
view sufficiently good to show up at least some details 
of the internal architecture of the bone must be 
obtained as well. as the special oblique posterior- 
superior view used for os calcis work. It is some- 
times only in the latter view that the fracture is 
recognisable. _ 

The notes and figures on prognosis set out below 
are based on the patients with fractures of 
the os calcis treated by the surgical staff at 


Weeks ; 
Cases.| of dis- Functional 


Type. 
ability result. 
1. Small fracture at anterior end of 6 13 G. 
i os calcis. 

2. Fracture of internal tuberosity. 4 10 G. 

3. Fracture of upper part of posterior 5 22 4G.,1F. 

surface (traction type). 

4. Fracture through the body of the 4 27 G. 
bone, which does not involve 
the subastragaloid joint. 

5. Fracture involving the sub- 13 32 6G.,6F., 
astragaloid joint but with little 1 B. 
or no displacement. 

6. Fracture involving the sub- 50 54 (21G.,18F., 
astragaloid joint with definite 11 B. 


displacement. 
G.=good; F.= fair; B.= bad. 


St. Bartholomew’s Hospital in the last ten years. 
The records of 82 fractures of this bone occurring 
in 72 patients have been examined. The fracture 
was bilateral in 9 patients, one of whom had 3 
fractures, the left os calcis being refractured 
some years later. All were males except 8; the 
average age was 42. In nearly all cases the injury 
was caused by the patient falling on his feet from a 
height, sometimes not great. Most fractures of 
the os calcis are due to compression of the bone as 
the patient lands on his heels, but the traction type 
(vide infra) occurs from the sudden pull of the tendo 
Achillis as the patient lands on his toes. 


It is probably well known that prognosis in fractures — 


of the os calcis is bad ; in fact for period of disable- 
ment and percentage of subsequent disability it 
ranks amongst the worst in the body. Although 
the os calcis is a small bone a number of different 
types of fracture are recognised, so many, in fact, as 
to make the nomenclature quite confusing. For 
the purpose of this article the use of as few sub- 
divisions as possible was contemplated, but six has 
been found to be the minimal number which suffices 
(see Table). 


and still later 


the foot, which is 


As these cases were spread over a period of about 
ten years several methods of treatment were employed. 
In many of the earlier cases either no splintage was 
used or else a wooden back splint for two or three 
weeks was followed by massage and movements. 
In later cases the foot was fixed in plaster for from 
4 to 6 weeks; | 


for 10 or 12 
weeks. More re- 
cently in cases 
where there has 
been deformity 
of the bone and 
the  subastra- 
galoid joint has 
been involved 
an effort has 
been made to 
correct the dis- 
placement 
mechanically 
by pulling the 
posterior part of the bone downwards and backwards 
by a calliper fixed in the posterior part of the bone 
and attached to the well-known Böhler’s traction 
apparatus; at the same time the bone has been 
compressed by a clamp, and the foot then immobilised 
in plaster. In four cases a subastragaloid arthrodesis 
had been performed. : 

As has been indicated above, the patient is 
concerned with the chances of permanent deformity 
of the foot and with the economic results likely to 
ensue. The latter are of the utmost importance to 
the working man. To estimate the economic results 
of these fractures we must look not to X rays to 
see whether perfect anatomical alignment of the 
fragments has been obtained but to the patient 
himself to find out whether he has pain or disability, 
when he was able to return to his previous work, and 
whether indeed he has not been permanently dis- 
abled. Of the 82 cases in this series the present 
condition of 52 
has been ascer- 
tained. The re- 
sults have been 
analysed to re- 
veal: (1) the 
length of time 
before work could 
be recommenced ; 
(2) the functional 
result as regards 


FIG. 1.—Types 1, 3, and 4 of fractures of 
the os calcis are here indicated. The 
normal ‘‘ tuberosity-joint angle ’’ formed 
between two lines, one from the highest 
point to the anterior angle and the other 
from the highest point to the upper 
Pore of the tuberosity (Böhler), is 
shown. 


FIG. 2.—Type 6, fracture of os calcis 
showing compression with flattening 
as indicated by complete loss of 


arbitrarily divided 


o “ tuberosity-joint angle ” so that all 
into good ; (G.), three points are in a straight line 
fair (F.), and (cf. Fig. 1). The heel is very short. 
bad (B.). In the 


Table, the average period of disability before 
work could be recommenced is given in weeks 
for each type of fracture, followed by a note of the 
functional result. These results clearly show how | 
closely the prognosis is linked up with the involve- 
ment of the subastragaloid joint. Where the joint 
was not involved good results were obtained, but 
of the patients in groups 5 and 6, less than half had 
good functional results and where there was also 
displacement of fragments a fifth had really bad 


734 THE LANCET] 
results, some being unable to do any work, others 
being capable only of light work and all having 
persistent pain. An arthritis in the subastragaloid 
joint seems to be the cause of the pain; the patient 
describes it as being on either side of the heel and 
indicates points where the pain is worst an inch below 
the malleoli on each side. In the first few weeks after 
a fall on the heel a patient may complain of severe 
pain under the heel when he bears any weight on it, 
but this is relatively transient and the persistent 
pain is at the sides, more particularly the outer side. 

The prognosis thus depends to a great extent 
on the type of fracture, but there are several other 
factors which must be taken into consideration. 
Amongst these are the method of treatment under- 
taken, the age and weight of the patient, whether 
he has a tendency to “rheumatism,” and last but 
by no means least his mental outlook. The last 
is a major consideration in determining recovery after 
any fracture, and in those, like that of the os calcis 
cases, which involve a long convalescence it is a 
most important factor. The patient who has no 
question of compensation to brood over, has his 
own business to return to (and the sooner the better 
for him), who expects and is prepared to put up 
with some pain and inconvenience, and above all 
has an optimistic temperament, will recover far 
quicker than one without such advantages. Often 
one can judge from the light-hearted and stoical bearing 
of a patient when first seen that he will return to 
work as soon as he is allowed, while another in similar 
plight may drag on gloomily with pain for weeks, 
perhaps suffering not only from severe pain but also 
from ‘‘ compensitis.”’ 

Recovery from any fracture is usually slower in 
the aged than the young, but age is a less important 
factor in os calcis fractures than is weight. It is 
hardly to be wondered at, if we consider the position 
of the os calcis, that the thin short subject makes a 
quicker recovery than does the heavy one. 

Persons prone to ‘‘rheumatism’”’ are more likely 
to get stiffness, pain, and arthritic changes following 
any injury than are others. 

As to the effect of treatment in our series the final 
result bears no constant relation to the method of 
treatment employed. Some patients who had but 
three or four weeks on a back splint had better 
functional results and less pain than those immobilised 
for aS many weeks in plaster, though mostly the 
advantage seems to be in the other direction. So 
many methods are advised for os calcis fractures that 
it is clear that none is entirely satisfactory ; but the 
one point in treatment that does appear to influence 
the result favourably is a reconstruction of the shape 
of an os calcis which has been crushed. There are 
several methods of traction and compression in use 
for this purpose. But it remains true that two 
patients with similar fractures and similar treatment 
may end up with very different functional results. 

A prognosis which may seem hopeless, when the 
os calcis is badly comminuted and deformed and the 
patient continues to have pain and disability, may be 
improved if an arthrodesis to fix the joint between the 
os calcis and astragalus, and perhaps cuboid as well, 
is performed. Two minor points deserve considera- 
tion. In some fractures of the os calcis the bone 
is not only compressed. but is considerably shortened 
in its antero-posterior length. This diminishes the 
leverage on which the tendo Achillis works and so 
gives a certain feeling of weakness to the patient, but 
should not prevent him from doing his work. In 
certain very severe cases, where the os calcis is not 
only greatly comminuted and compressed but the 


PROGNOSIS IN FRACTURES OF THE OS CALCIS 


[MaROH 28, 1936 


surrounding bones are also injured, the functional 
result may be excellent ; what really happens is that 
the os calcis and astragalus unite by bony union, 
and instead of a painful arthritis the patient has a 
painless solid joint. It is true that the foot may 
not be a very good shape, but this is a small price for 
a working man to pay for freedom from pain. 

In conclusion it must be realised when the sub- 
astragaloid joint is involved by the fracture there 
will be little movement in this joint, although the 
patient may have a good result so far as freedom 
from pain and ability to work are concerned. The 
movements of flexion and extension at the ankle- 
joint are of course unaffected, but inversion and 
eversion of the foot are very limited and the patient 
finds difficulty in walking over rough ground or on 
the side of a hill. 


SUMMARY 


The prognosis of fractures of the os calcis is 
considered after a study of the results in a series of 
82 cases. The results depend largely on whether the 
subastragaloid joint is involved. Prognosis also 
depends to some extent on the age, weight, and mental 
outlook of the patient and on the method of treat- 
ment employed. Those patients with fractures of 
the os calcis which do not involve the subastragaloid 
joint may expect to have a foot free from pain and 
to be able to return to work in three to six months. 
In those in whom the joint is involved the period of 
disability is likely to be on an average one year or 
longer ; many of these will have permanent pain and 
few may expect a good result. 


JOHN P. HosForpD, M.S., F.R.C.S., 


Temporary Assistant Director, Surgical Professorial 
Unit, St. Bartholomew’s Hospital, London. 


INFECTIOUS DISEASE 


IN ENGLAND AND WALES DURING THE WEEK ENDED 
MARCH 14TH, 1936 


Notifications.—The following cases of infectious 
disease were notified during the week: Small-pox, O ; 
scarlet fever, 2344; diphtheria, 1153; enteric fever, 
13; acute pneumonia (primary or influenzal), 1383 ; 
puerperal fever, 37 ; puerperal pyrexia, 117 ; cerebro- 
spinal fever, 24; acute poliomyelitis, 5; encepha- 
litis lethargica, 6; dysentery, 39; ophthalmia 
neonatorum, 101. No case of cholera, plague, or 
typhus fever was notified during the week, 

The number of cases in the Infectious Hospitals of the London 
County Council on March 20th was 5982, which included — 
Scarlet fever, 664 ; diphtheria, 1050 ; measles, 2798 ; whooping- 
cough, 712; puerperal fever, 21 mothers (plus 13 babies); 
encephalitis lethargica, 283 ; poliomyelitis, 5. At St. Margaret’s 
Hospital there were 21 babies (plus 13 mothers) with ophthalmia 
neonatorum. 


Deaths.—In 121 great towns, including London, 
there was no death from small-pox, 2 (1) from enteric 
fever, 106 (39) from measles, 5 (1) from scarlet fever, 
33 (5) from whooping-cough, 30 (5) from diphtheria, 
57 (17) from diarrhoea and enteritis under two years, 
and 84 (9) from influenza. The figures in parentheses 
are those for London itself. 

The mortality from measles is still rising, the figures for the 
last six weeks (working backwards) being 105, 84, 88, 78, 58, 34 
for the country as a whole, and 58, 47, 38, 18, 14, 13 for Greater 
London. Leeds reported 7 deaths, Manchester, Salford, and 
Shetticld each 4, Liverpool, Wallasey, West Hartlepool each 3, 
no other great town more than 2. Deaths from influenza 
are on the wane; this week they are scattered over 46 greut. 
towns, Manchester and Birmingham each reporting 5, Shemeld 
and Leicester each 4. Birmingham reported 5 deaths from 
whooping-cough. Deaths from diphtheria were reported from 
21 great towns, 3 from Manchester. West Hartlepool reported 
a death from enteric fever. 


The number of stillbirths notified during the week 
was 266 (corresponding to a rate of 39 per 1000 total 
births), including 37 in London, 


THE LANCET] 


[marca 28, 1936 735 


SPECIAL ARTICLES 


COMPENSATION AND THE RETURN 
TO WORK 


By Joun P. STEEL, M.D. Edin. 


MEDIOAL SUPERINTENDENT, SMITHDOWN ROAD HOSPITAL, 
LIVERPOOL 


WHEN compensation cases are referred for a 
definite opinion on the fitness of workmen for 
resumption of duty, a certain difficulty frequently 
arises in giving a report. Such cases divide them- 
selves into three categories : 


(a) Those who are fit and those unfit for work. 

(b) Those where there is doubt about the extent of the 
result of the injury. 

(c) Those suspected of endeavouring to obtain the 
greatest benefit for themselves as a result of the accident, 
irrespective of capacity for work. 


With those classified under (a) there is no difficulty, 
and an honest certificate can immediately be given, 
but those under (b) cannot readily be divided from 
the cases which are considered in the dubious category 
of (c). It is not fair to the patient to make a 
sharp dividing line between the doubtful case and the 
case considered to be the equivalent of a malingerer, 
without a very close investigation, not only of the 
sociological and physical state, but also of the mental 
attitude of the patient. 

When industry is at its height and there is 
little unemployment, these compensation cases are 
fairly simple, for the employer is only too pleased 
to have back a trusted man who is able to do some 
work for him, and he is willing and able to put 
profitable work (profitable to both the employer and 
the employee) into the way of a man who has had, 
and is returning from, an accident. But when the 
labour market is overstocked the large employer 
is able to call on any number of men to do the full 
work of the injured man at the same rate of wage. 
The economic factor governing a large business tells the 
employer to take on a man who can do a full day’s 
work for a full day’s pay, and he has to be content, 
therefore, to have the work done and to pay (or have 
paid by his insurance company) the man injured in 
his service at the reasonable rate of compensation 
laid down by the exigencies of the circumstances. 
In other words, when the labour market is glutted no 
employer (or at any rate very few) is able to offer 
what is commonly known as light work. This lack 
of “light work ” is prone to weigh hardly on the 
honest employee who has suffered an accident, and 
has been paid compensation, on behalf of his employer. 
Let ine quote two cases : 


(1) A man working at the docks, who had a good 
reputation with his employers and with his fellow work- 
men as a man who did all he could for his wages, received 
a crack fracture of his right tibia when a sack fell from 
a crane at the side of a ship he was loading. The fracture 
was treated in the routine way and he had a considerable 
period off duty, receiving the full amount of compensation 
he was entitled to. When this had to be reviewed, he 
was referred for special examination and no gross damage 
was found. 

(2) A man, whose duty it was to climb a ladder of 30 to 
50 feet, one day fell, through no fault of his own, and 
received a somewhat severe jarring, with but little to 
show for his accident. He, in turn, having been injured 
at work, received the full amount of compensation. 


Both of these cases were referred for examination, 
and in each the same difficulty arose. Whilst no 


crippling pathological condition could be found, yet 
there was a definite feeling that the patient was not 
able to take up his ordinary avocation. Ifa certificate 
had to be given on the present state of the workman, 
it would havé had to be honestly stated that there 
was no apparent or ascertainable physical disablement, 
but, nevertheless, it was quite obvious that neither 
man was able. to leave the hospital and start work— 
full work that is to say—the following morning. 
Both were more than anxious to get off the compensa- 
tion period and to earn full wages, for both had 
dependants relying on them. In neither case, 
however, did it seem fair to run the risk of putting 
them at once to the ordinary hazard of their occupa- 
tion, and a report had to be given saying that they 
were not fit for their ordinary duties, even though 
they wished to resume. 

One difficulty in these cases is the complete lack 
of “ light work.” Ifa man has had an arm in plaster 
for seven weeks and has had repeated X rays showing 
the fracture of a bone and the gradual process of 
repair, the doctor is not able to take off the plaster 
and say “‘ that arm is completely healed, there is now 
no fracture, and work can be started at once.” He 
says “‘a certain amount of re-education of muscle 
and nerve is necessary °” and recommends the use of 
the arm and the hand in increasing amount until 
normality is reached—in other words, a period of 
re-education. In more prosperous times such a 
workman who has been under compensation could 
be referred to light work which acted as re-education, 
but when the labour market is overstocked this is 
well-nigh impossible. The referee must then make 
up his mind whether those in ‘category (b) and (c) 
are, in the industrial sense, completely recovered 
or only partially recovered. For the major injury 
he has to take into account not only the physical 
disability which has been recovered from, but the 
psychological trauma. It is not reasonable to expect 
a man who is a window cleaner by trade to go from 
hospital (when all his abrasions and bruises are 
healed and he has had a few days convalescence) 
back to the work which caused his disability. There 
is bound to be some psychological shock, and the 
fear (say) of a repetition of his fall is liable to make his 
work such that he may fall again. - 

In cases coming under category (c) the referee 
cannot say at once, or even after considerable thought, 
that a man is “‘ swinging the lead,” for of all dangerous 
diagnoses malingering is the one which takes the 
most substantiating. Where there is any possible 
doubt—and the case of the workman must be 
considered as of primary importance for his labour 
is all he has to sell—a full assessment of physical 
state, mental ability, and mental retardation or 
apprehension due to the accident must be made. 
In these circumstances it does not seem reasonable 
to ask a physician or a surgeon to give a final report 
on the desirability of terminating compensation 
on his own single responsibility. 

Where there is the slightest doubt in my mind as 
to the desirability of re-education I have always 
endeavoured to have the man retained on compensa- 
tion for a sufficient length of time for his reference to, | 
and consideration by, a psychiatrist. I feel no loss 
of dignity in adopting this procedure, for not only 
is my opinion checked by a man who is a physician, 
but it is also considered by a practitioner who is able, 
and has the time, to assess the mental state and 
outlook of the injured man. I think that, before 


730 THE LANCET] 


the borderline case is put back to hard manual 
work at which he has suffered an accident and at 
which he has received psychological trauma, the 
opinion of an expert in psychological medicine should 
be obtained. In this way not only will justice be 
done to the injured man, but an additional safeguard 
will be offered to the employer against malingering. 
The opinion of the physician or surgeon, reinforced 
by that of the psychiatrist, will carry weight in any 
court of law. If “light work” is not available it 
would pay the large insurance companies to have a 
re-education centre for such cases, for in the good 
type of workman this re-education is essential before 
the full day’s work can be done for the full day’s pay. 


THE MATERNITY SERVICES 


A Manifesto by the British Medical 
Association 


UNDER the title An Urgent National Problem 
the British Medical Association has issued a reply to 
recent public statements about maternal mortality in 
Great Britain. ‘‘ Maternal mortality,” the Associa- 
tion has declared, “‘ is a scientific and administrative 
problem which deserves careful and scientific study, 
but, in the experience of practising doctors the 
publicity which it is receiving to-day is tending to 
terrify child-bearing women and is, in itself, a cause 
of increased mortality.” In the statement now issued 
the Association emphasises the fact that maternity 
is a natural physiological event, though it is one 
involving complex delicate and important processes. 
Departures from the normal occur in a small propor- 
tion of cases. The vast majority of cases are con- 


ducted with complete success in every respect, and,’ 


as demonstrated by comparable statistics, there is 
only one country in the world (Holland) in which 
safety appears to be slightly greater than in this 
country. In nearly every other country maternal 
mortality is considerably higher than it is here. 

Maternity and its conduct are not concerned merely 
with attendance during the actual process of delivery 
but comprise supervision from the time that changes 
consequent upon conception manifest themselves 
until the return to normal some short time after 
childbirth. This whole period cannot be isolated 
from the rest of the health history and experience 
of the mother whether before, during, or after the 
period of actual pregnancy and parturition ; it is an 
integral part of such medical help, advice, and treat- 
ment as the mother is accustomed to receive apart 
from maternity. All available evidence demonstrates 
that normal confinements, and those which show 
only minor departures from the normal, can be more 
safely conducted at home than in hospital. 

During recent years a number of authorities have 
established a type of antenatal clinic in charge of 
whole-time medical officers; they have provided an 
increasing number of hospital beds for maternity 
cases without careful selection of admissions on 
medical grounds, thus cutting off the local medical 
practitioners from a considerable part of their 
maternity experience. This action has been accom- 
panied by an appreciable increase in maternal 
mortality thereof. The Association points out that 
where a large number of maternity cases are aggregated 
in hospitals there is commonly an increased risk of 
puerperal infection; very disappointingly antenatal 
clinics, on their present lines, have not been and 
seem unlikely to be successful. These considerations 


THE MATERNITY SERVICES 


[MARCH 28, 1936 


are of the first importance when local authorities are 
considering communal action. 


The medical requirements of a woman during the 
period of maternity are these : 

1. Medical supervision throughout by the doctor of her 
choice, with specialist and hospital aids where needed. 

2. Efficient nursing and advice by a skilled midwife or 
maternity nurse of her choice. 

3. Provision of help in the house during the period of 
her actual incapacity. 

4. Supply of dressings, special apparatus, or means of 
transport when required. 


There are, of course, large numbers of women who can 
provide one or more or all of these requirements for 
themselves, but the Association is strongly of opinion 
that the State should see to it that, by some means 
or other, whether by an extension of the scheme of 
national health insurance or by the action of local 
health authorities, they should all be available for 
every mother. There would still remain urgent need 
for further action to persuade women to take advan- 
tage of the means provided for them, for research 
into the obscure causes of puerperal sepsis and other 
forms of maternal morbidity, and for the improve- 
ment of knowledge, skill, and care among those who 
have any part to play in the responsibility for the 
conduct of maternity. 

The statement concludes: ‘‘ Fully appreciative 
as it is of the great need for improving the position 
of midwives both as to training, status and finance, 
the Association believes that legislation to these ends 
is but a small part of that which is required to remedy 
the imperfections of the present system, and that it 
is essential to take steps in rapid succession to establish 
a complete maternity scheme on the lines indicated 
in this memorandum, envisaging from the outset the 
needs of mothers as a whole and the methods of 
providing for them.” 


Midwives and Their Views 


THE long delay in the appearance of the Midwives 
Bill after the promise of such a Bill had been made 
by the Minister of Health was due to the need to 
consult the local authorities which will have to 
administer its provisions. The interval has not been 
lost by organised midwives who have utilised it to 
find out more exactly what is the position of the 
midwife in independent practice at the present time. 
This investigation included the issue of a question- 
naire to all midwives believed to be in independent 
practice through England and Wales, and the 
abundant information thus accumulated was analysed 
for the Midwives’ Institute by Lady Forber (Dr. 
Janet Lane Claypon) with the help of Dr. Elizabeth 
Macrory. Lady Forber used a preliminary analysis 
of this material in the Fynes-Clinton lecture which 
was summarised in a leading article in our own 
columns (1935, ii., 1009). On the eve of publication 
of the Midwives Bill a considered report of this 
investigation has now been issued by the Institute in 
convenient pamphlet form.' 


THE MIDWIFE AS SHE IS 


The report is described by Miss E. M. Pye, president 
of the Institute, as a social document of importance ; 
she emphasises the fact that here is a true picture of 
the midwife’s life as she now lives it. Part I. gives 
the nearest estimate we have of the number of 
midwives in practice. Part II. sets out the causes 


1 The Midwife in Independent Practice To-day, pp. 32, 6d. 
(special prices for large quantities), from the Midwives’ Institute, 
57, Lower Belgrave-street, London, S.W.1. 


THE LANCET] 


which have adversely affected this practice. Here it 
is shown how deeply the increasing hospitalisation of 
parturient women (‘‘ which appears not yet to have 
reached its maximum ”) has cut into the midwife’s 
work. The greatest factor in the demand to be 
delivered in hospital is here found to be the campaign 
of publicity by which it was expected that maternal 
- mortality would be reduced. The belief has grown up 
among women that they are less liable in hospital 
than at home to succumb to the death which they 
are told may await them as a result of child-bearing ; 
this, it is suggested, carries with it a desire to have 
a doctor in case anytKing should go wrong and also 
probably to avoid pain by haying an anesthetic. 
Other factors of course are the saving of trouble 
and often of cost by confinement in hospital and the 
small space available for the purpose in modern 
flats. The fees charged by hospitals in many parts 
are so low that it is cheaper for the mother to go 
there than to stay at home for her confinement, 
although the actual cost in hospital must be much 
higher. In this section of the report the question 
naturally arises, What is the maternal death-rate in 
the practice of midwives? When in the past it has 
been shown that this death-rate is low, the statement 
has often been countered with the remark that the 
figures did not include the deaths of women sent in 
from the midwife’s practice to hospital. In the 
present investigation the cases sent into hospital are 
included and material is available for releasing the 
independent midwife from any blame for the alleged 
high maternal mortality. In this section also is a 
note on “undercutting and overlapping ° in which 
the great increase of midwives starting practice is 
attributed to the large number of unnecessary mid- 
wives who are being trained. Here it is stated that 
in a large number of areas the handy-woman is still 
sufficiently prevalent to be a source of trouble. If 
the midwife, and the midwife only, was required to 
notify the birth the presence of a handy-woman 
conducting the confinement would easily be discovered. 


A SALARIED SERVICE 


The report also estimates with care the number of 
midwives who would be needed for the proposed 
salaried service. Taking 100 births in the year as 
the number a midwife working whole time may be 
called upon to attend, it is suggested that just over 
2000 midwives would be needed in the large and 
small towns set out in the Registrar-General’s annual 
summary for 1934. The investigation indicates that 
the number of practising midwives now over 60 years 
of age is about 580 and that 1200 others under 
60 years of age will not be required. This does not 
include the rural or smaller urban areas, but in these 
there are few midwives with large practices, for most 
of the work is done by nursing associations, the 
practising midwives only taking relief work for the 
district nurses. In view of the probability that those 
displaced will be chiefly the older midwives, the report 
suggests that a small pension should be the form 
taken for compensation ; women over 50 years of age 
cannot start a new profession nor as a rule can they 
take up other work. The scale of pensions and com- 
pensation suggested should be studied in comparison 
with those proposed in the new Bill. 


QUESTION OF HIGHER TRAINING 


At this opportune time appears also an appeal for 
the higher training of midwives in a report? by the 
Council which for 31 years has furthered this object 
by every possible form of publicity and in so doing 


2 Woolwich : C. F. Thorn and Son, 60, Wellington-street, S.E. 


THE MATERNITY SERVICES 


[marcu 28, 1936 737 


has brought into being the British Hospital for 
Mothers and Babies at Woolwich from which highly 
trained midwives have gone out to all parts of this 
country and the dominions. 

“ Wo still greatly hope,” the report runs, “ that a two 
years’ training may be demanded by Government shortly, 
for all midwives whether State-registered or not. And 
as such a course would greatly diminish the numbers of 
pupils working now in maternity hospitals, we trust that 
their ranks may be recruited by State-registered nurses 
receiving a six months’ maternity nursing training in 
contradistinction to midwifery. This course which has 
been found to answer admirably in Holland has the further 
inestimable advantage of not interfering with the training 
of medical students. It is common knowledge that much 
of the training material, which is so urgently needed for 
their benefit and that of their future patients, is now 
absorbed by over 1500 pupil-midwives yearly who have 
not the faintest intention of using, on behalf of the working 
mothers or their infants, the experience they have gained.” 


MIDWIVES AND/OR MATERNITY NURSES 


The annual report of the British Hospital, just 
issued, contains an account of the midwifery service 
in Holland written by Dr. Eileen Wise, visiting 
obstetrician, and Miss M. M. Cashmore, sister-matron, 
who were asked to visit the State training schools for 
midwives in Amsterdam and Rotterdam. They 
discovered that trained maternity nurses, as apart 
from midwives, are an integral part of the Dutch 
midwifery service and to this fact is due, they think, 
in great measure the increased maternal safety. In 
Holland all operative midwifery is referred to well- 
equipped maternity hospitals, no obstetrician dealing 
with complicated cases at home. The midwives are 
State servants with a high status; the competitive 
entrance examination is only passed by a quarter of 
the candidates. The theoretical training is directed 
towards making the midwife capable of thinking. 
Her clinical training is extensive, simple, and prac- 
tical, and before its completion she acts as locum 
tenens for midwives absent from. their practices on 
refresher courses which take place monthly. The 
larger half of deliveries in Holland are attended by 
midwives, the remainder by doctors and maternity 
nurses. The latter are State-registered nurses who, 
on completion of their general training, have under- 
gone a further six months’ training in State maternity 
hospitals when they are State examined and 
registered. There is another class of maternity nurse 
with no general training but with 18 months’ training 
in State maternity schools, and these work among 
the poor under the district midwives. 


ROYAL SUSSEX County HosPITAL.—At the annual 
meeting of the governors on March llth ıt was 
reported that the ordinary income for 1935 fell short 
of the maintenance expenditure by £8344, and that 
the deficit had had to be met by drawing upon the 
limited reserve fund. In spite of the growth of the popu- 
lation of Sussex, and the increased demands made upon 
the services of the hospital, the income had fallen; and 
during the year in response to an urgent appeal to pro- 
vide and maintain at least another 100 beds, less than 
one-fifth of the money needed had been received. Com- 
menting on the Milk Marketing Board regulations the 
report states: “It is surely an anomaly that a child in 
health can be supplied with milk by the education authori- 
ties on better terms than hospital authorities can supply 
milk to that child when sick.” The governors regard 
the increased price of milk as being tantamount to a 
tax, and it is suggested that the rebate allowed to hospitals 
on the tax on certain spirits should be regarded as a 
precedent for granting relief on milk. The milk bill of 
this large hospital of 272 beds amounted in 1933 (the regu- 
lations came into force on Oct. Ist of that year) to £1467. 
This figure rose to £1588 in 1934 and to £1672 in 1935. 


738 THE LANCET] 


[marcu 28, 1936 


PANEL AND CONTRACT PRACTICE 


Prescriptions for which the Insured Person 
Must Pay 

IT sometimes happens that insurance practitioners 
are asked to issue prescriptions for patients who are 
receiving treatment at hospitals, possibly under 
arrangements made by the doctors concerned. 
Here is a case in point where the doctor received a 
telephone message from the almoner of a hospital 
asking him to issue a prescription for three Elastoplast 
bandages for a patient whose treatment at the 
hospital had involved the use of that number of 
bandages, the statement being made that unless the 
doctor would agree to do this the patient would be 
charged the value of the bandages. The doctor 
appealed for advice to the insurance committee and 
= was told that an insurance practitioner is called upon 
to prescribe for insured persons only during the time 
when he is actively engaged in treating them; his 
responsibility to prescribe ceases during the time the 
patient is in receipt of treatment by a member of a 
hospital medical staff. This point may not appear 
to be of much moment when the cost involved is but 
a few shillings, but a rather different complexion is 


assumed when an appliance such, for example, as- 


a spinal jacket is needed. This particular appliance 
may now be prescribed by insurance doctors when 
required for the treatment of fractures, diseases, 
or dislocations of the spine, and it seems illogical 
that an insured person should be at the risk of having 
to pay several pounds for an appliance ordered by 
a hospital surgeon which if it had been prescribed by 
his insurance doctor would have been provided 
free as part of medical benefit. The remedy would 
perhaps be for the surgeon, to whom the insurance 
doctor had referred the case, to inform the latter 
that the patient in his opinion needed the appliance, 
and for the insurance doctor in his discretion to order 
it on an insurance prescription. This’ procedure 
would follow very closely what happens when a 
member of a hospital staff advises a particular line 
of medical treatment, but would of course apply only 
to those out-patients who had attended the hospital 
on the advice of the insurance doctor. 


Ophthalmic Certificates 


Clause 9 (2) of the Terms of Service provides that 
if the condition of the patient is such as to require any 
ophthalmic treatment which is not within the scope 
of the practitioner’s obligations the practitioner, if 
so desired by the patient, shall furnish him with 
a signed recommendation that such treatment should 
be obtained. A man recently applied to his approved 
society for ophthalmic benefit and a letter was issued 
giving instructions as to procedure. He then went 
to his doctor and asked for a ‘* written recommenda- 
tion,” but as the doctor considered that his headaches 
were due to nasal catarrh—there was also slight 
conjunctivitis—treatment was given for the nasal 
condition, the doctor indicating that the question 
of possible ophthalmic treatment could be considered 
later. The patient did not return for further treat- 
ment but in due course the doctor received a letter 
from the society, reminding him of his obligation, 
stating that the society had been informed that he 
had declined to issue a recommendation for ophthalmic 
benefit as in his opinion glasses were not required, 
and asking quite nicely for a statement from the 
doctor as to the circumstances of the case. The 
doctor informed the society of his opinion, but was 
rather puzzled as to what obligation, if any, had been 


infringed. Clearly none at all, for the clause quoted 
above refers to the condition of the patient, and the 
mere fact that an insured person thinks he needs 
glasses, and obtains a letter from his society, cannot 
compel the doctor to give a written recommendation 
against his professional judgment. Societies who 
find the provision of ophthalmic benefit expensive 
will doubtless welcome the stand taken by this 
doctor, but it is rather hard that he should have to 
go to the trouble of explaining his quite proper 
action. 
Amputation of a Finger 


Referees appointed by the Ministry of Health 
pursuant to Article 43 (4) of the Medical Benefit 
Consolidated Regulations, 1928, have just issued the 
report of their inquiry which related to a question 
whether the amputation of the ring finger of the right 
hand at the metacarpo-phalangeal joint in the 
circumstances described is within the range of medical 
service. The operation in question was performed 
by Dr. X., an insurance doctor, on April 11th, 


1935, in the case of Miss Y., an insured person. 


Dr. X. practises in Cornwall, but there was not 
sufficient evidence before the referees of any custom 
or practice of the medical profession which is peculiar 
to the area in which this question arose, and accord- 
ingly in arriving at their decision they did not have 
regard to any such custom or practice. The inquiry 
was held at Truro on Jan. 21st, 1936. At the time of 
the operation the finger was useless, an X ray exami- 
nation having disclosed necrosis of the bone. The skin 
covering the proximal phalanx was healthy. The con- 
tentions put forward may be summarised as follows :— 


ON BEHALF OF THE INSURANCE COMMITTEE AND THE LOCAL 
MEDICAL COMMITTEE 

(1) That the clinical aspects of the case had to be taken 
into account. 

(2) That though there were no circumstances to add 
difficulty to the operation as a matter of technique by 
reason of the state of the hand the line of the incision 
required to be carefully determined so as to avoid the 
septic area, lest the sepsis should spread to the hand. 

(3) That there was a risk of secondary hemorrhage 
and that referees appointed under the medical benefit 
regulations had held, in the case of the removal of 
thrombosed and varicose veins in the leg with varicose 
ulcer, that operation was “‘ attended as it is incidentally 
by a considerable risk of secondary hemorrhage’? not 
within the range of medical service. 

(4) That therefore the operation in question in the 
circumstances of this case involved the application of 
special skill and experience of a degree or kind which 
general practitioners as a class cannot reasonably be 
expected to possess. 

ON BEHALF OF THE MINISTER OF HEALTH 

(1) That the operation in question did not involve the 
application of such special skill or experience as aforesaid. 

(2) That the difficulty of determining the line of the 
incision was not such as to demand in the circumstances 
of this case such special skill or experience as aforesaid. 

(3) That the risk of secondary hemorrhage in the hand 
was not comparable either in respect of its probability 
or difficulty of control to that risk in the leg and that 
therefore the decision of the referees in the case cited on 
behalf of the insurance committee was not an authority 
supporting that committee’s contention. 


Having considered the evidence submitted and 
the contentions summarised above, the referees 
accepted those of the Minister of Health and were 
satisfied that the operation in question did not involve 
the application of special skill and experience of a 
degree or kind which general practitioners as a class 
cannot reasonably be expected to possess. 


THE LANCET] 


PROTECTION OF SCIENCE AND LEARNING 
To the Editor of THE LANCET 


Sır, —The Academic Assistance Council was formed 
in May, 1933, to assist scholars and scientists who, 
on grounds of religion, race, or opinion, were unable 
to continue their work in their own country. Its 
services have been needed chiefly to help the 1300 
university teachers displaced in Germany, but it has 
also assisted refugee scholars from Russia, Portugal, 
and other countries. 


In coöperation with other organisations, the Council 
has assisted in permanently re-establishing 363 of 
the 700 displaced scholars who left Germany. A 
further 324 are still being temporarily maintained 
in universities and learned institutions while seeking 
more permanent positions. The Council has directly 
received over £46,000 in donations which, with the 
exception of the small amount used for paying fares 
of displaced scholars to positions overseas, adminis- 
trative expenses, and other incidental purposes, have 
been employed in subsidising research by our refugee 
guests. The Council, as the international centre for 
this work, has built up a place-finding organisation 
and information service which are proving of increasing 
usefulness. 

The Council hoped that its work might be required 
for only a temporary period, but is now convinced 
that there is need for a permanent body to assist 
scholars who are victims of political and religious 
persecutions. The devastation of the German univer- 
sities still continues ; not only university teachers of, 
Jewish descent, but many others who are regarded 
as “ politically unreliable ”? are being prevented from 
making their contribution to the common cause of 
scholarship. 

The Council has decided to establish as its per- 
manent successor a Society for the Protection of 
Science and Learning, which will continue the 
Council’s various forms of assistance to scholars of 
any country who, on grounds of religion, race, or 
Opinion, are unable to carry on the scientific work 
for which they are qualified. One function of the 
Society will be to build up an academic assistance 
fund to award research fellowships, tenable in the 
universities of Great Britain and other countries by 
the most distinguished of the refugee scholars. This 
fund will be administered under the auspices of His 
Grace the Archbishop of Canterbury, the president of 
the Royal Society, the president of the British 
Academy, Lord Horder, the Hon. R. H. Brand, 
and myself. 

I appeal confidently and urgently to all those who 
wish to assist in the defence of free learning and 
science to join the Society by paying a minimum 
annual subscription of one guinea. I hope that 
many will make a larger donation either to the Society 
or to the fund, or will undertake to covenant with 
the Society for a seven-year contribution, thus 
allowing us to recover income-tax on the donations. 
Gifts to the fund may be earmarked if desired for 
the establishment of particular fellowships or student- 
ships bearing the name of the donor. This appeal 
is made with the full coöperation of the organisers 
of the National Christian Appeal which is about to be 
made for the destitute non-Jewish refugees from 
Germany, since the Society will be giving assistance 
to only one section—namely, the scholars, among 
the German refugees, irrespective of their religious 


CORRESPONDENCE 


{manoH 28, 1936 739 


affiliations. It is therefore with confidence that I ask 
support from both the Christian and the Jewish 
world, and in particular from the university world, 
to place this most important part of the refugee work 
on a firm financial basis. 

Contributions and subscriptions should be sent to 
me at the offices of the Academic Assistance Council, 
12, Clement’s Inn-passage, Clare Market, W.C. 2, 
made payable to the ‘‘ Academic Assistance Council.” 

I am, Sir, yours faithfully, 
RUTHERFORD, 


President of the Academic Assistance 
March, 1936. Council. 


THE NUTRITION QUESTION 
To the Editor of THE LANCET 


Sir,—Dr. Hutchison omits an important point 
from his quotation from Dr. Friend’s ‘‘ The School- 
boy.” Dr. Friend says that “ probably a considerable 
proportion of the observed increase” (of septic 
conditions, since 1923) ‘‘is due to the fact that 
about that year the regulations as to sending boys 
to the infirmary were more strictly enforced, and 
treatment in the houses was no longer allowed.” 
Dr. Hutchison does not mention Dr. Friend’s most 
striking observation: that the attack-rate of frac- 
tures went up in a surprising manner during the 
period when the boys had vegetable margarine 
instead of butter, and fell promptly when butter 
was used again; surely satisfactory evidence of the 
protective action of this dairy product. Nor does 
Dr. Hutchison mention that during the period of war 
shortage, coincidentally with the physical regression, 
an increasing number of boys showed a disability 
to cope adequately with the normal school routine ; 
nor the fall in the incidence of acute and subacute 
rheumatism after the increase of fat in the diet. 
Surely if Dr. Friend’s very qualified evidence about 
septic conditions is worth quoting, his unqualified 
evidence on other points is worth quoting also. 
Strangely enough, Dr. Hutchison also omits the 
most convincing piece of evidence in support of his 
thesis—the increased frequency of complications of 
influenza since the boys have been on a more generous 
diet. 

Dr. Hutchison contradicts himself when he first 
ascribes lowered resistance to tuberculosis to a defi- 
ciency of fat in the diet, and later maintains that 
there is no proof that dairy products protect us 
against any of the great killing diseases. The fact 
that tuberculosis is declining may be evidence that 
the nutrition of the country is better than it was. 
But tuberculosis still kills about 30,000 a year; 
there is still much room for improvement. The 
death-rate from diabetes is only about one-fifth of 
this. Even if the increase in the prevalence of diabetes 
is due to an increase of over-eating, the choice before 
us is not between under-feeding with the danger of 
tuberculosis and over-eating with the danger of 
diabetes. There are such things as common sense 
and moderation. 

It is true that Dr. Spence says that, in his opinion, 
the main immediate cause of the apparent mal- 
nutrition of city children in Newcastle is the physical 
damage done by infective disease; but he also 
ascribes the failure of the children to recover equally 
to housing conditions and inadequate diet. Dr. 
Hutchison was a member of the committee appointed 
by the British Medical Association to determine the 
minimum expenditure on diet compatible with 


740 THE LANCET] 


health and working capacity. As the report of the 
committee was published without any reservations 
by Dr. Hutchison it may be assumed that he accepted 
their conclusions. The Newcastle report, in which 
Dr. Spence’s observations appear, and numerous 
other surveys show that a considerable proportion 
of families cannot afford, and actually do not get, 
diets up to the standard of this committee’s 
minimum. This applies particularly to families 
with young children. 
| I am, Sir, yours faithfully, 


Bishops Stortford, March 22nd. JOHN MARRACK. 


THE ZUND-BURGUET TREATMENT 
To the Editor of THE LANCET 


Str,—My attention has been drawn to Mr. Barwell’s 
assertion in his article on Prognosis in Deafness 
(THE LANCET, Jan. 25th, p. 214) that the results of 
the Zind-Burguet treatment “‘ appear to be evanes- 
cent.” As one who has had ten years’ uninterrupted 
experience of the electrophonoide method, I feel it 
incumbent on me vigorously to deny this aspersion 
upon what I firmly believe to be a valuable treatment 
when properly understood and properly applied. 
A quarter of a century ago, at an annual congress of 
the Société Française d’Oto-Rhino-Laryngologie, a 
lively discussion on this subject was closed unanswer- 
ably by a member with the words, “‘My dear 
colleagues, the outcome of this long discussion is 
that those who understand the method of Zünd- 
Burguet are favourable to it, while those who know 
nothing about it are unfavourable to it.” Apparently 
the situation to-day is exactly similar. 

Out of a record of some four hundred cases 
I would quote the following as examples of permanent 
improvement :— 

(1) A girl of 16, suffering from chronic catarrhal deaf- 
ness, who in three years has improved for the voice 
hearing from R. 8”, L. 18” to R. 78”, L. 240” and is thus 
able to earn her living as a typist. (2) A lady who, at 21, 
experionced an attack of unilateral subacute otitis which 
left her with a reduction of voice hearing in one ear to 24’, 
and a severe, increasing vertigo which incapacitated her 
for three years. She underwent fifty treatments, with the 
result that the vertigo disappeared after ten sittings 
and has never returned, and the hearing became normal. 
She has remained thus normal for a period of nine years 
and has become an ardent mountaineer. (3) A lady of 22 
with otosclerosis (so diagnosed by several otologists). 
Treatment in 1925 brought a voice hearing of R. 14’, 
L. 4” after fifty sittings to R. and L. 180”. She has kept 
touch with me and has not gone back. She is now earning 
her living as a teacher. (4) A lady of 29, also a case of 
otosclerosis. Whisper hearing in 1932 was R. 10”, L. 15”. 
In 1933 it had reached, under the electrophonoide treat- 
ment, R. and L. 240”, an improvement which has so far 
(1936) remained permanent. (5) A lady of 39, who became 
deaf in one ear from mumps in 1927. I was lucky enough 
to get her under treatment within a month of its onsct. 
This case was successful and the result has been retained. 
Details will be found in the Clinical Journal for Feb. 8th, 
1928. 


My results in cases of presbyacusis were published 
in your columns (1934, ii., 306) and speak for them- 
selves. The cases just quoted are but a very small 
tithe of examples of permanent successes that I have 
obtained. The two greatest factors in such results 
are perseverance and codperation on the part of both 
patient and surgeon. Some of my patients have 
obtained lasting results in a comparatively short 
time; others have done so only after two years. 
These essentials do not appear to be appreciated by 
those who have decried the Zind-Burguet method. 
I need hardly mention, in addition, that appropriate 


GASTRIC ACIDITY AND ITS SIGNIFICANCE 


[MARCH 28, 1936 


constitutional treatment is a necessary concomitant. 
This point I have endeavoured to make clear in my 
** Otosclerosis ’’ (London, 1933). 

I am, Sir, yours faithfully, 


Harley-street, W., March 19th. MACLEOD YEARSLEY. 


PROGNOSIS IN SPINAL CARIES 
To the Editor of THE LANCET 


Sir,—I am glad to read Sir Henry Gauvain’s 
elucidation of the points I raised. I feel that his 
letter forms a valuable addendum to what he had 
already written. At the same time I am sorry to 
note that the word ‘“‘discharged’’ is acquiring a 
double meaning. I am aware that in the services the 
letters D.D. are being used to designate fatalities, 
but in this case the outcome is specified by the 
qualification discharged dead. It was this word 
“ discharged ” that led me astray as I associate this 
word with the hospital’s designation for cases which 
have left the institution cured, relieved. or incurable. 
I am correcting the figures in my own copy of THE 
LANCET to read :— 


Period under review September, 1908, to March 
1935— 


dist, 


Case3 admitted . 1666 
Still under treatment ka T 84 
Discharged— 
Cured, relieved, incurable ae 1521 
Died in hospital .. ie F 61 
1666 1666 


I am, Sir, yours faithfully. 
Leeds, March 21st. S. D. Persy FISHER. 


GASTRIC ACIDITY AND ITS SIGNIFICANCE 
To the Editor of THE LANCET 


Sır —Dr. Hurst’s letter in your issue of Jan. 18th 
interests me much because Dr. Vanzant and I have 
recently studied the relations between hæmoglobin 
and gastric acidity in some 3500 persons with hæmo- 
globin readings ranging from 25 to 130 per cent. 
and no demonstrable disease in the stomach and 
duodenum. We have found that, as the hæmo- 
globin falls off below 75 per cent. mean gastric 
acidity decreases, and the incidence of achlorh ydria 
rises. 


While making this study we found records of dozens 
of atypical cases in which, in spite of the presence 


of a marked secondary anemia, the acidity was higher 


than normal. On examining these records we found 


that in most cases the probability was that the patient 
had an ulcer; the only reason why the diagnosis 


had not been made was that the roentgenologtist 


had not been able to see a lesion. We then examined 


dozens of records of patients with marked an:emia 


due definitely to bleeding from an ulcer and found 
in almost every case that the acidity was 10 to 
15 points above normal, instead of the 20 or 30 points 
below normal that was to be expected trom our 
experience with persons with severe hypochromie 
anemia and no ulcer. 

These observations can now be of great help to 
the physician who cannot find the cause of a severe 
secondary anwmia. If the gastric acidity is low, 
he should continue to search for perhaps a carcinoma 
of the stomach or cæcum or for bleeding hemorrhoids; 
but if the acidity is abnormally high, and especially 
if the patient gives a history suggestive of peptic 
ulcer, the physician can be almost certain that an 
ulcer is present, even if it cannot be visualised. As 


THE LANCET] 


PRURITUS OF THE VULVA AND ANUS 


[maRCH 28, 1936 741 


a corollary of this, when a markedly anemic patient 
comes with a diagnosis of duodenal ulcer but a low 
gastric acidity and perhaps few symptoms of ulcer, 
the clinician will do well to keep searching for the 
source of the bleeding because it probably is not in 
the duodenum. Actually, in several cases like this 
in which the search was continued at the Mayo Clinic, 
a bleeding lesion was found in the large bowel. 

On re-reading Dr. Hurst’s letter, one can easily 
understand now why 17 of his 41 anemic patients 
could have a high gastric acidity. Twenty-one were 
suffering with duodenal ulcer. All of which shows 
again that when two able observers disagree it is 
usually because their methods or their material were 
different or because some unrecognised extra factor 
was at. work.—I am, Sir, yours faithfully, 

WALTER C. ALVAREZ. 

Mayo Clinic, Rochester, Minnesota, March 10th. 


PRURITUS OF THE VULVA AND ANUS . 
To the Editor of THE LANCET 


Sir,—May I refer to several points raised by your 
appreciative and critical annotation on the subject 
of my papers in your issue of March 14th (p. 617). 
While it is true that the incidence of skin eruptions 
at any site may “‘ cause” the symptom of: pruritus 
at that site, until the «etiology of the skin eruptions 
is determined can any claim to have established the 
‘cause ° of their symptoms be upheld? The 
differentiation of the different types of skin eruptions 
in which irritation of the vulva is a prominent 
symptom, when the eruption occurs on the vulva, 
does not solve the etiology of these eruptions. The 
etiology of many eruptions is still unknown. I 
submit that generally the various types of skin 
eruptions which occur on the vulva are not 
differentiated, but that they are merely classified 
under their most prominent symptom and are called 
‘< pruritus vulve.”’ 

Your annotation expresses surprise at the infre- 
quency of ringworm. Scrapings from suspected 
cases were in fact negative, and, if results of treat- 
ment can be regarded as diagnostic, cure was obtained 
without the use of fungicides. In regard to the 
absence from my lst of pruritus of “a menopausal 
or endocrine ” origin, does not such a diagnosis 
involve the assumption that the skin of the vulva is 
governed by internal factors which have no influence 
on the skin at any other site? I am unaware of any 
records of cases of generalised pruritus, or of pruritus 
` at sites remote from the vulva, in which this diagnosis 
has been definitely established, and in which no 
skin changes were present. It is a facile diagnosis, 
acceptable to the patient, since it often confirms her 
own opinion, and it absolves from further examina- 
tion of the parts. It is also in harmony with the 
opinion which is very commonly accepted that the 
skin of the vulva is a pelvic organ : as the expression 
goes, ‘‘ pruritus vulve belongs to the gynecologist.” 
It is for this reason that cases of vulval pruritus 
are rare in the skin clinics of general hospitals ; they 
are more-commonly referred to gynecological clinics. 
Few, if any, gynecologists claim a specialised 
knowledge of skin affections, and the absence of 
a differential diagnosis of vulvar skin eruptions is 
therefore not surprising. 

Dr. Agnes Savill’s conclusions in your issue of 
March 21st raise the curious problem as to why 
fecal organisms should suddenly become pathogenic 
to the skin, for even with the most careful hygiene 
it is inevitable that the parts near the anus should 
be contaminated by these organisms, from infancy 


upwards. Analysis of a large number of urines 
in my cases yielded such varied results that no 
definite conclusions could be drawn from them, 
and irritation appeared to be equally acute in the 
patient with a neutral sterile urine; with a urine 
loaded with phosphates; or with a urine in which 
there was an excess of oxalates, as in the cases in 
which cultures of B. coli were obtained. The analysis 
and treatment of vaginal discharges do not usually 
fall within the province of the skin physician, but 
the results of treatment may, particularly where 
the patient has some idiosyncrasy. 

I have had one case of anal irritation due to worms, 
but as the eruption did not involve the vulva, this 
case was not included in the series recorded. 

I am, Sir, yours faithfully, 
ELIZABETH HUNT. 

Manchester-square, London, W., March 23rd. 


EPILEPSY AND ALLERGY 
To the Editor of THE LANCET 


Sir,—The interesting case recorded by Drs. 
Costello and Fox in your last issue, with reference 
to an unusual relationship between asthma and 
epilepsy, raises the question of whether epilepsy can 
be associated with allergy. I have recently seen in 
consultation an almost identical case, except that 
epilepsy was preceded by migraine which invariably 
culminated after a few hours in either petit or grand 
mal, on the occurrence of which the migraine ceased. 
The skin tests to foods, &c., all proved negative. The 
patient, a woman of 22, had suffered from migraine 
and epilepsy for many years, and the case may be of 
interest as affording additional evidence that some 
cases of epilepsy may be of allergic origin. As far as 
could be ascertained, there was no family history of 
allergy. The cyanosis referred to by Drs. Costello 
and Fox was not, of course, present in a case of 
migraine, but information as to the mechanisms of 
the two conditions would be of interest. 

I am, Sir, yours faithfully, 

Harley-street, W., March 23rd. o G. H. ORIEL, 


MORAL PROBLEMS IN HOSPITAL PRACTICE 
To the Editor of THE LANCET 


Sır, —The American work with this title by Father . 
Patrick A. Finney, C.M., reviewed in your issue of 
March 14th (p. 640), has already been severely 
criticised in the October, 1935, number of the Catholic 
Medical Guardian, the organ of the Catholic Doctors’ 
Guild. The “‘nihil obstat,” and other marks of 
ecclesiastical approval that it bears, certainly imply 
that the book contains no actually heretical teaching, 
but they do not guarantee that the author wil 
command universal acceptance by his co-religionists 
in his application of Catholic principles to medical 
practice. On one important question Father Finney 
has failed to distinguish between a decided and 
binding dogma of the Church and a matter on which 
opinion is divided—viz., ectopic gestation. Catholic 
doctors in this country are advised that operation on 
the unruptured tube is perfectly permissible, since the 
tube is in a diseased state, and they do in fact carry 
out the usual procedure in treating this condition. 

We entirely concur that “the conduct which is 
enjoined by Father Finney on hospital sisters ” is 
contrary to the accepted relationship between the 
medical and nursing professions in this country and 
places a quite unsuitable responsibility on the nursing 
sister. Naturally it is assumed that in hospitals 
conducted under Catholic auspices operations 


742 THE LANCET] 


definitely regarded as unlawful by Catholics, such as 
direct abortion and sterilisation, cannot be performed, 
but this does not in our opinion justify turning a 
nurse into the surgeon’s invigilator. It appears, 
however, that in America the situation is different 
to anything that prevails in Europe, and there are 
many Catholic hospitals owned and managed by 
Catholic religious orders which have no Catholic 
doctor on the staff and no priest readily available. 

Finally we would point out that since Catholics 
attach much greater importance to the sacrament of 
baptism than do many others, it is necessary to give 
particular and detailed instructions to the nurses in 
the interests of the child. Here again, however, we 
must admit that Father Finney goes far beyond the 
common interpretation of medical obligation, and 
also of medical practice. The ‘‘duty’’ to baptise 
the unborn child is strictly conditioned by a further 
obligation not to mishandle the dead mother uselessly 
or to endanger the living. It is hardly conceivable 
that nurses should perform post-mortem Cesarean 
sections or that they should rupture the membranes 
in order to baptise an infant only possibly alive! 
Few Catholic doctors in the course of a long profes- 
sional life feel called upon to do either of these things. 

The Catholic faith is rational and seeks to conserve 
life, the life of the body and the life of the soul. 
It is unfortunate if its aims should be misunderstood 
through an interpretation tinged perhaps with excess 
of zeal.—I am, Sir, yours faithfully, 


ERNEST E. WARE, 


March 22nd. Master of the Catholic Doctors’ Guild. 


THE FUTURE OF THE CORONER 
To the Editor of THE LANCET 


SIR, —I have been much interested in the con- 


troversy about the coroner system which has been 
discussed during the past year in your columns and 
was the subject of a leading article in your issue of 
Feb. 15th. As a result of similar scandals arising in 
the coroner system in Suffolk County, Massachusetts, 
which includes Boston, the coroner system was 
abolished in this State by legislative act in 1877. 
The Massachusetts Bar Association and the Massa- 
chusetts Medical Society through their joint action 
brought about this change. They based their 
criticisms upon the following : 

1. The coroner was required to’ exercise both medical 
and legal functions, a straddling of two professions, 
difficult to compass even for an exceptionally brilliant 
person. 

2. The office of coroner, while perhaps necessary under 
the primitive conditions existing in the early Anglo-Saxon 
period, had become an anachronism following the develop- 
ment of police and judicial systems. 

3. In the investigation of a death by violence two 
primary questions present themselves : (a) what caused the 
death ? the answer to which can only be supplied by 
medical investigation; (b) who caused the death? a 
matter for the police and the courts to determine. 


Under the Massachusetts medical examiner system, 
medical men are called upon to determine the cause 
and, if possible from the medical facts disclosed, 
the manner of the death, in cases in which death is 
supposed to be due to violence. Inquests are limited 
to cases in which death may have been due to the 
act or negligence of another, and are held before a 
judge of a court of first instance, without a jury. If 
probable cause of action is found the suspect is held 
for grand jury investigation, and if an indictment is 
issued the evidence is presented before a superior 
court with jury. Within the recent period inquests 
have been sharply limited. Deaths under anws- 


THH FUTURE OF THE CORONER 


[Marcu 28, 1936 
thetics, for example, are not inquested unless there is 
an indication of criminal negligence. In most other 
cases the police and the lower courts have already 
taken cognisance of the matter before the medical 
investigation has been completed in detail. 

The medical examiner system has been subjected 
to 58 years of trial in this jurisdiction and has been 
adopted in neighbouring States,in New York City, 
and in Essex County, New Jersey. As I have 
suggested, the system makes for simplicity, utility, 
and efficiency. 

I am, Sir, yours faithfully, 


TIMOTHY LEARY, 
-Medical Examiner, Suffolk County, Massachusetts. 
Boston, March 10th. 


AN ADDRESS IN HARLEY STREET 
To the Editor of THE LANCET 


Smr,—In your issue of March 14th you published 
a letter with reference to medical refugees in this 


country. I have consulted the Jewish authorities 
interested in the question and find that to the best 
of their knowledge about 140 German doctors have 
received permission to practise here, of whom 35 
have been permitted to practise in the Harley-street 
area. This latter group consists of men of specialist 
rank in their own country. To see these figures in 


their proper perspective, may I add that there are 
about 57,000 names on the Medical Register and I 
believe there are about 40,000 doctors in practice 
in Great Britain. 
I am, Sir, yours faithfully, 
March 24th. SAMSON WRIGHT. 


THE RECORD BREAKER 
To the Editor of THE LANCET 


Sir,—In your account last week (p. 664) of the 
discussion on Fatigue at the Hunterian Society 
I am reported as having said that “‘ the record breaker 
was not usually the educated person.” I shall be 
obliged for the opportunity to correct this mis- 
statement which is likely to call forth a storm of 


indignant protest; in fact, premonitory rumbles 
have already reached me. In replying to questions, 


I had endeavoured to differentiate athletic psycho- 
logical types, in particular contrasting the highly 
strung, usually encountered in the devotees of events 
of speed and those demanding accuracy of technique, 
with the more stolid unemotional participants in 
long-distance events and feats of endurance. The 
great majority of the former belong to what for 
convenience one terms the educated class; with rare 
exceptions the latter are manual workers. No 
mention of ‘record-breaking’? was made: were 
this under consideration, an analysis would show 
that the educated and, on occasion, the very highly 
educated are well represented. 
I am, Sir, yours faithfully, 
Brook-street, W., March 21st. ADOLPHE ABRAHAMS. 


A QUESTION OF PROFESSIONAL 
CONFIDENCE 


To the Editor of THE LANCET 
Srr,—The letter of Iatros moves me to send you 


articulars of another tragedy also revolving round 
he gonococcus, though in this case I am happy to 
add that the patient has not suffered. 

Dr. A, practising in contract with the X insurance 
committee, treated his patient Miss N for acute gonococeal 
vaginitis and endometritis and when she was convalescent 


sent her into the area of Dr. B, practising in contract 


ACT 


THE LANCET] 


with the Y insurance committee. Before she made the 
journey to stay with her aunt, who with her husband are 
valued patients of Dr. B’s, Dr. A wrote to Dr. B saying 
“you will shortly be asked to accept as a temporary 
resident Miss N ”?” and giving particulars. While Miss N 
was under his care Dr. B had occasion to inform Dr. A 
of her progress both by telephone and by letter, eventually 
returning her to his care with a final letter. Then came the 
completion of the temporary record form. Dr. B, having 
some acquaintance with the organisation of the Y insurance 
committee’s office and knowing girls were in employment 
there, did not feel inclined to make a diagnosis of gonorrhea 
which might meet their eye; he further had a delicacy 
about possible publication within a few miles of the 
residence of the patient’s uncle and aunt of a fact which 
he had managed to avoid telling them when the patient 
was actually under treatment in their house—namely, 
that their unmarried niece had acquired venereal disease. 
He therefore completed the form so far as was necessary 
to inform Dr. A of facts not included in the direct 
correspondence. 


The clerk to the Y insurance committee thereupon 
returned the record form on the ground that it 
contained insufficient professional details; and also 
acted in the same way in a similar case. Dr. B saw 
no reason to alter a form which he had every reason 
to consider satisfactory to Dr. A; and, since the 
action of the clerk constituted evidence that his 
professional statements were scrutinised by a layman, 
to wit, the clerk, he had every reason to avoid giving 
details which would constitute a breech of professional 
confidence. He has therefore in cases where there is 
reasonable ground to suppose patients would object 
to disclosure of details treated them without accept- 
ance as temporary residents, to the detriment of his 
pocket but the integrity of his reputation. He 
obviously cannot return records which the clerk has 
already refused to accept and forward; and every 
reason to decline to amplify them to satisfy the clerk. 

Since these occurrences the clerk has included the 
two temporary record forms in complaints made by 
him against Dr. B, and at the hearing of the first of 
these complaints stated that two of the temporary 
record forms had been returned by him because they 
were not full enough, and Dr. B had failed to return 
the same. This statement passed unchallenged by 
any of the members of the medical service sub- 
committee which has twice recommended deductions 
from Dr. B’s remuneration for delay in returning 
medical records of which these are two. Dr. B 
cannot explain himself to the insurance committee 
without breaking confidence ; and when he challenges 
the right of the clerk to return records for reasons 


- connected with professional information and comments 


that another insurance committee known to him make 
provision for the forwarding of such records from 
one practitioner to another under cover, the com- 
mittee reply that they ‘‘ join issue.” 
$ I am, Sir, yours faithfully, 
March 21st. Iatros II. 


To the Editor of TUE LANCET 


Sirn,—I was much interested in the letter of 
*‘Tatros’ last week and in your reply, as I have 
recently dealt with a similar case. As the letter 
reads, and with the lack of fuller information, Dr. A 
‘was in my opinion absolutely right in the action he 
took and in giving the information he did to the 
girls mistress. Granted that it was not strict 
etiquette to examine the bed letter, at any rate the 
girl was Dr. A’s patient and the inspection of the 
letter was made quite openly in the presence of the 
nurse. Evidently some condition was present quite 
different from an acute abdomen. In a general 
hospital, as this obviously was, a girl is not placed in 


A QUESTION OF PROFESSIONAL CONFIDENCE.—PARI® 


[maARoH 28, 1936 743 


a V.D. ward without the corroboration and positive 
evidence which the hospital is capable of obtaining 
and verifying; we may be sure that the girl was 
suffering from a gonococcal infection. 

For myself I rather blame the physician in charge 
of the case that he did not advise Dr. A that the 
girl was not a case of ‘‘ acute abdomen ” for which 
she had been sent to the hospital. Knowing what 
Dr. A did (apart from his inspection of the bed 
letter) was he to allow this girl to return to an 
unsuspecting mistress who would continue to believe 
that the girl’s past had been a creditable one, to 
a house where perhaps there were young children, 
where perhaps she would use the same towels and 
sleep in the same room with another maid ? Which 
of us would like this to happen in our own house ? 
Knowing the months these cases often take to be 
cured, is it probable that a general hospital would 
keep a patient all this time, and what about 
recrudescence after apparent cure? One is, I am 
afraid, a trifle suspicious of these girls with a ‘“‘ highly 
creditable record ” and in any case she would not 
remain innocent long after a stay in the V.D. 
ward of a general hospital. What alternative had 
Dr. A, and what would have been his position if 
as a result of his silence others had become infected ? 
The dismissal was perhaps s2nt rather crudely and 
suddenly to a girl with a highly creditable record— 
hence her hysterical state. It might have been 
wiser if Dr. A and the mistress had decided to tell 
the girl that the illness would be a long one and that 
the mistress could not await her return. 

In your note you mention that the condition 


present might have been confused with other condi- 


tions such as effects produced by contraceptive 
measures. This would not be very creditable to the 
bacteriological staff of a general hospital, and the 
fact that she was in a V.D. ward should justify 
Dr. A in the action he took. 

I am, Sir, yours faithfully, 


March 22nd. F.R.C.S. 


A DISCLAIMER.—We have received from Dr. Stanley 
Hartfall and Dr. Hugh Garland a disclaimer of any 
association with the recent publicity given in the 
press to the gold treatment of rheumatoid arthritis. 
The connexion of their names, they state, with the 
articles in question has been due to the action of a 
news agency which has circulated paragraphs taken 
from a short communication by them to the last 
number of the Leeds Medical Society Magazine. 


PARIS 


(FROM OUR OWN CORRESPONDENT) 


DEATH OF ARNOLD NETTER 


AFTER addressing a meeting in Paris on March Ist 
of the Assemblée française de Médecine Générale, 
Dr. Arnold Netter died suddenly while the discussion 
was still in progress. Professor of the faculty of 
medicine of Paris and honorary physician to the 
Trousseau Hospital, he had distinguished himself 
a3 a pediatrician and had made valuable studies 
of broncho-pneumonia, cerebro-spinal meningitis, 
infantile paralysis, and lethargic encephalitis; his 
work on the relationship between zona and chicken- 
pox was also of considerable value. The dramatic 
circumstances of his death are reminiscent of a scene 
at the Academy of Sciences, before which Dr. Lucas- 
Championniére was presenting a report when he 
collapsed suddenly and died. Dr. Netter was an 


444 THE LANCET] 


octogenarian, but his last discourse, on the fixation 
abscess with special reference to its use in encepha- 
litis, had won applause for its intrinsic merits as well 
as in tribute to its author’s. personality. It may be 
noted that the opinion of the meeting seemed strongly 
in favour of the use of fixation abscesses in many 
forms of illness ; though a more critical attitude was 
maintained in at least one quarter. 


CREMATION IN FRANCE 


In the March number of Annales @hygiéne Dr. 
Emile Malespine has published a historical survey, 
conceived in a philosophical spirit, of the disposal 
of the dead. As he points out, the mode of destruction 
of a dead body is far less complicated than the 
psychological and spiritual problems connected 
with it. ‘‘The problem of the cadaver is inseparable 
from the problem of the cult of the dead, and this 
cult has its roots in the deepest forces of humanity 
and the spirit of religion, and it dominates the 
social life. A nation loses its raison d’étre, a nation 
dies if it no longer feels the mysterious threads 
attaching it to its dead and to the past.’ It was 
during the French Revolution that the idea of 
cremation took concrete form in a project for its 
realisation, but this project was referred back to a 


commission in which it was duly buried. It was not- 


till 1874 that cremation was again considered as a 
practicable solution of the problem of the disposal of 
the dead. In this year the bodies of three women 
were cremated in Germany in a Siemens furnace. 
The idea spread, and soon schemes were afoot for 
the creation of crematoria in most of the large towns 
of Europe. In 1889 the crematorium of Père- 
Lachaise in Paris was inaugurated, and in the same 
year 49 cremations were effected in this centre. 
Since then there has, indeed, been a steady rise in 
the number in Paris, from one decade to another, 
but the figures certainly do not testify to any great 
and popular movement in favour of this mode of 
disposal of the dead. Thus in 1890 there were 
121 cremations. In 1900 the number rose to 297, 
and in 1910 to 473. There were 560. cremations in 
1920, 899 in 1930, and 904 in 1934. At the present 
time cremation is requested in barely 1 per 1000 
deaths, and it does not seem as if in France it is 
likely to make great headway. Why? Dr. Malespine 
is careful to avoid specific references to the attitude 
of the Roman Catholic Church to cremation, and he 
seems more inclined to be philosophically resigned 
over, than to tilt against, those psychological 
inhibitions which play so important a part after as 
well as during life. Respect for the dead cannot be 
contemptuously dismissed with such a catchword as 
“ fetishism of the cadaver.” 


CENTENARY OF THE 
ROYAL MEDICAL BENEVOLENT FUND 


Tue hundredth annual general meeting of the 
supporters of the Fund was held in the library of 
the Medical Society of London on Tuesday last, 
March 24th, at 5 P.M., Sir Tuomas BARLOW, president 
of the Fund, presiding. The members stood in silence 
for a brief space in respectful tribute to his late Majesty, 
King George V., a patron of the Fund since 1913. 

Mr. R. M. HANDFIELD-JONES, hon. secretary, tlen 
presented the annual report. He said that the 
annual meetings were purely formal and designed 
to meet statutory requirements. But he was able 
to state that the president had invited the honorary 
local secretaries to meet at his house to discuss an 


CENTENARY OF THE ROYAL MEDICAL BENEVOLENT FUND 


(maron 28, 1936 


appeal to be made in April and sent to everyone on 
the Medical Register, except where a benevolent 
fund is already in existence.- The meeting at Sir 
Thomas Barlow’s house would discuss how the 
appeal can be made more powerful. With the same 
object a conversazione will be held shortly, when the 
Royal Society of Medicine has offered the use of its 
premises and have asked the members of the Fund 
to be their guests. 


ANNUAL REPORT 


He then read the report which showed a story of 
expansion, very slow at first but substantial of 
recent years. For example, while in early days the 
annual subscriptions never exceeded £2250, by the 
ninetieth year of the Fund the income from this 
source had risen to £7000 and had reached £14,500 
in the centenary year. The committee however had 
had to expend nearly £700 in annual grants more 
than was actually received in income during the 
year, so numerous and urgent had been the appeals. 
By the jubilee year of the Fund (1886) the Fund had 
distributed £60,000 among the less fortunate members 
of the profession; by the centenary year close on 
£400,000 had been thus expended. The report 
concluded by stating that a brief historical record 
of its activities, written by Sir Humphry Rolleston, 
would be issued in April with the general appeal to 
practitioners. 

Commenting on the report Sir THOMAS BARLOW 
remarked that he did not know of acharity which dis- 
played more kindliness in the way it was administered. 


FINANCIAL STATEMENT 


Dr. LEwis G. GLOVER, hon. treasurer, in presenting 
the accounts, pointed out that from January to 
December grants are allocated carrying on for the 
next year, thus committing the Fund to a large 
expenditure in the immediate future. The Fund 
was solvent but care had to be exercised over expen- 
diture. The number of grants and annuities had 
increased by 138 over the previous year; in 1935 
there were 240 more beneficiaries than in 1927. The 
money invested at the moment was £225,000 ; £2058 
had been received through the B.M.A., allocated by 
subscribers to the Fund. The actual amount of 
money distributed was £2415 more than was given 
in the last year, including £865 for Christmas gifts, 
money resulting from Sir Thomas Barlow’s letter 
in the medical press at Christmas, and from collec- 
tions at meetings, mostly B.M.A. and panel com- 
mittees. £1123 were received from the Ladies’ Guild 
as the proceeds of a charity matinée, and £207 from 
the provinces as the result of dinners and dances and 
social functions held in aid of the Fund. The working 
expenses were 9 per cent. this year as against 9°3 per 
cent. last year, and he would point out that societies 
analogous to their own in calculating percentage of 
working expenses take into account all money 
received in legacies, in which case the expenses of 
the Fund would be only 5 per cent. of the total 
income received. 

Dr. W. P. S. BRANsoN expressed the gratitude of 
the meeting to the honorary officials of the Fund, 
and Dr. HERBERT SPENCER, who seconded the pro- 
posal, said he thought £100,000 would be a good 
figure to aim at for the centenary appeal. 

At the conclusion of the meeting the hon. treasurer 
announced, relative to the special appeal which is 
to be issued in April, that Sir Thomas Barlow had 
headed the list of contributors to the centenary fund 
by a donation of £1000. 


THE LANCET] 


[Marow 28, 1936 745 


OBITUARY | 


ALEXANDER ROBERT TWEEDIE, F.R.C.S. Eng. 


AURAL SURGEON, NOTTINGHAM GENERAL HOSPITAL 


THE death of Mr. Tweedie, the well-known otologist 
and laryngologist of Nottingham, occurred suddenly 
in Nottingham on Wednesday, March 18th. 

Alexander Tweedie received his medical education 
at St. Bartholomew’s Hospital, entering the medical 
school with a scholarship, qualified in 1900 with the 
English double diplomas, and in the following year 
obtained the F.R.C.S. Eng. After qualification he 
did post-graduate work in Vienna and then held a 
resident appointment at the Royal Free Hospital, 
but having selected laryngology as a specialty he 
became clinical assistant to the Hospital for Diseases 
of the Throat, Golden-square. He then went into 
practice in Nottingham where he was prompt to 
make his mark. He was elected assistant surgeon 
to the Nottingham General Hospital and to the 
Children’s Hospital, and also held the appointment 
of aural surgeon to the Midland Institution for the 
Blind. In the South African war he served as civil 
surgeon in the South African Field Force. On his 
return to practice he became surgeon to the ear, nose, 
and throat department of the General Hospital and 
laryngologist to the Nottingham City Mental Hospital, 
and soon had a large consulting practice. As the 
result of these varied experiences he made well- 
informed communications to the Journal of Laryngo- 
logy, Rhinology, and Otology—to the staff of which 
journal he was attached—to the British Medical 
Journal, the British Dental Journal, The Lancet, and 
the Journal of the R.A.M.C., while in collaboration 
with Keith he contributed to the Proceedings of the 
Royal Society of Medicine a communication on con- 
genital anomalies of nose, palate, and upper lip. 
This does not exhaust his communications to the 
Proceedings of this society, while he was a useful 
contributor to the debates and became president of 
the otological section. He was a prominent member 
of the Nottingham Medico-Chirurgical Society and 
an ex-president of this society. He was a corre- 
sponding member of the Austrian Otological Society 
and the Paris Society of Laryngologists, and treasurer 
of the Oto-rhino-laryngological Collegium. 

Tweedie did fine and varied service during the 
European war. He personally raised a second line 
of ambulances and went overseas to be present at 
the opening of the Gallipoli campaign. He had under 
his administration a large medical organisation at 
Alexandria, served in the expedition to Tripoli 
against the Senuse, and had at one time charge in 
upper Egypt of a large medical district where he 
was commanding officer at the Citadel Hospital, 
Cairo. He was present at the final assault on Gaza 
as medical officer to one of the divisions, and joined 
in the pursuit of the Turks to Jaffa and Jerusalem. 
He was demobilised with the rank of lieutenant- 
colonel and was mentioned in dispatches. After the 
war, on his return to Nottingham, he found time in 
addition to the care of his practice to play an important 
part in the institutional care of the deaf and of the 
blind while also acting as local aural specialist to the 
Ministry of Pensions. In 1920 he was elected to the 
Nottingham City Council and served on various com- 
mittees in connexion with health, care of mental 
deficiency, and management of asylums, but he did 
not seek re-election at the end of his term. 

His death occurred in a dramatic manner. He had 
been present at a scientific meeting in Nottingham 


and had just spoken the closing words of the meeting 
when he suddenly collapsed and died. He was not 
known to have been in ill-health. 


THOMAS MAJOR TIBBETTS, M.D., 
D.P.H. Lond. 


Dr. T. M. Tibbetts, whose sudden death occurred 
at the age of 67 on March 13th, was a well-known 
practitioner in Cradley Heath and the surrounding 
country. He received his medical training in 
Birmingham and graduated as M.B. in 1892, taking 
the D.P.H. of the English Royal Colleges a little 
later. His whole professional] life was passed in the 
Cradley Heath district where his services to public 
health were varied and valuable. He was for 
40 years M.O.H. to the Quarry Bank U.D.C., and in 
his reports made outspoken attacks on sanitary 
defaults of overcrowding and other abuses. He 
became accepted as a leading authority on these 
subjects, while on the institution of the National 
Health Insurance system his activity on behalf of 
the great movement in the early days was of great 
local influence. In 1916 he wrote a useful treatise 
on the “‘ Duties and Perplexities of the Panel Doctor.” 
He treated the subject with breezy cheerfulness and 
plain good sense, and though not forgetting the 
duties and obligations of the medical man towards 
his profession, pointed to the duties, owed by the 
profession to the State, which by the National 
Insurance Acts were brought into the form of a 
contract. Dr. Tibbetts is survived by his wife, a 
daughter, and three sons, one of whom, Dr. A. 
Tibbetts, was practising in partnership with him. 


SIR KEDARNATH DAS, C.LE., M.D. Calcutta 


Sir Kedarnath Das, whose death is announced 
from Calcutta, was principal of the Carmichael 
Medical College, and professor of obstetrics and 
midwifery there. Born in 1867, he was educated at 
the Scottish Churches College and Calcutta Medical 
College, and graduated in 1892. His appointment to 
the Carmichael College came in 1919 after long 
service to the Campbell Medical School, and he has 
for many years been the doyen of the medical 
profession in Calcutta. To Mr. V. B. Green- 
Armytage we are indebted for the following appre- 
ciation of his former colleague :— 


“ Kedarnath Das was a man of outstanding ability 
and striking appearance, standing well over 6 feet in 
height. Exceedingly well read, his main hobby was 
his library and the collection of data for his monu- 
mental work, ‘The Obstetrics Forceps—Its History 
and Evolution,’ which meant 12 years of unremitting 
patient toil and involved an enormous amount of 
cross-correspondence between authorities throughout 
the world; and when it is remembered that this 
correspondence was done in his own handwriting, 
working in a climate not conducive to burning the 
midnight oil, with a fan whirring above, winged 
insects buzzing around and sweat pouring down his 
arms, one must but applaud his inspired enthusiasm 
and admit that he produced the only masterpiece 
on this subject that has ever been published in the 
English language. l 

“ Kedarnath Das was India’s greatest obstetric 
guru, and wrote innumerable articles on his own 
speciality. The honours he received gave pleasure 
to all because they were well earned by integrity, 
loyalty, and sheer personal merit. He was much 


746 THE LANCET] 


beloved by all his professional brethren, and as a 
consultant and administrator, his experience and 
acumen was of the utmost value. He was particularly 
proud of the fact that he was the first Goodeve 
Scholar at the Eden Hospital, and was in close 
touch with it and its professors throughout his life. 

“ Whatever he did, he did thoroughly with punc- 
tilious care as regards detail and procedure, and 
I remember when we first opened the DumDum 
Aerodrome, he was one of the earliest to join, and 
although well over 60, was one of the first to make 
a flight over Calcutta, taking intense joy that he was 
thereby inspiring the youth of Bengal to become 
air-minded. His house was ever open to all medical 
men in Calcutta and many a pleasant afternoon 
I have spent there. Nothing gave him more pleasure 
than showing you round his library and then taking 
you to the Carmichael Hospital to demonstrate his 
unique collection of forceps and appliances which he 
had procured from all over the world, and which he 
had presented to the hospital museum.” . 


Sir Kedarnath Das was a foundation fellow of the 
British College of Obstetricians and Gynecologists 
and an honorary fellow of the American Association 
of Obstetricians. He was knighted in 1932. 


WILLIAM HOLLAND WILMER, M.D. Virginia 


WE announced last week the death of Wiliam 
Wilmer, the distinguished American ophthalmologist 
and director of the Wilmer Ophthalmological Institute, 
Baltimore. His name is well known in this country 
where certain of his patients enjoyed prominent 
public positions. 

Born in 1863, the son of Richard Wilmer, 
the bishop of Alabama, he received his medical 
education at the 
University of Vir- 
ginia, graduated 
in medicine there 
in 1885, and 
undertook a long 
course of post- 
graduate study in 
his own country 
and in England. 
He contributed to 
scientific journals 
articles on various 
aspects of ophthal- 
mology and also 
on medical aviation 
in which he was 
greatly interested. 
At the seventeenth 
annual conference 
of the Oxford 
Ophthalmological 
Congress he 
delivered a very 
good address on 
the results of the operative treatment of glaucoma. 

At the outbreak of war Wilmer already held a 
commission in the medical reserve corps of the 
U.S. Army. He became appointed commandant of 
the Medical Research Laboratories (Air Service), 
Long Island, and at the close of hostilities was in 
surgical charge of the air service of the U.S.A. 
Expeditionary Forces. He was awarded for his 
services the D.S.M. medal in 1919 and was later 
appointed a Commander of the Legion of Honour. 
His professional, philanthropic, and social duties in 
his own country were numberless, and at the time of 


OBITUARY 


[MARCH 28, 1936 


his death he was professor of ophthalmology at the 
Johns Hopkins University and director of the 
associated Wilmer Ophthalmological Institute. This 
institute expresses a desire among Wilmer’s patients 
and friends that a wide scope should be given to his 
activities and that his name should be commemorated 
in connexion with them. In coöperation with the 
Rockefeller Foundation and the Commonwealth 
Fund a sum of nearly four million dollars was raised 
and the Wilmer Ophthalmological Institute was 
started providing an opportunity for the study of 
every phase of ophthalmology. In 1929 General 
Wilmer was elected president of the Association of 
Military Surgeons of the United States. 


DOROTHY MABEL HANSON, M.B. Liverp. 


WE regret to announce the tragic death, on 
March 21st, of Dr. Dorothy Mabel Hanson, who was 
killed instantly when her car was crushed between 
two trams near Westminster Bridge. Dr. Hanson 
was educated at the Belvedere School, Liverpool, 
and subsequently studied at the Bergman-Osterberg 
Physical Training College, Dartford, for at that time 
she intended to become a teacher of games and 
gymnastics. After teaching for a year at a school in 
Southend-on-Sea she went to the Manchester School of 
Massage to study for the teachers’ certificate of the 
Chartered Society of Massage and Medical Gymnastics. 
With this qualification she returned to Dartford to 
teach medical gymnastics, but left again in order to 
qualify as its medical officer by securing the M.B., 
B.Ch. degree at the University of Liverpool, her 
home town. Apart from these years the whole of the 
rest of her working life was spent in the Dartford 
College. As lecturer in anatomy and remedial 
exercises and as resident medical officer she fulfilled 
two quite distinct functions and therefore had 
opportunities of coming into perhaps more intimate 
contact with succeeding generations of students 
than any other teacher. She was the doyenne of 
the staff, and for most of those who knew her was 
so much a part of the College that her sudden and 
tragic death on March 21st came as a profound 
shock not only to her present colleagues and pupils, 
but also to very many others who had passed through 
the College. She was for many years a member 
of council and examiner for the Chartered Society, 
where her specialised knowledge of physical training 
work and postural problems will be sorely missed. 
She was only 42 years of age. 


ELEANOR HODSON, M.B. Edin. 


Dr. Eleanor Hodson, who died on Feb. 26th in 
Canterbury, had a wide reputation as ophthalmologist 
and social worker. She was a native of Mickleover, 
Derbyshire, graduated at the University of Edin- 
burgh as M.B., B.Ch. in 1900, and after serving for a 
time as house surgeon to the National Eye Hospital, 
Dublin, went to Calcutta where she practised for 
some years as a specialist in diseases of the eye. On 
her return to England she continued to carry on her 
ophthalmological work, travelled much, and grew 
interested in many aspects of continental life, while 
in England she became known as a fine rider to 
hounds. At the outbreak of war, failing to obtain 
appointment as a specialist with the British Army, 
she became attached to the Croix Rouge and during 
the first period of operations was in charge of various 
French hospitals. Invalided home in the later phases 
of the war, she was invited to serve with the R.A.M.C. 


(Continued at foot of opposite page) 


| 
AN TEE a ov as 


. devastated areas. 


THE LANCET] 


[MARCH 28, 1936 747 


PARLIAMENTARY INTELLIGENCE 


NOTES ON CURRENT TOPICS 


Nutrition and National Health 
THE DEBATE IN THE LORDS 


IN the House of Lords on March 18th the Bishop 
of WINCHESTER asked H.M. Government if in view 


‘of widespread malnutrition and the existence of a 


large milk surplus they would take steps to extend 
still further the provision already made to supply 
liquid milk to school-children and to initiate a scheme 
on similar lines for expectant and nursing mothers 
and for children under 5. He took his stand largely 
on the new standard by which to judge nutrition 
taken by Sir John Orr in his report entitled ‘“‘ Food, 
Health and Income.” There was, he said, plenty 
of milk available. He would ask the Government 
the question whiclt had been recently asked in the 
Times: ‘‘Why should not some of the milk now 
poured into factories be poured down human throats? ” 
Against any additional expenditure which might 
be entailed they must set the saving there would 
be in respect of hospitals and medical services. 
In the long run he believed the nation would save 
rather than lose. 

The Earl of RADNOR asked the Government whether 
they were proposing to take steps to bring the needs 
of agriculture and the needs of the nation so far 
as nutrition was concerned more into line. They 
knew for certain that it was fresh food that the 
people needed to bring their nutrition up to standard 
and it was in this country that fresh food could be 
produced satisfactorily. There was a very wide 
gap to-day between the price that the producer got 


‘and the price the consumer paid. He did not know 


whether any Government would ever have the 
courage to have a searching inquiry into the costs of 
distribution. 

Viscount ASTOR spoke of the report, probably 
the most important of all, of an international com- 
mission of experts which had met in London. Being 
& report of experts it had been ignored by most 
people. These international experts were unanimous 
in saying that there was a real problem of malnutrition 
and that milk was one of the most important diets 
that should be dealt with. At the Assembly of the 
League of Nations last September three days were 
devoted to the discussion of this subject, after which 
the Assembly passed unanimously a resolution 
indicating that there ought to be a comprehensive 
inquiry into (1) nutrition and public health, (2) the 
repercussions on agriculture and economics of an 
improved nutrition policy. As a result of that 
a committee of which he (Lord Astor) was chairman 
was set up on which sat medical experts, agriculturists, 
economists, and others. The committee would 
present an interim report to the Assembly next 
September. In their interim report his committee 
would deal only with the Western World; at some 
future time they would deal with the Far East, 
where the problem of malnutrition was far more 
serious than it was in Europe. They hoped very 


much that as nutrition improved so cheap foods 


(Continued from previous page) 


and was appointed anesthetist and reception officer 
at Military Hospital No. 1, Canterbury. At the 


conclusion of hostilities she was decorated by the 


French Government and continued to take’ a great 
interest in the sufferings of the French in the 
When Canterbury decided to 
“adopt” the villages of Morval and Lesbceufs 
Dr. Eleanor Hodson was an energetic worker, while in 
other philanthropic movements she was a conspicuous 


- figure. 


would be allowed to go from countries where they 
could be produced most cheaply into other countries 
where from causes of climate or other reasons they 
could not be produced so cheaply. The price of 
milk to-day was too high. A great deal could be 
done to reduce the cost of production. He urged 
the Government to accept the Bishop of Winchester’s 
proposal. He also hoped that the Government 
would give a lead in developing a wise nutrition 
policy. | 

Lord LUKE said that for the last few months he 
had had the privilege of serving the Government in 
their campaign for improving the nutrition of the 
nation. There had been for several years a Standing 
Advisory Committee to the Ministry of Health 
on Nutrition. In 1935 the Government reconstituted 
the committee with wider terms of reference and 
Lord Kennet, then Minister of Health, invited him 
(Lord Luke) to become its chairman. The com- 
mittee had been asked to find out what food the 
people of this country were eating and to advise 
whether it was satisfactory from the health point of 
view. His committee were fully able to endorse 
the views now generally held in regard to the 
consumption of milk. The committee had been 
able already to produce a report on the nutritive 
value of milk which had been presented to the 
Minister of Health and would, he understood, be 
published very shortly. He hoped that the Govern- 
ment, even if they could not accept the precise 
terms of the motion, would be able to indicate that 
they would consider favourably proposals for the 
increased supply of milk to nursing mothers and 
children. 

THE GOVERNMENT’S REPLY 


Viscount GAGE, replying for the Government, said 
that the problem they had to consider was not 
whether the people were receiving sufficient food to 
maintain life, but how far the dietaries of the various 
classes of the community were adequate to promote 
and maintain full health. That was a question on 
which in their present state of knowledge various 
opinions were no doubt possible. No one would 
suggest that there was no room for improvement, 
but they would be viewing this matter in a wholly 
false light if they did not take into account not merely 
the high standard of living in this country as compared 
with other countries, but also the steady improvement 
which had taken place both in the standards of 
nutrition and in public health. Some striking 
figures were given in Sir John Orr’s book. 


These figures showed the increases in the estimated 
annual consumption per head of certain foodstuffs and 
indicated the percentage of consumption in 1934 as 
compared with the period immediately before the war: 
Fruit, 188 per cent.; potatoes, 101 per cent.; other 
vegetables, 164 per cent.; butter, 157 per cent.; eggs, 
146 per cent.; cheese, 143 per cent. ; meat, 106 per cent. ; 
wheat, 93 per cent. 

“It will be seen that, with the exception of wheat, 
flour and potatoes, there has been a substantial increase 
in the consumption of most of the principal foods since 
before the War. The largest increases have been in fruit, 
fresh vegetables, butter and eggs. In each case the rate 
of increase has been greater since 1924-28 than in the 
previous fifteen years. 

“ These increases in consumption of animal fat, and of 
fruit and fresh vegetables, are increases in foods of high 
biological value.” 


Notwithstanding the industrial depression there ~ 
had been no halt in the improvement of public health, 
and for this the health services could claim their 
share of credit. Of course, it could not be assumed 
that in all parts of the country and in regard to 
every class of the community these average figures 
would apply equally. Nevertheless it -could be 
hardly disputed that the recent. social history of this 
country revealed rising standards of living, improving 


748 THE LANCET] 


standards of nutrition, and better health accompanied 
by a remarkable increase in the length of life. 


USE OF SURPLUS FOODSTUFFS 


The problem to which much attention had been 
given was that of discovering means to make better 
use of surplus foodstuffs of high nutritional value 
in the interests both of public health and the agri- 
cultural industry. The problem had been termed one 
of the marriage of health and agriculture. No doubt 
the increase which they all desired to see in the 
consumption of these health-giving substances could 
readily be attained by drastic reductions in price, 
but a marriage arranged on these terms might well 
be a marriage of convenience to health, but it would 
not be particularly welcome to agriculture. But 
the Government were fully alive to the supreme 
importance of nutrition to health and had been 
giving, with the assistance of the Advisory Committee, 
very close attention to the newly acquired knowledge 
on the subject. Fortunately, as the Medical Research 
Council had pointed out, the essential teachings of 
modern science could be reduced to a few simple 
statements :— 


“ On the dietary side, the broad requirements can be 
simply stated to the public by saying that much more 
milk (‘safe’ milk), cheese, butter, eggs (especially egg- 
yolk), and vegetables (especially green vegetables) ought 
to be consumed. In particular, milk ought to be the 
chief drink for children, and especially in the first years, 
while bread and other cereals should in these early years 
be greatly reduced.” 


THE PRESENT CONSUMPTION OF MILK 


It was clear, said Lord Gage, that of all food- 
stuffs milk was from- the nutritional point of view 
by far the most important. Milk was almost a 
perfect food. Yet the consumption of liquid milk 
in this country was abnormally low. It averaged 
about 3 pints per head per week as compared with 
54 in the United States. He thought they might 
be assured of the value of the schemes already in 
existence. 

Under the milk-in-schools scheme, which covered all 
children in grant-earning schools and also adolescents 
attending junior instruction centres aided by the Ministry 
of Labour, 22,750,000 gallons were consumed during the 
first year, on which grant amounting to £401,000 was 
paid. The number of children participating in the scheme 
had varied monthly between 2,250,000 and nearly 
2,900,000. In recent months the number had averaged 
about 2,600,000. The Milk (Extension of Temporary 
Provisions) Bill, which had recently passed through 
Parliament, would enable the milk-in-schools scheme to 
be continued for a further 12 months until the end of 
September, 1937. The Education Act, 1921, enabled 
local education authorities to provide free meals, including 
milk, for children who needed this help to enable them 
to take full advantage of the education provided for them. 
Children obtaining milk in this manner often received 
two-thirds of a pint or one pint per day. Since that 
scheme began the number of children in public elementary 
schools in England and Wales receiving free milk had 
risen from 100,000 to 275,000. Finally, under the 
Maternity and Child Welfare Act, 1918, local authorities 
in England and Wales were empowered to provide free 
or cheap milk for expectant and nursing mothers and 
children under 5 years of age. The provision of free milk 
under these arrangements depended on the recommenda- 
tion of the medical officer and the inability of the recipient 
to pay for the milk. Practically all the 422 maternity 
and child welfare authorities provided some free milk, 
or at less than cost. About half the milk supplied was in 
the form of dried milk. Full information as to the annual 
consumption of milk under maternity and child welfare 
schemes was not available, but it had been roughly 
estimated to be equivalent to 7,000,000 gallons— 
3,500,000 gallons of liquid milk and 65,000,000 lb. of 
dried milk. 

The Ministers of Health and Agriculture had for 
some time been examining the possibility of a further 


PARLIAMENTARY INTELLIGENCE 


[mance 28, 1936 


extension and encouragement of these milk schemes, 
The question of consumption was at present under 
the examination of the Milk Reorganisation Com- 
mission, and it would be premature to introduce 
any new scheme for the provision of milk until the 
Commission’s report had been received. 


Workmen’s Compensation for Injuries 


In the House of Commons on March 20th 
Mr. MAINWARING moved the second reading of the 
Employers’ Liability Bill, He said that it sought 
to amend the law in respect of the liability of 
employers to their workmen for injuries caused to 
them by the negligence of a fellow workman, and 
to attach responsibility for such injuries directly to 
the employer. The Bill was designed to remove an 
anomaly in the law, the doctrine of common employ- 
ment, which had been in existence in this country 
for practically a century. is country alone of 
the great industrial nations had such a law in opera- 
tion. An employer was deemed to be responsible 
for injuries caused in any circumstances by one of 
his employees to anybody other than his own servants. 
If an accident resulted in injury to anybody who 
had common employment in the undertaking then 
the employer was not responsible. 

Mr. A. HENDERSON seconded the motion for the 
second reading. He said that they were not asking 
that the workman should be placed in a favoured 
position, but that he should receive equality of 
treatment with any other member of the community 
who was injured as the result of the negligence of 
another person. 

Sir J. WARDLAW MILNE moved the rejection of the 
Bill. He said that insurance against an indefinite 
risk of this kind would have to be effected at a high 
rate. If the Bill became law the temptation to 
try to prove negligence on the part of a fellow work- 
man would be irresistible, and whereas now much of 
the compensation paid out was paid without recourse 
to the Courts, in future there might be protracted 
cases in the High Court and that would not be for 
the benefit of the workmen of this country. 

Sir D. SOMERVELL, Attorney General, said that 
the doctrine of common employment was part of the 
common law of the country. The Bill proposed to 
alter part of that law. The important point in 
considering this Bill was that Parliament had affirmed 
the principle that compensation should be awarded 
irrespective of negligence. The Bill sought to make 
the measure of compensation dependent on the 
proof of negligence. Even assuming that industry 
could bear this change without detriment to itself, 
this was, on the whole, a bad use for the money. 
The effect of the Bill would be in many cases to put 
a working man in the difficult position of having to 
make up his mind whether he would risk an action 
for negligence. 

The Bill was rejected by 146 votes to 85. 


Midwives Bill 


In the House of Commons on March 18th Sir 
KINGSLEY Woop, Minister of Health, introduced the 
Midwives Bill, which was read a first time. An 
explanatory and financial memorandum, which is 
prefaced to the Bill, states that the main purpose of 
the measure is to improve the standard of domiciliary 
midwifery in England and Wales by establishing an 
adequate service of salaried midwives. Certain local 
authorities already exercise to some extent their 
powers in regard to midwifery under the Maternity 
and Child Welfare Act, 1918, either by subsidising 
the midwifery work of local nursing associations or 
by themselves employing midwives. The present 
Bill places an obligation on each local supervising 
authority to secure an adequate service within its 
area, provides for an Exchequer grant towards the 
cost of the new service, and deals with other related 
matters. 


Under Clause 1 it will be the duty of every local super- 
vising authority to secure, whether by making arrange- 


THE LANCET] 


PARLIAMENTARY INTELLIGENCE 


[marcu 28, 1936 749 


ments with welfare councils or voluntary organisations 
for the employment of midwives as whole-time servants 
or by itself employing midwives, that an adequate number 
of salaried midwives is available in its area to attend on 
women in their own homes as midwives or maternity 
nurses: the clause provides for the submission to the 
Minister of proposals for carrying out this duty after 
consultation with the local bodies concerned. 

Clause 2 provides for the advertisement by each authority 
of the terms of employment in the new service, which is 
to be on a whole-time basis, and for certain superannuation 
matters in relation to midwives so employed. 

Under Clause 3 of the Bill authorities will be required 
to fix scales of fees for the services of their midwives, 
when acting as such or as maternity nurses, and to 
recover in each case the appropriate fee, or, if the financial 
circumstances of the patient do not permit of the payment 
of the whole charge, such part, if any, as she or the person 
legally liable to maintain her can afford. 

Clause 4 sets out the provisions governing the grants 
which it is proposed shall be made by the Exchequer 
towards the cost of the new service. The grants will 
range from about 85 per cent. of the additional expen- 
diture in the case of the poorest areas to about 20 per 
cent. in the case of the richest areas, and will amount in 
all to about half the cost in each year of the new service. 

Clause 5 of the Bill provides that a midwife who is 
not appointed by an authority as a salaried midwife and 
who agrees to cease practice and to surrender her certifi- 
cate shall receive compensation based on her emoluments 
for the last three years, and that any midwife who is 
required to surrender her certificate by reason of age or 
infirmity shall receive compensation based on her emolu- 
ments for the last five years. 


The remaining clauses contain provisions for 
preventing unqualified persons from practising as 
nurses in maternity cases, for securing the periodical 
attendance of certified midwives at courses of instruc- 
tion to be provided by authorities, and for enabling 
authorities to defray certain expenses incurred by 
them under previous Midwives Acts. 


In the House of Lords on Tuesday, March 24th, 
Viscount GAGE introduced a Bill to consolidate 
and amend certain enactments relating to public 
health. The Bill was read a first time. 


HOUSE OF COMMONS 
WEDNESDAY, MARCH |8TH l 
Quality of Margarine Supplied in Royal Air Force 


Mr. Leaca asked the Under-Secretary of State for Air 
if the low-priced and inferior quality of margarine sup- 
plied to the Air Force was of the type to which vitamins A 
and D had been artificially added or was it of the non- 
vitamin containing variety.—Sir P. Sassoon replied: 
The margarine supplied to apprentices and boys in the 
Royal Air Force is vitaminised, but not that supplied to 
airmen. 

Mr. Leac: Can the right hon. gentleman say whether 
the insertion of these vitamins in margarine can actually 
be performed with success; and does he know that butter 
contains both these vitamins ? 

Sir P. Sassoon: I believe medical authorities consider 
that vitaminised margarine is equal if not superior to 
butter because the vitamin content of butter varies 
according to the seasons of the year. 


Gastric Disorders Among Omnibus Men 


Mr. SHort asked the Lord President of the Council if 
he would say what progress the Industrial Health Research 
Board of the Medical Research Council had made respect- 
ing the investigation of the cause of gastric disorders 
among omnibus men.—Capt. Marcrsson (Parliamentary 
Secretary to the Treasury) replied: I am informed that 
the investigation is being actively pursued, but that it 
has only recently begun and is still in an early stage. 
It will necessarily take some time to collect reliable 
statistics to show whether an excessive incidence of gastric 


disease is, in fact, associated with this occupation. If an 
affirmative answer is obtained it is proposed to extend 
the inquiry to a study of possible causes. 


Temperature and Humidity Conditions in 
Hospitals and Schools 


Mr. MARKHAM asked the Minister of Health whether 
any inquiry was proceeding in this country at the moment 
into the question of temperature and humidity conditions 
in schools, hospitals, &c.; and, if not, whether he would 
take steps to institute such inquiries.—Sir KINGSLEY 
Woop replied: I understand that inquiries relating to 
questions of warmth and comfort in buildings are being 
carried out by an inter-departmental committee of the 
Medical Research Council and the Department of Scientific 
and Industrial Research, and that a further report will 
shortly be issued by the Council. In these circumstances 
I do not at present think it necessary to institute further 
inquiries with special reference to schools or hospitals. 


THURSDAY, MARCH 19TH 
Medical Treatment in Training Centres 


Miss Warp asked the Minister of Labour if he could 
yet inform the House what steps he proposed to take to 
provide medical treatment for young men.—Lieut.- 
Colonel MurrHEeap (Parliamentary Secretary to the 
Ministry of Labour) replied: Arrangements are being 
made to provide treatment in appropriate cases for young 
men in the special areas of the ages of 18-24 inclusive 
who are willing to attend a training centre, but who are 
at the moment prevented from doing so by reason of 
remediable defects. 

Miss WaRD: Can my hon. friend say what the arrange- 
ments are ? 

Lieut.-Colonel MUIRHEAD: The arrangements are 
being undertaken, but they are not yet completed. I 
cannot give any date for their completion, but they are 
being pressed on as quickly as possible. 


Instruction on the Dangers of Alcohol 


Mr. PALING asked the President of the Board of Educa- 
tion whether any steps had been taken by the Board to 
carry out the recommendation of the Royal Commission 
on Licensing, paragraph 699, that His Majesty’s inspectors 
should inquire as to the extent to which instruction on 
the dangers of alcohol was carried out in the schools 
they visited ; and if he could present any return or report 
showing the results of the inquiries made.—Mr. OLIVER 
STANLEY replied : The Board’s ‘‘ Handbook of Suggestions 
on Health Education ” contains a chapter on the hygiene 
of food and drink, which was revised after the publication 
of the report of the Royal Commission on Licensing, 
and the Board consider that a knowledge of its contents 
should be regarded as part of the necessary equipment 
of every teacher. H.M. inspectors have been instructed 
to pay particular attention to, and to report on, the 
health instruction given in schools, but I am unable to 
furnish a report such as the hon. Member desires. 


Special Schools for Mentally Defective Children 


Sir Francis FREMANTLE asked the President of the 
Board of Education if he would say for how many children 
accommodation was available in special schools for men- 
tally defective children; and for how many accom- 
modation was available 25 years ago.— Mr. OLIVER STANLEY 
replied: There is accommodation available in special 
schools for 16,562 mentally defective children as com- 
pared with accommodation available in 1911 for 11,854. 

Sir F. FREMANTLE: Does the right hon. gentleman 
think that is satisfactory progress considering the import- 
ance of the problem ? 

Mr. OLIVER STANLEY: In a recent circular I issued I 
pointed out that there was a need for better residential 
accommodation for these children in certain areas, and 
I urged local authorities to make progress in the matter. 

Sir Francis FREMANTLE asked the President of the 


_ Board of Education if he would arrange for the notifica- 


tion of defective children on leaving school to the mental 
deficiency authority——Mr. OLIVER STANLEY replied: 
Provision is made in Article 4 of the Mental Deficiency 


750 


THE LANCET] 


PARLIAMENTARY INTELLIGENCE 


[MARCH 28, 1936 


(Notification of Children) Regulations for the notification 
of mentally defective children due to leave special schools 
on or before attaining the age of 16. There is no power 
whereby local education authorities can notify children 
leaving other schools, but the Board have suggested 
that such children could be informally brought to the 
notice of the mental deficiency authorities for friendly 
supervision on @ voluntary basis. 

Sir F. Fremant te: Is the right hon. gentleman looking 
after this to see if it is carried out properly because the 
information generally is that it is not carried out ? 

Mr. OLIVER STANLEY: The whole question of closer 
coöperation is now under consideration by the local 
authorities. 


Small Traders and National Health Insurance 


Mr. ARTHUR HENDERSON asked the Minister of Health 
whether he proposed to introduce legislation to allow 
shopkeepers to become voluntary contributors under the 
National Health Insurance Acts for the purpose of quali- 
fying for the receipt of benefits, including medical, sick- 
ness, and disablement benefits.—Sir KinestEy Woop 
replied : The answer is in the negative. The new scheme 
which the Government has announced its intention of 
introducing will be limited to pensions insurance. The 
Government feel that the success of the new scheme would 
be jeopardised by the inclusion of health insurance, 
because the contribution required to provide the com- 
bined benefits would be so substantial as to make the 
scheme unacceptable to many persons who are anxious 
to secure the pensions benefits. I would remind the hon. 
Member that under the National Insurance Act, 1911, 
shopkeepers and other persons working on their own 
account had the opportunity of becoming voluntary 
contributors for health insurance purposes, but, the 
option was withdrawn by the Act of 1918 because of the 
meagre response to the offer. 


Spahlinger Treatment for Tuberculosis 


Sir Francis FREMANTLE asked the Minister of Agri- 
culture if adequate experiments were being made in this 
country to check those in Northern Ireland on the Spah- 
linger vaccine for the prevention of tuberculosis in cattle ; 
how long these experiments would take; and whether, 
if it be proved successful, he would take steps to secure 
its general adoption.—Mr. Exuior replied: I am in close 
touch with the work that has been and is being carried 
out in Northern Ireland in connexion with the Spahlinger 
vaccine, The question of conducting tests with the vac- 
cine in this country is under consideration, I am, how- 
ever, not yet in a position to make a statement as to 
the scope or duration of any experimental work which 
may be undertaken. 


MONDAY, MARCH 23RD 
Small-pox in India 


Mr. LeacHu asked the Under-Secretary of State for 
India whether he had received any information with 
regard to small-pox outbreaks in India; and whether 
the outbreaks this year had been heavier than usual at 
this period.—Mr. BUTLER replied: There has recently 
been an acute epidemic of small-pox in Bengal. Complete 
up-to-date figures for the Province as a whole are not 
yet available, but in Calcutta 1558 deaths from small-pox 
have occurred this year up to March 7th. This is greater 
than the average of recent years, but the disease comes in 
waves at irregular intervals. 


TUESDAY, MARCH 24TH 
Cerebro-spinal Fever in Army Camps 


Mr. Day asked the Secretary of State for War to state 
the number of cases of cerebro-spinal fever reported and 
admitted to hospital at Aldershot and/or Catterick during 
the previous 12 months; and whether there had been 
any reports from other camps in Great Britain.— Mr. DUFF 
Coorer replied: The number of cases of cerebro-spinal 
fever for 1935 were: Aldershot, 7; Catterick, 2. In 
addition there were 14 cases from various stations through- 
out Great Britain, making a total of 23. The number of 
cases from Jan. lst, 1936, to date are: Aldershot, 1; 


Catterick, 4. In addition there were 7 cases at Woolwich, 
2 at Chatham, and 1 at Windsor, making a total of 15. 


Puerperal Fever in Derbyshire 


Mr. Hotuanp asked the Minister of Health how many 
cases of puerperal fever had occurred in Derbyshire during 
the past three months ; how many of such cases originated 
in maternity institutions; whether the source of the 
infection had been traced; and with what results.— 
Mr. SHAKESPEARE (Parliamentary Secretary to the 
Ministry of Health) replied: Thirteen cases of puerperal 
fever were notified in Derbyshire during the 13 weeks 
ended March 14th. One case occurred in one of the 
maternity institutions which are provided or subsidised 
by local authorities and which are, therefore, required 
to report to my right hon. friend. There were also 1l 
cases of the condition known as puerperal pyrexia in 
the same institution during that period. Investigation 
showed that the source of infection could probably be 


traced to a throat infection in a member of the staff, and’ 


the institution was temporarily closed and the premises 
disinfected. 


MEDICAL SICKNESS, ANNUITY AND LIFE 
ASSURANCE SOCIETY 


a 


The annual report announces that 1936 is a bonus year 
for members of this society, which is the only insurance 
company paying a reversionary bonus on its sickness and 
accident policies as well as on its life policies. The surplus 
available for distribution depends on the profits of the 
sickness fund and therefore varies according to the 
society’s experience; in 1932, for example, the bonus 
was 12s, for each guinea per week insured on each premium 
paid in the preceding five years, while in 1927 the figure 
was 15s. per guinea. The directors take an optimistic 
view of the prospects for 1936, as the present experience 
seems to be favourable. Prospective members of the 
society are advised that it is open only to the medical 
and dental professions ; that it is conducted on a ‘* mutual 
profit” basis; that, if desired, combined policies are 
issued embodying both life and sickness assurance ; that 
loans for the purchase of practices and house property 
are offered; and that pension policies are available for 
insurance practitioners and members of the British Medical 
Association. In presenting the report of the 51st year of 
the society the directors speak of continued expansion. 
The total funds have increased by £147,526 to £1,239,639. 
The premium income of the life assurance fund amounted 
to £101,268, and the rate of interest earned on this fund 
was £4 6s. 3d. per cent. after deduction of tax. The new 
annual premiums again reached a record figure, amount- 
ing to £10,071 ; the payments for sickness claims increased 
slightly to £53,494. The total premium income increased 
to £202,460, and the expenses of administration were 
reduced by 1:8 per cent. of last year’s figures to £19,685 ; 
this is 9-7 per cent. of the total premium income. The 
growth of the society in the last few years has made it 
necessary to secure larger offices; fortunately it was 
possible to find the accommodation in the same building 
in which the society has had its offices since 1914, at 300, 
High Holborn, London, W.C.1. 


RHEUMATIC CLINIC FOR ABERDEEN.—The pro- 
vision of a clinic for the treatment of rheumatic 
diseases at Aberdeen is being considered. It is thought 
the Royal Infirmary buildings at Woolmanhill which will 
shortly become vacant might be reconstructed for this 


purpose. 


CARDIFF ROYAL JNFIRMARY.—There has been a 
gradual increase in expenditure at this hospital 
amounting to between £4000 and £5000 a year, and 
as there is no prospect of reduction, a regular addi- 
tional income of £5000 a year must be obtained. 
The chairman of the finance committee has suggested 
that the weekly contributions from workmen should be 
raised from 2d. to 3d. a week. 


THE LANCET] 


[marcon 28, 1936 751 


MEDICAL NEWS 


University of Oxford 


On May 5th in convocation it will be proposed to 
confer the honorary degree of D.Sc. on Sir Cuthbert 
Wallace, P.R.C.S., Sir’ Walter Langdon-Brown, Dr. 
Robert Hutchison, Prof. Charles Singer, Sir Henry Dale, 
F.R.S., and Sir George Newman. The degrees will prob- 
ably be conferred when the British Medical Association 
meets at Oxford this summer. 

A Radcliffe travelling fellowship has been awarded to 
Dr. A. P. Meiklejohn, Robinson senior scholar of Oriel 
College. 


University of Liverpool 


At recent examinations the following candidates were 
successful :— 
D.P.H. 
Part I.—J. D. Bryan, W. N. M. Mason, T. H. 
F. Pygott, H. R. Shone, Edna L. Smart, B. A. 
Mary M. Thomson, and T. P. E 


pT 

W. Barnetson, A. Boules, D T, Cran, N. G. Gandhi, R. G. 
Ghoshal, A. G. Hiremath, M. T. Ismail, B. B. Mukerjee, 
W. Murray, M. S. Rao, and. z. ae Slimon. 


Pierce, 


W. Crawford, K. O’Toole, S. E Ting, and T. P. Tu. 


Dr. R. G. Ghoshal has been recommended for the 
Milne medal. 


University of Leeds 


Mr. J. C. Gillies has been appointed honorary demon- 
strator in anatomy, and Mr. D. J. Cork lecturer in dental 
pathology and bacteriology. 

At recent examinations the following candidates were 
successful :— 

M.D. 

Bessie Brown and W. H. Tod. 


CH.M. 

P. R. Allison. 

FINAL EXAMINATION FOR M.B., CH.B. 

Part I.—N. Baster, Joan M. Bateson, G. R. Bedford, Rose- 
marie Se H. Cohen, A. A. Driver, R. W. Elis, M 
Fox, V. Geoghegan, = ar Gray, G. W. 
Greig, T. Hardy, G 
anes one, Aene j, F. P. 
Baer oy Pay. H. Rhodes, Joyce M. Rhodes, Phyllis 
M. Richards, R hin ER G. B. Robinson, H. Silverman, C. L. 
Summerfield, J. C. T. Sykes, D. Taverner, H. Thistlethwaite, 
L. G. Topham, Mary Townend, Leila M. Wainman, J. W. 
Walker, F. J. D. Webster, and F. W. Wigglesworth. 

Part II.—G. N. Blackburn, Olive M. Callow, Marie H. Cal- 
verley, G. Clarke, J. C. Coates, W. Davidson, W. G. France, 
W. Hobson, J. Holden, R. L. Lamming, D. M. Leiberman, 
S. Mattison, W. S. A. oken: G. Quayle, O. Scarborough, J. P. 
Senior, Winnie Shaw, C. E. Stuart, E. H. Tomlin, C. W. Ward, 
and H. L. L. Wilson. 

Part III..—R. L. Lamming (with first class honours); J. © 
Coates and W. Hobson (with second class honours) ; 
Blackburn, Olive M. Callow, Marie H. Calverley, G. Clarke, 
W. Davisdon, W. G. France, J. Holden, D. M. Leiberman, 
S. Mattison, W. S. A. Oakes, G. Quayle, O. Scarborough, Winnie 
Shaw, C. E. Stuart, E. H. Tomlin, C. W. Ward, an H. L. L. 


Wilson. 
FINAL EXAMINATION FOR L.D.S. 
H. C. Brewerton, O. B. Clarke, T. W. Frost, and W. Pickup: 


D.P.M. 
A. D. D. Broughton and E. Smith. 


D.P.H. 
J. C. G. Anderton, E. L. Brittain, and J. W. Whitworth, 


University of Manchester 


Mr. John Morley, lecturer in systematic surgery in the 
University, has been appointed to the chair of surgery 
in succession to Prof. E. D. Telford who will retire in 
June. 

Mr. Morley, on leaving Bienen Stortford College, entered 
the University of Manchester and graduated M.B. with first- 
class honours in 1908. He obtained the degree of Ch.M. in 
1911 and became F.R.C.S. Eng. in the same year. During 
his course he gained many awards, including the graduate 
scholarship in medicine, the Bradley scholarship in clinical 
surgery, the Tom Jones exhibition in anatomy and the Tom 
Jones surgical scholarship, and the Ashby research scholarship 
in the diseases of children. He held a demonstratorship in 
anatomy inthe University from 1910 to 1911 and was lecturer 
in clinical anatomy from 1912 to 1920 when he was appointed 
a lecturer in applied anatomy. This appointment continued 
until, in 1930, he took up his present position. During the war 
he held the rank of captain in the R.A.M.C. (T.F.), and was 
awarded the Croix de Chevalier of the Legion of Honour for 
services in Gallipoli. Mr. Morley is consulting surgeon to 
Ancoats Hospital, assistant surgeon to the Manchester 
Royal Infirmary, and a consulting surgeon for children to 
St. Mary’s Hospitals, Manchester. His best known work is his 
book on ‘‘ Abdomina] Pain,” published in 1931. ; 


Taylor, : 


University of Sheffield 


At recent examinations the following candidates were 
successful :— 


P. B. L. Potter. 
FINAL EXAMINATION FOR M.B., OH.B. 


Parts II. and III.—R. T. Gaunt, J. R. Grimoldby (with second 
class honours); E. D. Belbin, H. A. Cole, J. L. Dales, P. M. 
Inman, S. Miles, E. L. M. Millar, and Cyril South. 


Scholarships for Sons of Medical Men 


Sir Milsom Rees scholarships of £100 each to Port 
Regis Preparatory School, Broadstairs, have been awarded 
to E. H. B. Smith, son of Major E. C. A. Smith, I.M.S., 
and to J. M. H. Dickson, son of Dr. W. S. Dickson. 


Medical Art Society 


The second exhibition of this society, which was founded 
last year, will be held in July. It is proposed that the 
members dine together before visiting the exhibition. 
A certain number of frames of stock sizes will be available 
for the exhibits of country members. Further information 
may be had from the hon. secretary, Prof. C. A. Pannett, 
St. Mary’s Hospital, London, W.2. The president is 
Sir Leonard Hill, F.R.S. 


General Medical Council 


At the meeting of the executive committee held on 
Feb. 24th it was announced that the folowing names 
erased from the Medical Register under Section 14 of the 
Medical Act, 1858, had now been restored : 


Bennett, Thomas Kinnear, Joseph 
Browne, Patrick F. Mackenzie, Andrew H. 
Fraser, Patrick Murphy, John K. 
Horsley, Lancelot O’Brien, Catherine M. 
Jones, Lewis Weston, Alfred W. 


A reported amendment of the 1928 Act in the Union of 
South Africa enables holders of New Zealand medical 
degrees to be registered in the Union, and revokes the 
right of holders of the M.D. of Royal Universities of Italy. 
A new regulation by the Saudi Government forbids any 
doctor, dentist, veterinary surgeon, dental operator, or 
accoucheuse to practise in the Kingdom of Saudi unless 
registered under specific conditions by the public health | 
department. 


National Ophthalmic Treatment Board 


This board has completed a film called ‘‘ Do You See ? ” 
which illustrates in story form the need of watchfulness 
against eyestrain, and emphasises the danger of receiving 
eye treatment from anyone but a qualified eye specialist. 
One sequence of the film deals with the history of spectacles 
and another shows the activities of the National Eye 
Service centres which the Board has established in 
coéperation with the British Medical Association. These 
centres provide for examination of the eyes of persons 
of limited means by medical eye specialists at a nominal 
fee. The address of the Board is 1, High-street, 
Marylebone, W.1. 


The Grenfell Association 


Dr. H. L. Paddon gave an address, entitled Twenty-one 
Years with Sir Wilfrid Grenfell in Labrador, at a meeting 
on March 18th of the Grenfell Association of Great Britain 
and Ireland, at which Lord Horder presided. He said 
that Grenfell found pathetic relics of two races, Eskimos 
and Indians, which were suffering grieviously from contact 
with white men. He described the havoc played by 
epidemics of small-pox, influenza, scarlet fever, and 
measles. The tragedy of the native races could not be 
stayed, but there still remained the white settlers and 
mixed stock, and Labrador could be made an industrial 
asset of the Empire, though the country’s resources were 
still undeveloped. Tuberculosis and nutritional disease 
were disappearing in the districts round the hospitals and 
medical centres. Lord Horder said there was no form 
of human activity for which he would like to appeal more 
strongly than for the Grenfell Association. Mr. Vincent 
Massey, High Commissioner for Canada, ascribed to 
Grenfell the honour of having removed the reproach 
often applied to Labrador ‘‘ The land that God gave Cain.” 


M.D. 


752 THE LANCET] 


Grading of Milk , 

Sir Kingsley Wood, the Minister of Health, having 
considered representations made to‘him upon the Draft 
Milk (Special Designations) Order, 1936, has decided to 
make some modifications in the Order and to postpone the 
date of operation till June Ist. 


Laryngo-phoniatry 

Ten lectures on this subject will be given from May 11th 
to 16th at the Hôpital Bellan, 7, rue du Texel, Paris XIV. 
Further information may be had from Dr. Jean Tarneaud, 
27, Avenue de la Grande Armée, Paris XVI. 


London Hospital 

Sir William Goschen, chairman of this hospital, an- 
nounces that of the £80,000 required for extensions only 
£13,674 has so far been subscribed. It is becoming increas- 
ingly difficult to carry on the work of the institution, and 
as a result of lean and difficult years in the past the loan 
account stands at £81,000. 


Royal Waterloo Hospital, London 

This hospital’s income last year rose from £24,005 to 
£24,997, but the weekly cost of each in-patient also rose, 
from £3 8s. 3}d. to £3 10s. 103d. The out-patient depart- 
ment is very much congested and it has become neces- 
sary to extend the building. 


Westminster Hospital 

At the end of 1935 over £178,000 had been given or 
promised to the rebuilding fund of this hospital, and 
during the last three months promises of sums amounting 
to a further £12,500 have been received. The sum of 
£25,000 is needed before the new medical school building, 
which is badly needed, can be completed. 


Clinic for Endocrine Disorders 

A new out-patient department for the treatment of 
endocrine disorders is to be opened at Guy’s Hospital, 
London. It will be regarded purely as a reference depart- 
ment, and for the present there will be only one session 
weekly. Dr. P. M. F. Bishop, as honorary clinical endo- 
crinologist, will be in charge of the clinic. 


Harvey’s Statue at Folkestone 

On Wednesday next, being the anniversary of his birth 
in Folkestone, the statue of William Harvey on the Leas 
will be unveiled in a form more worthy of his birth- 
place. The statue, 30 ft. in height, cast in bronze, on a 
granite plinth and pedestal, has been decolorised since 
its erection in 1881 by the salt air to a mottled green. 
The inscription on the base, which has long been hardly 
discernible, is being renovated for all who will to read :— 

WILLIAM HARVEY. 


The Discoverer of the Circulation of the Blood. 
. Born in Folkestone April 1, 1578. 
Died in London June 3, 1657. 
Buried at Hempstead, Essex. 


Harvey’s memory is also recalled in Folkestone by the 
stained-glass window in the parish church, and by the 
grammar school founded by one of his relations. 


Congress on Hepatic Insufficiency 

An International Congress on Hepatic Insufficiency will 
be held at Vichy from Sept. 16th to 18th immediately 
after the International Congress on Gastroenterology 
which is taking place in Paris from Sept. 13th to 15th. 
The congress at Vichy will meet under the presidency of 
Prof. Maurice Loeper (Paris), and the subjects for dis- 
cussion have been arranged in two sections. Prof. Noel 
Fiessinger (Paris) will preside over the medicine and 
biology section, and among those who will contribute to 
the discussions are Dr. R. Debré, Dr. Gilbrin, Dr. Seme- 
laigne, Prof. Binet, and Prof. Lemaire (Paris), Dr. Olmer 
(Marseilles), Dr. Erich Urbach (Vienna), Dr. A. Parhon 
(Bucharest), and Dr. Hamilton Fairley (London). Prof. 
Mauriac (Bordeaux) is to preside over the therapy section, 
and the speakers will include Prof. Brulé, Prof. M. Villaret, 
Prof. L. Justin-Besancgon, Dr. R. Cachera, and Dr. R. 
Fauvert (Paris), Prof. Piery and Dr. Milhaud (Lyons), 
Dr. De Grailly (Bordeaux), Dr. F. Gallart-Mones (Barcelona), 
Prof. B. Pribram (Berlin), Prof. P. Duval, Dr. J. C. Roux, 
and Dr. Goiffon (Paris). Dr. J. Aimard is the general 
secretary of the congress and may be addressed at 24 
Boulevard des Capucines, Paris, IXe. 


MEDICAL NEWS 


[MARCH 28, 1936 


ro 


Princess Alice Hospital, Eastbourne 

The Marchioness of Hartington opened the nurses’ home 
extension at this hospital on March 23rd. 
London Homeopathic Hospital 


It is proposed to provide an enlarged casualty depart- 
ment at this hospital for the reception and treatment of 
the increasing number of accident and ambulance cases, 


Birmingham Children’s Hospital 

A babies’ block is to be erected at this hospital and a 
public appeal made to pay for the building and equipment. 
Mr. Peter Bennett has promised to give £10,000 under a 


seven years’ deed of covenant. 


Research Fellowship in Medicine 

The Council of the Royal Society invite applications for 
the E. Alan Johnston and Lawrence research fellowship in 
medicine which is tenable in any hospital or medical 
school in the British Isles. The fellow is elected for two 
years and receives an annual st'pend of £700. Particulars 
will be found in our advertisement columns. 


Bath Mineral Water Hospital 

Mr. Sidney Robinson has offered £35,000 for the build- 
ing of the projected new hospital on a site which has 
already been cleared. Last year he gave £5000 to meet 
the cost of the additional nurses’ quarters, and his earlier 
gifts include £3000 for the erection of a new ward and 
£1500 to facilitate the organisation of a national research 
laboratory. Mr. Robinson makes his offer on the condition 
that building shall begin within two years. 


Incorporated Society of Chiropodists 

The annual dinner of the society was held on Saturday 
evening last at the Trocadero, the president of the society, 
Mr. John H. Hanby, welcoming at the reception over 
200 members and their guests. The toast of the evening 
was proposed by Mr. Norman Lake, senior surgeon to 
Charing Cross Hospital, who told the story of the early 
struggles of the society, to which the chairman replied, 
recalling the steady and practical advance of recent 
activities, and dwelling on the good work done at the 
Foot Hospital. The toast of the medical profession was 
proposed by Sir Henry McMahon and acknowledged by 
Mr. W. H. Ogilvie and Dr. A. W. Oxford. Thereafter a 
large number of the company danced. 


St. Mark’s Hospital, London 

The annual general meeting of the governors of this 
hospital was held on March 19th. Sir Percy Vincent, 
the Lord Mayor, presided, and, in proposing the adoption 
of the report of the committee of management, said that 
1935, the centenary year of the hospital, had been one of 
great activity in all departments. The number of patients 
admitted to the wards had been 1129, which was the 
highest recorded. The income had exceeded the expen- 
diture, but the surplus was accounted for by legacies, 
which could not be regarded as normal income. After a 
hundred years of humanitarian work in the City of London 
St. Mark’s needed £60,000 to meet its increased responsi- 
bilities. An appeal for that sum had been launched in 


1934, and £8745 had been received in response. It was 
proposed to build a modern nurses’ home, to increase 
the bed complement, to provide a self-contained paying 
patients’ block, to install a second operating theatre, and 
to improve the cancer research, X ray, and out-patient 
departments. The hospital records showed the importance 
of early treatment, but, owing to lack of accommodation, 
hundreds of cases had to be turned away, with disastrous 
results. The need had become so urgent that plans were 
on foot to begin work on the extensions, and it was hoped 
that the foundation-stone of the new nurses’ home would 


be laid during the present year. The hospital was doing 
a noble and useful work, and he hoped it would receive 
the support from the public which it undoubtedly deserved. 

Mr. Lionel Norbury, the senior honorary surgeon of the 
hospital, said that there were 201 people on the waiting- 
list at the present moment, and the number seldom fell 
below that. A considerable proportion of those 201 
people were cancer patients, for whom early treatment was 
of the utmost importance, and it was therefore imperative 
that the size of the hospital should be increased at the 
earliest possible moment. 


THE LANCET] 


Medical Diary 


SOCIETIES 


ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W. 
WEDNESDAY, April Ist. 

History of Medicine. 5 P.M. Mr. F. N. Doubleday : 
Jobn Keats, Poet and Doctor. : 

Surgery. 2 P.M. (King’s College Hospital, Denmark 
Hill, S.E.), Operations by Mr. C. P. G. Wakeley, Mr. J. 
Everidge, and Mr. H. C. Edwards. Cases will be shown, 
and there will be a Demonstration of Microscopic 
Sections, including Adenolymphomata of the Salivary 
Glands. 4.30 P.M., Dr. R. D. Lawrence: Sugar Meta- 
bolism in Hyperthyroidism. Mr. H. C. Edwards : 
The Value and Technique of Gastroscopy. Dr. R. A. 
McCance: Sodium Deficiency in Surgical Practice. 


WEST LONDON MEDICO-CHIRURGICAL SOCIETY. 
FRIDAY, April 3rd.—8.30 P.M. (De Vere Hotel, Kensington), 
Prof. Hey Groves and Mr. Sangster Simmons : Treat- 
ment of Fractures. 
WEST KENT MEDICO-CHIRURGICAL SOCIETY. 
FRIDAY, April 3rd.—8&.45 P.M. (Miller General Hospital, 
Greenwich), Dr. F. Hudson Evans, Dr. L. W. Bain, 
Dr. Edward Glover, and Dr. S. S. Lindsay: That the 
Neurotic Patient should be Treated by His Own 
Family Doctor. 
HARVEIAN SOCIETY. 
THURSDAY, April 2nd.—8&.30 P.M. (Manson House, 26, 
Portland-place, W.), Dr. W. E. Chiesman and Dr. G. 
de Bec Turtle: Heematemesis. 


LECTURES, ADDRESSES. DEMONSTRATIONS, &c. 


UNIVERSITY OF BIRMINGHAM. 
TUESDAY, March 3lst.—3.30 P.M. (General Hospital), 
Dr. B. C. Tate: Demonstration of Skin Diseases. 
FRIDAY, April 3rd (Queen’s Hospital), Prof. W. Gemmill: 
Demonstration of Surgical Cases. 


ROYAL INSTITUTION, 21, Albemarle-street, W. 
TUESDAY, March 3l1st.—5.15 P.M., Prof. Edward Mellanby, 
F.R.S.: Drug-like Actions of Some Foods. 


INSTITUTE OF HYGIENE, 28, Portland-place, W. 
WEDNESDAY, April 1st.—3.30 P.M., Dr. R. Fortescue Fox: 
Arthritis in Women. 
CHADWICK LECTURE. 
THURSDAY, April 2nd.—8.15 P.M. (Royal Institute of 
British Architects, 68, Portland-place, W.), Mr. Lionel 
Pearson: Modern Hospital Construction. 


BRITEN POSTGRADUATE MEDICAL SCHOOL, Ducane- 
road, W. 

MONDAY, March 30th.—11.30 A.M., Prof. F. R. Fraser: 
Tuberculosis Complicating Pregnancy. 

TUESDAY.—2.30 P.M., Dr. King: Hepatic Function and 
Jaundice. 

WEDNESDAY, April 1st.—Noon, Clinical and pathological 
conference (medical). 2.30 P.M., Clinical and patho- 
logical conference (surgical). 3.30 P.M., Mr. Aleck 
Bourne : Disproportion and Difficult Labour. 

THURSDAY.—?2.15 P.M., Dr. Duncan White: Radiological 
Demonstration. 3 P.M., Dr. Chassar Moir: Operative 
Obstetrics. 

FRIDAY.—Noon, Dr. A. A. Davis: Gynæcological Patho- 
logy. 3 P.M., Dr. Alan Moncrieff : Hygiene of the 
New-born Child. 5 P.M., Sir James Walton : Surgical 
Aspects of Dyspepsia. 

Daily, 10 A.M. to 4 P.M., medical clinics, surgical clinics 
or operations, obstetric and gynæcological clinics or 
operations, 

FELLOWSHIP OF MEDICINE AND POST-GRADUATE 
MEDICAL ASSOCIATION, 1, Wimpole-street, W. 

MonpDay, March 30th, to SUNDAY, April 5th.—INFANTS 
HOSPITAL, Vincent-square, S.W.  All-day course in 
infants’ diseases. Mon.,Wed., and Fri., 8 P.M., primary 
F.R.C.S. course (anatomy and physiology).—NATIONAL 
TEMPERANCE HOSPITAL, Hampstead-road, N.W. Wed., 
Dr. Reginald Lightwood: Recent Views on Anæmia 
in Childhood. Fri., 8.30 P.M., Dr. Lightwood : Rational 
Prescribing for Children. Sat. and Sun., all-day course 
in general medicine and surgery.—WEST END Hos- 
PITAL FOR NERVOUS DISEASES, Gloucester-gate, 
Regent’s Park. Tues., 8.30 P.M., Fundus Oculi Demon- 
stration by Mr. Lindsay Rea for M.R.C.P. Candidates. 

Courses are open only to members of the Fellowship. 


H E TAL FOR SICK CHILDREN, Great Ormond-street, 


WEDNESDAY, April 1st.—2 P.M., Dr. Bertram Shires: 
Radiography of the Chest. 3 P.M., Dr. G. H. Newns: 
Pulmonary Diseases. Morbid Anatomy Demonstra- 


tion. 
Out-patient Clinics daily at 10 A.M. and ward visits at 


2 P.M. 
NATIONAL HOSPITAL FOR DISEASES OF THE HEART, 
Westmoreland-street, W. 
TUESDAY, March 31st.—5.30 P.M., Dr. 
Smith: Œdema and its Treatment. 
MANCHESTER ROYAL INFIRMARY. 

TUESDAY, March 31st.—4.15 P.M., Dr. A. Ramsbottom : 
The Treatment of Peptic Ulcer with Special Reference 
to Larostidin. 

FRIDAY, April 3rd.—4.15 P.M., Dr. F. R. Ferguson : Demon- 
stration of Neurological Cases. 

ANCOATS HOSPITAL, Manchester. 
THURSDAY, April 2nd.—4.15 P.M., Clinical Meeting. 
GLASGOW POST-GRADUATE MEDICAL ASSOCIATION, 

WEDNESDAY, April Ist.—4.15 P.M. (Royal Samaritan 

Hospital for Women), Dr. John Gardner: Prolapse. 


B. T. Parsons- 


“ALLEN, H. W 


MEDICAL DIARY.—APPOINTMENTS.—BIRTHS, MARRIAGES, AND DEATHS [MARCH 28, 1936 753 


Appointments 


p] . D.M. Oxon., D.P.H., has been appointed 
Medica Registrar at the Prince of Wales’s General Hospital, 

ondon. 

BADENOCH, A. W., M.D. Aberd., F.R.C.S. Eng., 
Registrar at the Metropolitan Hospital, London. 

BLAND, J. O. W., M.D. Camb., Senior Demonstrator of Bac- 
teriology at St. Bartholomew’s Hospital, London. 

Boycott, J. A., B.M. Oxon., Assistant Bacteriologist to St. 
George’s Hospital, London. 

BREWER, H. F., M.D. Camb., Clinical Pathologist to St. Bartho- 
lomew’s Hospital, London. 

CLARKE, J. H., M.D., D.P.H., Medical Officer of Health for the 
County of Lincoln (Kesteven). 

CRUICKSHANK, ALEXANDER, M.B. Aberd., F.R.C.S. Eng:, Sur- 
eo Registrar at the Prince of Wales’s General Hospital, 

ondon. 

CUTHBERT, J. A., M.B. Edin., D.P.H., Assistant Medical Officer 
of Health for Dundee. 

DEVLIN, W. L., M.B. Belf., D.P.H., Assistant Medical Officer 

- for Rhondda. 

REBURN,-.CYRIL, M.R.C.S. Eng., Second Assistant Pathologist 
at the Royal Sussex County Hospital, Brighton. 

RovuGHEAD, J. A., M.B. Glasg., D.P.H., Medical Officer of Health 
to the Burton Latimer, Desborough, and Rothwell Urban 
Councils, the Kettering Rural District Council, and Assistant 
Medical Officer to the Northants County Council. 

Topp, T. .. M.S. Lond., F.R.C.S. Eng., M.C.0.G., Hon. 
Assistant Gynecologist to the Royal Hospital, Salford. 
WINTERTON, W. R., M.B. Camb., F.R.C.S. Eng., M.C.O.G., 
Assistant Surgeon to the Hospital for Women, Soho- 

square, London. 

Sheffield Royal Hospital.—The appointment of the following 
Clinical Assistants is announced :— 

LUDLAM, G. B., M.B. Edin., D.L.O., Ear, Nose and Throat 
Department ; 

FAULKNER, S. H., M.D. Belf., M.R.C.P.I., D.O.M.S., Oph- 
thalmic Department; and 

Kemp, F. H., M.B. Birm., X Ray Department. 

Certifying Surgeons under the Factory and Workshop Acts: 
Dr. J. T. MorraT (Coggeshall District, Essex); Dr. T. H. 
McLEOoD (North Walsham District, Norfolk). 

Medical Referee under the Workmen’s Compensation Act, 
1925: C. W. GRAHAM, M.B., F.R.C.S., of Edinburgh, for 
all Sheriff Court Districts at present comprised in the 
Sheriffdoms of Fife and Kinross ; the Lothians and Peebles ; 
and Stirling, Dumbarton, and Clackmannan ; with a view 
to his being employed in ophthalmic cases. 


Surgical 


Births, Marriages, and Deaths 


BIRTHS 


ADAM.—On March 16th, the wife of Dr. W. Blane Adam, of 
Crowborough, of a daughter. 

Byrom.—On March 19th, at Muswell Hill, Kathleen, wife of 
F. B. Byrom, a daughter. 

CONYERS.—On March 16th, at Sutherland-avenue, W., the 
wife of J. H. Conyers, F.R.C.S. Eng., of a son. 

DAVENPORT.—On March 17th, at Welbeck-street, the wife of 
Robert Davenport, F.R.C.S. Eng., of twin sons. 

Davipson.—On March 13th, in London, the wife of Dr. James 
Davidson, Brampton-grove, N.W., of a daughter. 

DAVIES.—On March 17th, at Walmer, the wife of Dr. D. A. 
Davies, of a daughter. 

Day.—On March 14th, at Norwich, the wife of Dr. George H. 
Day, of a son. 

JACKSON.—On March 19th, to Marjorie (née Kerr), wife of 
H. B. Jackson, M.B., M.R.C.P. London, of Sheringham— 
a daughter. 

MARKS.—On March 20th, the wife of Dudley P. Marks, M.B. 
Camb., F.R.C.S. Eng., of Stratford-on-Avon, of a daughter. 

PAaGAN.—On March 15th, at Southampton, the wife of Dr. A. T. 
Pagan, of a son. 

SPICER.—On March 14th, at Southsea, the wife of Captain 
W. R. C. Spicer, R.A.M.C., of a son. 


MARRIAGES 


KNox—CrvustT.—On March 21st, at St. Bartholomew the Great, 
Robert Knox, M.D. Lond., of Cambridge, to Lynda Crust, 


of Miningsby. 
DEATHS 


BowER.—On March 19th, at Avenue Mansions, N.W.3, William 
Bower, M.B. Camb., late of Ware and Hendon. 

DODWELL.—On March 18th, at Albert Bridge-road, S.W., 
Philip Rashleigh Dodwell, M.D. Lond., in his 73rd year. 

EaMeES.—On March 13th, at Derby, Ernest Victor Eames, 
L.R.C.P. Edin., late of Heanor, Derbyshire. 

Hanson.—On March 2Iist, in London, in motor-car accident, 
Dorothy Mable Hanson, M.B. Liverp. 

Low.—On March 21st, at Singapore, consequent on a fall, 
John Meredith Low, M.R.C.S. Eng., Capt., R.A.M.C. 
SHADWELL.—On March 21st, at Richmond, Arthur Shadwell, 

M.D. Oxon., F.R.C.P. Lond., aged 81. 

TWEEDIE.—On March 18th, Alexander Robert Tweedie, 
F.R.C.S. Eng., late Colonel R.A.M.C., T., retd., of Not- 
tingham. 

W8ITAKER.—On March 22nd, suddenly, at Farncombe, Surrey, 
Sir James Smith Whitaker, M.R.C.S. Eng., late Senior 
Medical Officer to the Ministry of Health, in his 71st year. 


N.B.—A fee of 7s. 6d. is charged for the insertion of Notices of 
Births, Marriages, and Deaths. 


754 THE LANCET] 


[MARCH 28, 1936 


NOTES, COMMENTS, AND ABSTRACTS 


THE ART OF MEDICINE? 


By CHRISTOPHER HowaArp, M.R.C.S. 


EARLY DIAGNOSIS: TREATMENT OF PNEUMONIA 


To make an early diagnosis is often to win half 
the battle in a case of serious illness, for as a rule 
treatment only fails because it is not administered 
sufficiently soon. Take, for instance, early pneu- 
monia. In this disease there may be no chest 
signs to commence with, except widespread pain, 
but there are, I think, three signs which, if present, 
enable one to make a definite diagnosis and so to 
free one’s mind of the incubus of the unknown. 
The first is the working of the nostrils, which is 
present even when there may be no very obvious 
respiratory embarrassment; and it is a sign which 
the best of physicians I have met, the late Dr. Ogle, 
continually impressed upon his clerks. The second 
is a pungent burning skin, which is immediately 
felt by the trained hand, and which may exist in 
the absence of a very high temperature, and for 
which I have never heard any adequate physio- 
logical explanation. And the third is the complete 
absence of chlorides from the urine. These three 
signs form a valuable trinity to remember, for the 
more one practises physic the greater is the realisa- 
tion that one physical sign is worth half a dozen 
symptoms. 

I sometimes think that of the great systems of the 
body it is the respiratory which has lagged behind 
in spectacular methods of treatment, for though the 
amelioration of tuberculosis of the lung is much for 
which to be thankful, the method is, broadly speaking, 
the same as that practised in the sunlit groves of a 
Greek temple; only now instead of worshipping 
4Esculapius, we kneel to the great god Laboratory. 
Pneumonia still, by right of facts and statistics, 
bears the title of Captain of the Men of Death, origin- 
ally given to it by John Bunyan, and a careful study 
of the literature, especially that pertaining to the 
use of serum in this disease, does not convince me 
that treatment has improved in the last half-century. 
Expectant treatment, which means carefully observing 
and assisting the various processes by means of 
which immunity is eventually established, goes on 
quietly saving lives, whilst one after the other of the 
so-called specific treatments arise, with a flourish 
of manufacturer’s trumpets, and all too soon, in 
relation to the expectations aroused, pass into the 
limbo of forgotten things. When people lived 
normal, out-of-door country lives, pneumonia, and 
to a greater extent still, tuberculosis, were not 
common diseases, but when they herded together 
into factories at the end of the eighteenth and the 
beginning of the nineteenth centuries, and the town- 
ships, which are now blots on the surface of the 
earth, formed themselves, tuberculous disease, espe- 
cially in the lungs, spread like a forest fire. The 
greatest contribution of medicine towards the defeat 
of this disease has really been an endeavour to put 
people back into the country for a longer or a shorter 
period of time, and gradually to teach the people 
to say, with John Donne, that ‘“‘ cities are sepulchres 
and they who dwell there are carcases.”’ 

In the treatment of pneumonia, one should use 
morphia in the same way as a revolver, that is to 
say, never until it is necessary, and then properly ; 
for both morphia and the revolver, if properly used, 
need not be employed again. One night’s rest and 
freedom from pain, following the exhibition of an 
adequate dose, is far more helpful than the partial 
relief to be obtained from repeated small doses. 
For the early stages of pneumonia, as well as for 
large areas of pleurisy, our two most valuable and 
safest therapeutic aids are morphia and leeches, but 


1 Abstract of an address delivered on Feb. 27th, 1936, before 
the Hunterian Society of St. George’s Hospital. 


for «esthetic reasons the latter are far too little used. 
Some while ago I came across an old leech woman 
who for many years had made a good living froma 
leech farm somewhere down in the Cotswolds. She 
was now living on an old-age pension, and bereft of 
other means of resource, because the fashion for the 
use of leeches has so completely disappeared. I do 
not know whether she was a typical laudator temporis 
acti but she told me that leeches had joined in the 
general decay of the world, and no longer bit or 
swallowed as they used todo. My own impression 
is that the leeches we used in the hospital ten or 
fifteen years ago were better at their job than those 
which to-day I occasionally hire from the chemist. 


MECHANICAL ASSISTANCE TO DIAGNOSIS 


“ In the early diagnosis of empyema, radiological 
signs are inferior to physical signs, and in three of 
our cases pus was aspirated from the pleural cavity 
on clinical grounds before any change was demon- 
strable in the X ray film.” I take this sentence from 
a recent and valuable article on the pneumonias, 
which appeared in THE LANCET, for there is a wide- 
spread and childlike faith in X ray examinations, 
many regarding such examinations as infallible. 
Claude Bernard, the French physiologist, used to 
say that when you meet with a fact opposed to 
prevailing theory you should adhere to the fact and 
abandon the theory, even when the latter is sug- 
gested by great authorities and generally adopted— 
but it is of imperative importance in medicine to 
be certain of one’s facts. I have seen an obvious 
case of pneumonia denied its correct diagnosis 
because an X ray examination revealed nothing, and 
it was only after considerable probing that it was 
found that the picture had been taken with the 
wrong type of tube and was therefore useless. Simi- 
larly, I have heard of an obvious case of typhoid 
fever being deprived of its name because an agglu- 
tination test was negativé; which reduces enteric 
from the status of a syndrome to that of a peculiarity 
and particularity of a given specimen of blood- 
serum. It is more important to delineate a likeness 
when making a diagnosis than to allow treatment to 
await the result of a bench test. 

When the radiograph first came into general use, 
the older and wiser physicians fought a rearguard 
action against too rapid a surrender of the indivi- 
dual’s skill in examining by sight and sound but 
much of this teaching has died with the teachers. 
The X ray is of such supreme value in so many 
differing conditions, that we must needs remind our- 
selves that it is not infallible, and that the attainment 
of skill in auscultation and percussion, which in its 
apotheosis takes many years, is still necessary. The 
man will always beat the machine except when 
reason is deserted and faith only remains. Then, 
just as in the days of Laennec’s stethoscope, the 
magic tube will be invested with healing as well as 
with diagnostic properties. ; 

Emerson’s statement that the end of the human 
race will be that it will eventually die of civilisation 
has a particular bearing also upon the science of 
medicine, for in every sphere the replacement of 
the man by the machine must eventually result in 
sterility. It is therefore of interest to learn that 
various teaching centres are now inaugurating lectures 
and courses in the science of medicine, for there are 
at last a few people who are beginning to realise 
that there is little value in the student who can 
discourse learnedly on the hydrogen-ion concentra- 
tion of the blood, and yet cannot, by the naked eye, 
differentiate between a nephritic and a diabetic 
urine. More reliance upon the use of the eyes and 
the fingers, and less upon the laboratory, will pay 
us a dividend of success both in diagnosis and treat- 
ment, and to further this end I think that a general 
practitioner should be appointed to give lectures in 
every teaching hospital. 


| THE LANCET] 


The only times that a physician should close his 
eyes are when he is using a stethoscope or palpating, 
for if the mechanism of the sense of sight is tem- 
porarily not used, the other senses gain in acuity. 
Usually it is as well to watch the patient’s expres- 
sion during the whole course of the examination, 
but as neither the stethoscope nor the bulbs of the 
fingers (never use the tips) are productive of pain, 
it is infinitely worth while to become momentarily 
blind, for then all things, such as diastolic murmurs 
and liver margins, shall be added unto you. In a 
famous book on diseases of the gall-bladder, it is 
stated that a physician literally carries his brains at 
the tip of his fingers, which is delightful, and in the 
case of many physicians whom I know would be, 
from the point of view of quantity, more than a 
possible conception : but such statements strengthen 
one’s opinion that the word ‘‘ literally ” is responsible 
for even more lapses in literature than the much- 
abused words ‘‘ unique ” and ‘‘ meticulous.” 

“ Look before you feel” should be one of the 
frequently recurring texts of anyone who aspires 
to teach medicine. The novice and the indifferent 
doctor always press, probe, and pummel as the first 
step to a diagnosis, and this way disaster lies. The 
clue to the inflamed appendix is found by noting the 
restriction in the movement of the abdominal wall, 
not in the imposition of two hundred pounds of 
doctor on to the patient’s belly, accompanied by a 
naive inquiry as to whether it hurts. Often the 
presence of blood inside the peritoneum can be 
deduced from a small area of bruising appearing on 
the abdominal skin. Such a sign is sometimes diffi- 
cult to see unless the whole abdominal wall is examined 
with a strong light, but when found it is very sug- 
gestive, and may indeed be pathognomonic. 


THE DIAGNOSTIC VALUE OF PAIN 


It is never too late and never too early to remind 
ourselves how deceptive may be the site of pain. 
Many people who suffer from pain in or over the 
heart are convinced that they have some fell cardiac 
disease and they are too frightened to consult a 
doctor and to learn the truth, which is that cardiac 
pain is more often a symptom of disease in the gall- 
bladder or liver than in the heart itself. The reverse, 
of course, also holds true, and for example pain in 
the lower jaw, usually the left side, may be a sign 
of heart disease, as also may be the sensation of 
having a lump in the gullet. One perhaps need not 
hasten to add that in themselves neither of these 
signs is of any value, and is only to be taken in con- 
junction with all the minutiz which go to make up 
a clinical picture and so point to the diagnosis. 
‘When a patient comes into my consulting-room 
complaining of a pain in the heart region, I lay myself 
long odds against the presence of any cardiac lesion. 
Shortness of breath, swelling of feet, irregular pulse, 
indigestion, blueness or clamminess of the skin, 
nausea and giddiness, mental change, and a thousand 
others, are the complaints of heart cases. It is 
astonishing how badly disorganised a heart may be 
without giving rise to pain. The inevitable excep- 
tion, of course, is furnished by angina, and there, 
though the pain is absolute agony, the fear of impend- 
ing, sudden, and dramatic death is even more alarming, 

It is very important to differentiate between 
gall-bladder disease and affection of the coronary 
arteries, which is sometimes more difficult than it 
sounds. Nearly 50 per cent. of cholecystitic cases, 
whether or not complicated by the presence of stones, 
give a story of more or less pain in the heart. This 
awareness of the precordial region may show all 
degrees from occasional palpitation to attacks of 
pseudo-angina. If evidence incriminating either the 
gall-bladder or the vascular supply of the heart is 
hard to evaluate, help may often be obtained from 
an electrocardiograph where the presence of a flat- 
tened or inverted T wave may aid in the differential 
diagnosis, and in so doing will furnish us with one 
of the comparatively rare occasions in which an 


‘NOTES, COMMENTS, AND ABSTRACTS 


Ca 


[maRcH 28, 1936 755 


electrocardiographic tracing is of practical value in 
general medicine. | l 

It is probable that a really acute attack of sciatica 
furnishes the most agonising pain to which a healthy 
man or woman in comfortable circumstances is 
liable, and I still think that in spite of many other 
vaunted remedies the best treatment is to give 
morphia, a quarter of a grain, repeated perhaps for 
three nights in succession, and that this treatment 
will sometimes see the end of an attack. There is no 
reason’ to suppose that the drug has any specific 
effect upon the inflamed nerves, but it gives rest to 
the tortured body, and in this rest the affected nerves 
must share. Old-fashioned but still popular text- 
books, warn us against prescribing morphia in such 
cases, but I think their authors forget that it is to 
all intents and purposes impossible for a layman to 
obtain morphia and therefore the risk of causing 
an addiction is minimal, and it is my firm belief, 
from experience in my own practice, that the easily 
obtained barbiturates are far more dangerous and 
much less effective as a prescription. 


[After some shrewd remarks upon influenza as 
seen in private practice, when the characteristic 
features of the pain must be noted, Dr. Howard 
went on to say that there may be a diagnostic sense 
enabling some to escape the danger of prescribing 
the wrong drug or making mistakes in dosage, but 
the allergic states constitute, he pointed out, a real 
danger which may beat the prescriber of the most 
simple drugs. He said :—] 


Quinine is a common offender, but I think the 
most poisonous substance I have come across when 
ingested by a particular patient, was any form of 
potato. Even minute quantities, used for instance 
to thicken a soup, produced immediately profound 
collapse. Potato is not common, but eggs are quite 
common as instigators and inciters of these anaphy- 
lactic reactions, and no amount of desensitisation 
appears to have more than a temporary effect. 
Another drug commonly giving rise to untoward 
reactions is iodine, and now that in various forms it 
is widely advertised for external application, and 
that to its very presence next to the skin in the form 
of a locket or socks is being attributed a miraculous 
healing power, it is well to remember that even in 
minute quantities iodine may be a poison. If only a 
slight susceptibility exists, nothing but a running 
nose and red eyes may be noticed but a more pro- 


‘nounced reaction may be evidenced by a severe 


rash covering all the surface of the body. Iodine is 
excreted as iodide in the urine, sweat, saliva, milk, 
and the secretions of most of the glands, and there 
is a curious fact to remember, that the intensity of 
the reaction is often inversely proportional to the 
amount absorbed. People object to the administra- 
tion of drugs which upset them or which give them 
an ugly, spotty, and blotchy skin, but it is not until 
one has examined a good many patients for a good 
many years that one begins to realise how rare it is 
to see a really lovely skin. The woman patient who 
had the most perfect skin I ever saw was almost a 
moron, so presumably the ectoderm exhausted itself 
on its attainment and had little left in hand for the 
highest nerve centres. 

Itching of the skin is difficult to treat and is not 
& very common complaint, though of course localised 
itching, such as pruritus ani, is a very common com- 
plaint. It is usually badly treated and the patient 
continues to excoriate himself until a second infec- 
tion is superadded and the misery of itching is 
intensified by the presence of discharge. The rational 
treatment consists first in the cure by injection of 
any internal hemorrhoids, and the diminution of 
local congestion consequent upon this step leads in 
about half the cases to a cure of the pruritus. If, 
however, the skin, by scratching and secondary 
infectien is hypertrophic and obviously involved, 
the whole area should be painted with solution of 
camphor and iodine in spirit until it becomes harder 
and less inflamed. Then a few injections of benzyl 


~ 


756 THE LANCET] 
benzoate in oil may give relief. This relief is likely 
only to be temporary unless the peri-anal skin is 
treated carefully for at least a year. There are many 
varieties of continuation treatment, but the most 
effective of the important directions are, first, that 
the area must be washed after every motion, and then 
La Rola must be carefully rubbed in. This is a 
patent preparation for which I can find no substitute. 
Every night the area should be dabbed with witch- 
hazel. No powder of any sort should be allowed 
and no dietary rules, except of course in the case 
of diabetics, are of value. All ointments are useless, 
but in some cases amazing relief can be given and 
permanent cure obtained by extracting 24 c.cm. of 
blood from a vein in the anti-cubital fossa, mixing 
it with an equal amount of 2 per cent. novocain, 
and injecting it carefully, subcutaneously, into the 
peri-anal area. Personally I think that auto-hemo- 
therapy in its varying forms is far too little used in 
England, and for various diseases of allergy, and for 
such conditions as migraine, and for vague forms of 
petit mal, it offers a useful field of therapeutic 
endeavour, 
COSMETIC SURGERY 


I confess that as yet I do not consider that «esthetic 
shortcomings fulfil the conditions which should be 
present before the continuity of the flesh is broken. 
At a clinic in Paris I have seen queues of middle- 
aged women, all of whom had recently had their 
faces lifted, their noses altered, their eyelids tightened, 
or their breasts raised. With the Psalmist they might 
inquire of Providence for how long they had recap- 
tured a faint semblance of youth, for at best the 
fancied improvement can only be obtained for a 
very few years. When I asked some of them their 
reason for submitting to these painful manceuvres 
they rather archly replied that it was a question of 
Vamour, but I rather fancy that amour propre is a 
better reason, because there is something in the mis- 
fortunes of our friends which is not displeasing to us 


POPULAR MISCONCEPTIONS 


It would be impossible to enumerate all the popular 
misconceptions about the functioning of the body, 
but the following are a few to which many people 
still cling with conviction and sometimes emphasis. 

(a) That insomnia is dangerous to health and leads to 
mental exhaustion and insanity. There is no jot or tittle 
of proof that such is the case, and though bodily rest is 
essential, mental oblivion, even apparent, is not neces- 
sary to recurrent and adequate activity of the mind. 
The amount of sleep required by a given organism varies 
between very wide limits. The best brain workers and 
those who by the world’s standards are acclaimed as great, 
often sleep very little. I am not in the least advocating 
less sleep, but you will be told by your patients that 
insomnia is necessarily harmful, and this is a bogy that 
should be laid. 

(b) That overwork leads to a nervous breakdown. 
Brain work itself never leads to any damage of the nervous 
tissue, but five minutes’ fear, or a day’s worry, which is 
civilisation’s substitute for fear, may affect a person 
permanently and irreparably for the worse. 

(c) That a carefully planned diet is essential to health. 
With obvious exceptions, such as sufferers from diabetes 
or peptic ulcers, the ordinary mixed diet provides such a 
wealth of the necessary factors, including salts and vita- 
mins, that any alteration is much more liable to do harm 
than good. It has only lately been shown that it is pos- 
sible to have too many vitamins, just as it is possiblo to 
have too few, but only those unfortunates who exist on 
the hunger line need fear that that great chemical synthetic 
machine, the body, will be unable to extract from the 
ordinary mixed diet exactly what is required for the 
complete and proper functioning of each and every organ. 

(d) That modern life is too strenuous. MHueffer once 
wrote a book called “ Ladies Whose Bright Eyes,” and 
in it gives a good picture of the rigours of the Middle 
Ages, and the largest executive in the biggest office, 
surrounded by twenty telephones and a hundred typists, 
will be less fatigued at the end of the day than the same 


NOTES, COMMENTS, AND ABSTRACTS 


[MARCH 28, 1936 


oOo u 


man would be after five minutes in the galleys, or an hour 
at the court of Imperial Spain. 

(e) That, and it is a most popular misconception, 
constipation is the root of all evils. Except in the rarest 
cases, the sequels of constipation are all subjective pheno- 
mena, and the headache and the lassitude are entirely 
due to self-suggestion. The mass suggestion of the adver- 
tisers is a sufficient reason for the auto-suggestion. 


Some of your patients who fancy that they suffer 
from any of these five health misconceptions will 
want you to advise treatment at a spa. The habit 
of going to a spa to undergo what is optimistically 
known as a cure is probably a survival of the days 
when magic healing properties were attributed to 
certain places, often wells or springs situated, pre- 
ferably, in a part of the country difficult of access, 
To make a pilgrimage in search of health is a real 
exercise, and the necessity of taking certain steps 
and of undergoing certain ritual performances fixes 
the idea of a cure so firmly in the sufferer’s mind 
that the stage is set prettily for the worked for and 
expected result. An odd commentary on spas in 
general is provided by the fact that the inhabitants 
of such places seldom, if ever, drink the nauseous 
waters or undergo the ritualistic ablutions them- 
selves, but perhaps like Jeremiah they question 
whether there is any balm in Gilead. To Jeremiah’s 
further question as to the presence of a physician 
they can return a strongly affirmative answer, for 
in this respect as a profession we retain a trifle of 
our priestly function, and the healing waters cannot 
usually be obtained, externally or internally, without 
the laissez passer of one of the many spa doctors, 


I suppose that for people of a gouty and plethoric 
nature some temporary good must come from an 
annual pilgrimage to a place where dict and regime 
and magical waters are to hand, and the yearly 


treatments may do something to delay what one 
writer has so aptly called that slide in ugly anguish 
from vaccines and bedpans to the tomb. Having, 
for my sins, smelled the waters at some spas both 
at home and abroad, I confess that I find a feeling 
of great sympathy for Samuel Butler when he said 
that ‘‘ when the water of a place is bad it is safest 
to drink none that has not been filtered, either through 


the berry of a grape or else a tub of malt. These 
are the most reliable filters yet invented.’ When, 
however. patients are becoming a nuisance and are 
wearying, it is one way of escape to send them to 


a spa. 
I have noticed that clever people are usually fools 


about their own health. The nice clever people, 
those who have great gifts and an accompanying 
simplicity of soul, fall into the hands of charlatans 
and dishonest healers because, knowing nothing of 


objective pathology. they will accept any statement 


or treatment which the quack likes to suggest. 
One can love this type even though at times a con- 
siderable irritation is produced by some further 
piece of evidence of stupidity. The difficult and 
rather worthless type is the successful, usually rich, 
person, who having differentiated himself from the 
common herd by the amassing of money, or the 
purchase of a title, must needs be individual in his 
therapeutic adventures. The common basis for the 
absolute and stupid faith which such a man exercises 
in respect to some new treatment is conceit, for he 
cannot bear to be as other men are and must always 
know better than the ordinary mortal. Examples 
of this stupidity, of this Athenian demand for some 
new thing, are so numerous that I will not attempt 
to chronicle them, but every practitioner probably 
hears: of a case of this sort about once a month; 
such as that of a patient who after a colostomy for 
an inoperable growth goes to a quack, and as a result 
attributes his improving health to the new remedies 
and not to the cessation of septic absorption and of 
obstruction consequent upon his colostomy. During 


this brief period of feeling better he harries his friends 
until they too are shepherded into the false fold. 
Then when the growth slowly progresses and the 
sufferer, after going more or less rapidly downhill, 


THE LANCET] 


NOTES, COMMENTS, AND ABSTRACTS 


[marcu 28, 1936 757 


crawls away to die quietly, he is either too ashamed 
or too callous to revoke the glowing testimonials he 
had previously broadcast. 


Dr. Howard concluded with some amusing examples 
of the distrust among medical men of innovations, 
and the confidence of the public in the veteran prac- 
titioner. These people, he said, are apt to exclaim 
with Oliver Wendell Holmes that ‘‘ Age lends the 
graces that are sure to please.” I looked up the rest 
of the quotation and have now memorised it as a 
retort when I am next told that an older doctor is 
preferable, for I find the ensuing line is, ‘‘ Folks want 
their doctors mouldy, like their cheese.” 


‘ 


PSYCHOLOGY FOR MEDICAL STUDENTS 


ADDRESSING the Medical Society for Individual 
Psychology on March 12th, Sir WALTER LANGDON- 
Brown spoke of the efforts being made to provide 
medical students with a basic training in psychology. 
The Curriculum Conference, of which he was a 
member, reported last May in favour of an elementary 
course of lectures towards the end of the preclinical 
period. The lectures at this stage, said Sir Walter, 
should bring the facts of psychology into relation 
with the student’s own attempts at adjustment to 
daily life and environment, and they should be given 
by a medical man rather than a pure psychologist ; 
for in T. A. Ross’s words, ‘‘ it would be extremely 
easy to ensure hatred of all psychology if the student 
were put through a serious course of academic 
psychology.” Later, when he reached his clinical 
period he must be prepared to realise that imagined 
ills required, equally with organic ones, investigation 
and treatment. Such investigation and treatment 
called for simpler, more practical, and less specialised 
methods if they were to be of any subsequent value 
to the general practitioner. Not all mental and 
psychological conditions, of course, were suitable 
for treatment by the practitioner; the psychotic 
patient was often inaccessible and an obsessional 
state often required long and specialised treatment. 
But an understanding of all neuroses and psychoses, 
and a practical knowledge of how to treat the main 
bulk of neuroses with which he would later have to 
deal in general practice was essential for the medical 
student. 

The conference had recommended the continuance 
of demonstrations in a mental hospital, but emphasised 
the importance of making a student familiar with the 
psychological aspects of all patients. Demonstra- 
tions should be held—by physician, surgeon, or 
psychologist—at least once a fortnight throughout 
the student’s period of in-patient clerkships, and 
in this way the teacher of medical psychology should 
be able to draw upon the material in the hospital 
as a whole. The teaching of this subject should be 
woven into the ordinary teaching of medicine and 
surgery, and it was important that the teachers should 
approach their subject free from the trammels of 
pre-war materialistic medicine in which most of the 
present generation were brought up. The stimulus 
to provide a broader and more psychological approach 
to medicine was not only desired from students of 
psychology and reasearch; the pressure to teach 
the neuroses is coming from below; the students 
themselves were eager for it, and if they did not get 
it from one school they would go elsewhere. 

In the subsequent discussion Dr. EDWARD 
MAPOTHER criticised an assumption implicit in Sir 
Walter Langdon-Brown’s thesis—namely, that the 
psychoses and neuroses were two separable, and 
distinct entities. This was not generally accepted ; 
indeed there were good reasons why the study 
and perhaps the practice of the two should proceed 
by codrdinated and codperative methods.—Dr. HENRY 
YELLOWLEES maintained that the psychiatrist was 
in fact already successfully engaged in dealing with 
mental disorder of all kinds whether neurotic or 
psychotic. Treatment of the neuroses did not 
postulate a different method or viewpoint from that 


of the psychoses, and there were many instances 
of a little knowledge being a dangerous thing.— 
Dr. T. A. Ross expressed general agreement with 
Sir Walter’s views. Many neuroses were aggravated 
by the accumulation of biochemical and other 
physiodiagnostic data; it would be in the interests 
of all concerned to have the simple teaching methods 
applied which the speaker had described.—Dr. DAVID 
FORSYTH said that the methods advocated had the 
virtue of assisting the future medical generation 
to correlate the old with the new concepts in medicine. 

Dr. MARGARET LOWENFELD said that experience 
of child psychology confirmed the urgent necessity 
for a new viewpoint in the treatment of nervous 
disorders in children.—Dr. A. T. Witson doubted 
whether it was possible to teach a new mode of 
approach to anyone confirmed in a mechanistic 
philosophy of causation. Preclinical teaching should 
be behaviourism; the bias at present was towards 
the analytic—Dr. R. A. NOBLE pointed out that 
one of the intentions of the Curriculum Conference 
was to add to the existent demonstrations of and 
lectures in psychiatry ; not in any way to replace 
them. Physicians’ distrust of psychology would be 
dispelled by a recognition of the fact that to be a 
good medical psychologist a man must primarily and 
essentially be a good physician.—Dr. C. M. BEVAN- 
Brown, the chairman, said that Sir Walter’s proposi- 
tions were generally those for the advocacy of which 
the Society stood. For their satisfactory achieve- 
ment it would be necessary to destroy, or at least 
modify, the mechanistic concept. The difference 
between the old schools and the new was funda- 
mentally a difference of philosophic standpoint. 
Hitherto the materialistic standpoint had been 
predominant. 


AIR RAID PRECAUTIONS 


IN connexion with the measures being taken to 
mitigate the effects of possible air-raids, the Order of 
St. John of Jerusalem and the British Red Cross 
Society have agreed to place their organisations at 
the disposal of both central and local governments in 
order to supplement official resources. We under- 
stand that the St. John Ambulance Brigade have 
issued a special order to their divisions all over the 
country making provision for the training of 
(1) instructors, (2) the existing rank and file of the 
Brigade, and (3) the general public as an auxiliary 
reserve. The British Red Cross Society, through its 
county branches, is taking similar action. Already, 
it is stated, over 900 officers of the Brigade, many of 
them medical men, have been through intensive courses 
of instruction in London, and many of these, having 
obtained their instructor’s certificate, are conducting 
classes elsewhere. The British Red Cross Society 
have many hundreds of officers who are also qualified 
to instruct. The demand for these trained men and 
women is said to be rapidly increasing, for the medical 
officers of health of boroughs and urban districts 
have been officially advised to organise first aid and 
decontamination posts in their areas, the personnel 
of which will be voluntarily supplied by these trained 
members of the St. John Ambulance Brigade and the 
British Red Cross Society. Those taking the courses 
of the Brigade and the Society undergo examination 
and receive certificates. Subsequent examinations 
are held to ensure continued efficiency. 


HYGIENE IN BRIEF 


A CRITICISM often levelled at the study of preventive 
medicine is that, though vitally important and 
necessary, itis generally dull. It is thus satisfactory that 
however listlessly the reader may take up the author- 
ised text-book of theSt. John Ambulance Association, ! 
he will be interested in spite of himself for it is packed 


1 Hygiene or the Gospel of Health. The authorised text-book 
of the St. John Ambulance Association. Third edition. By 
Neville M. Goodman, M.D. Camb., D.P.H. Lond., Lecturer 
and Examiner for the St John Ambulance Association; 
Lecturer in Public Health and Sanitation, the London Hospital. 
Tondon St. John’s Gate, Clerkenwell, E.C.1. 1935. Pp. 195. 

S. s 


758 THE LANCET] 


with meat from start to finish, prepared in a palatable 
and digestible form. Dr. Goodman is a sane optimist. 
He believes, with Dr. Alfred Cox, that health can be 
bought and that it is not the people who make the 
slums. It is hard to choose quotations where so 
much is worth quoting, but two examples of his 
pithy utterances may be given. ‘‘ An Englishman’s 
home is said to be his castle; it should ag least be 
a healthy, modern one, not an insanitary medizval 
ruin.” And again, ‘‘ The good housewife must know 
where to draw the line between making her home a 
kind of museum of cleanliness and a slovenly abode 
of dirt. At either extreme her husband and family 
will only return home with reluctance.” Appended 
to each chapter is a questionnaire which can be 
answered from the text and should prove useful to 
examinees, 


WHITAKER’S ALMANACK 


THE new edition of Whitaker’s Almanack not 
only contains the new House of Commons and a 
conspectus of the National Government as reconsti- 
tuted after the general election, but also the changes 
consequential on the death of King George V. and 
the accession of Edward VIII. The Almanack is 
thus so modern that we turned with misgiving to the 
title page with the signs of the zodiac, to find with 
relief that it remains as it always was. The Almanack 
is still the completest guide we have to the activities 
of our fellow human beings and might well be the 
most acceptable gift for anyone allowed to possess 
only one book and already familiar with the Bible 
and Shakespeare. By way of quotation a single 
item of curious information must here suffice. 
Contrary to general belief, of the 40 million inhabitants 
of England and Wales less than 1 per cent. were 
born in Scotland, while of the five million inhabitants 
of Scotland nearly 3°5 per cent. were born in England 
or Wales. Whitaker can. be relied upon to refute 
many other well-worn fallacies. The price is 3s. 
in paper cover and 6s, in cloth. 


V acancies 


For further information refer to the advertisement columns. 


Barnsley Municipal General Hospital.—First Asst. M.O. £650. 

Belgrave „Hospital for Children, Clapham-road, S.W.—Two 
H.P.’s and one H.S. Each at rate of £100. 

Birmingham, Canwell Hall Babies’ Hospital.—Res. M.O. At 
rate of £250. 

Birmingham City. —Sen. Asst. M.O.H. £750. 

Birmingham City, Maternity and Child Welfare Dept.—Three 
Temp. M.O.’s, Each £10 per week. 

Birmingham, Queen’s Hospital.—Bacteriologist and Clinical 
Pathologist. £600. Also Res. Surg. Reg. £125. 

Bolton Royal Infirmary.—H.S. £125. 

Brain, alas Sussex Hospital for Women, Windlesham-road.— 


Bristol, Brentry ‘Colony for Male Mental Defectives, Westbury-on- 
Trym. —Res. Med. Supt. £650 

Bristol gu oe Hospital and Sanatorium.—J un. Asst. Res. 

BRN T ORE Medical School, Ducane-road W.—Three 

"5 

Burnley, Victoria Hospital._—H.P. At rate of £150. 

Cambridge, Addenbrooke’s Hospital.—H.P. Also H.S. to Special 
Depts. Each at rate of £130. 

Cardiff Royal Infirmary.—H.S. for Ophth. Dept. At rate of £40. 

Chester, East Lancashire Tuberculosis Colony, Barrowmore Hall.— 
H.P. At rate of £150. 

Cumberland County Council.—<Asst. County M.O.H. and District 
M.O.H. £800. 

Durham County Mental Hospital.—First Asst. M.O. £594. 

Eastbourne Royal Eye Hospital, Pevensey-road.—H.S. £100. 

Exeter, Royal Devon and Exeter Hospital.—H.S. to Ear, Nose, 
and Throat Dept. At rate of £150. 

Golden-square, Throat, Nose, and Ear Hospital, W.—H.S. £100. 

Son H ospilal FA Rectal Diseases, Vauxhall Bridge-road, S.W .— 

es. H.S 

Gravesend and North Keni Hospital.. H.S. £125. 

Greenwich Metropolitan Borough.—M.O.H. £1100. 

Harrogate and District General Hospital.mHon. Physician. 

Hospital for Consumption and Diseases of the Chest, Brompion, 

.W.—Res. Surg. O. £150. Also Asst. Res. M.O. and 

3 H.P.’s. At rate of £150 and £50 res } respectively. 

Hospital for Epilepsy and Paralysis Vale, W.—Res. 
M.O. Also H.P. At rate of £150 ane £100 respectively. 

Hospital of St. John and St. Elizabeth, 60, Grove End-road, N.W.— 
Res. H.S. At rate of £75. 

Huddersfield Royal Infirmary.—Cas. O. £200. Also H.P. and 

Anesthetist. £150. 
Hull oal Infirmary.—First H.P. At rate of £175. 


VACANCIES 


[maRoH 28, 1936 


Ilford, King Cans Hospital.—H.P. ‘and two H.S.’s. Each at 
Vincent-square, Westminster, S.W .—H.P, 


5. 

Ipswich, East Suffolk and Ipswich Hospitel.—H.S. £144. 

Kent Education Committee.—Half-time Asst. M.O. £350. 

Laboratories of Pathology and Public Health, 6, Harley-street, W.— 
Third Asst. Pathologist. £450. 

Leedi Hospital for Women.—Hon. Surgeon. Also Hon. Obstet. 

urgeon. 

Leeds Maternity Hospital, Hyde Terrace.—Res. Surg. O. At 
rate of £200. Also two H.S.’s. Each at rate of £75. 

Leeds University.—Chair of Anatomy. £1000. Also Tutor in 
Obstetrics and Gynecology. £500. 

Liverpool Sanatorium, Delamere Forest, EF rodsham.—Second 
Asst. to Med. Supt. £200, 

Liverpool, Walton Hospital.—Res. Asst. M.O. £200. 


London County Council.—Two Asst. M.O.’s (Grade II.). Each 
£250. H.P.’s. Each £120. Also Clin. Asst. £150. 
L.C.C. Central Histological Laboratory, Archway Hospital, 


Archway-road, N.—Asst. Pathologist. £650. 
London Lock Hospitals.—Two Res. M.O.’s. One for Male Dept. 
One for Female Dept. Each at rate of £175. 
London University. See Chair of Anatomy at St. 
Bartholomew’s Hospital Medical College. £1000. 
Macclesfield General Infirmary.—Second H.S. At rate of £150. 
Maidstone, Kent County Ophthalmic and Aural Hospital.. 
Ophth. H.S. At rate of £200. 
Manchester, Ancoats Hospital. Res. M.O. At rate of £150. 
Manoni Booth Hall Hospital.—Jun. Asst. M.O. At rate 
o 
Manchester Royal Children’s Hospital, 
Surg. O. At rate of £125. 
egistrar to Medical 


Pendlebury.— Res. 
Out- 


patients. At rate of £150. 
Margate, Royal Sea-bathing Hospital.—Asst. Med. Snph: £500. 
Ma Hospital, Denmark Hill, S.E.—Asst. M.O.’s. Each 
7 
Mount Vernon Hospital, Northwood.—Asst, Radiologist. £500. 
National Hospital for Diseases of the Heart, Westmoreland- 
street, W.—Res. M.O. Also Out-patient M.O. At rate 
of £150 and £125 respectively. 
Royal Gwent Hospital.—Cas. O. £175. Also 


Nes, Mss 
ae On 
Ne A Queen Mary Hospital, Hanmer Springs.—M.O. 
ou. 

Oldham Royal Infirmary.—Cas. O. and H.S. for Fracture Dept. 
At rate of £175. 

Portsmouth Royal Hospital.—Cas. O. At rate of £130. 

Preston and County of Lancaster Royal Infirmary.—H.P., Cas. 
H.S. Also H.S. Each at rate of £150. 

Queen Mary’s Hospital for the East End, Stratford, E.—Asst. 
Radiologist. £150. Also Obstet. H. S. £ 

Reading, Royal Berkshire Hospital. —H.P. Also Cas. O. Each 
at rate of £125. 

ERMI, coe Earlswood Instiitution.—Jun. Asst. M.O. At rate 
oO ¢ 

ie Surrey Royal Hospital.—Jun. H.S. At rate of 

Rochdale Infirmary and Dispensary. ag oond H.S. £150. 

Rotherham Hospital.—Cas.H.S. £150 

Royal Free Hospital, Gray’s Inn-road, W.C.—Res. Cas. O. 
At rate of £150. 

Royal Namal Orthopedic nt aed 23 4, Great Portiland-street, 
W.—H.S. At rate of £150. 

Royal Society, Burlington House, W.—E. Alan Johnston and 
Lawrence Research Fellowship in Medicine. £700. 

St. Mary’s Hospital for Women and Children, Plaistow, E.— 
Res. H.S. and Res. H.P. £155 and £150 respectively. 
Salford City. —Asst. M.O. for Venereal Diseases Treatment 

Centre. £500. 
Salford, Hope Hospital.—Res. Obstet. Officer. £400. 
Salisbury General Injirmary.—H.S. At rate of £125. 
pana Free Hospital for Women, Marylebone-road, N.W.— 
H.S. At rate of £100. 
Sheffield Children’s Hospital.—H.S. At rate of £100. 
a a Sag Southlands Hospital.—Second Asst. Res. 


Southend-on-Sea General Hospital.—Obstet. Registrar. £125. 

Soui ER Oera Jor Women, Clapham Common, S.W.— 
S 

Surrey County Council.—Ophth. Surgeon. £750. 

Swanley Hospital Convalescent Home, Parkwood.—Res. M.O. 


At rate of £200. 
University College Hospital, W.C.—Hon. Clin. 
Asst. in X Ray Dept. 
West London Hospital. Hammersmith-road, ae —Physician. 
Wigan, Royal Albert Edward Infirmary and Dispensary.—Res. 
Med. and Surg. O. and Reg. $250. Also H.S. £150. 
Willesden General Hospital, Harlesden-road, N.W.—Hon,. Anwes- 


thetist. 
Tonkan TOES Orthopedic Hospital, 


Gower-street, 


Kirbymoorside.— 


The Chief Inspector of Factories announces a vacancy for a 
Certifying Factory Surgeon at Nelson (Lancs.). 


SCARBOROUGH’s NEW HospitTaL.—The new hos- 
pital at Scarborough, which is being built at a cost of 
£128,000, is to be opened in September. Between 
£12,000 and £15,000 is required to meet the capital 
expenditure. Its maintenance cost will exceed that of the 
present hospital, but it is hoped that a new contributory 
scheme, which will bring in at least £3000, will make this 
good. 


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